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Making Inpatient Environments more Dissociation Friendly Dr Mel Temple Consultant Psychiatrist & Psychotherapist 1 Making Inpatient Environments more Dissociation Friendly Workshop – you’ll be doing some work! • Outline: – Background – Challenges – Considerations – Training – Our Experience & Service User / staff video – Round-up 2 Making Inpatient Environments more Dissociation Friendly • Background – Myself - consultant psychiatrist & psychotherapist (accredited IPT / EMDR), background in trauma work & complex cases, community & inpatient management – The Retreat – Quaker charitable mental health organisation developed in response to asylum care and pioneers of “humane” treatment approaches to mental health with relationships, compassion, collaborative care and a sense of community at the centre. – The Unit - New unit to be developed from closure of old 12 bedded “complex cases” unit which had become “too high risk” and concerns raised on external scrutiny. – The NHS Placement Landscape – High complexity (c-PTSD / dissociation / personality disorder / eating disorder), high risk, often detained already multiple failed in-patients / out-patient 3 approaches Making Inpatient Environments more Dissociation Friendly 4 Making Inpatient Environments more Dissociation Friendly • The Challenges - Brainstorming – Why do the patients need inpatient care? • Community approaches are in general considered the best approach so why might you consider inpatients? • Acute units vs specialist units – What difficulties do patients with dissociative disorders experience on inpatient units? – What difficulties do staff experience in managing these patients? 5 Making Inpatient Environments more Dissociation Friendly • Why might patients • Acute unit need inpatient care? – Acute crisis – – – – – Safety – No other option – funding issues Distress levels – Lack of skills needs Stuck – revolving door addressing as can be more “untreatable” traumatising Unable to manage outpatient treatment • Specialist Unit – Planned admissions – Funding difficulties / process – Best place for treatment – 6 only 1 unit! Making Inpatient Environments more Dissociation Friendly Service User Experiences Staff Experiences • • • • • • • • Experience of Helpless / hopeless around knowing what to do • Anger – rejection • Pull back • Sense of incompentence • Activation of own issues • Lack of structure or support around staff to assist them • Reliance on the use of medication 7 Invalidating “told off” Told manipulative, lying Labelled Controlled Feel helpless Disbelieved – trauma secrecy cycle continued • Re-traumatised • May be further victimised • Over medicated Making Inpatient Environments more Dissociation Friendly • Considerations…more brain storming! – Environmental Aspects – Staffing • Levels, Attributes, Training, Ongoing support – Unit Programme Aspects – Use of MHA? MCA? – Use of Medication? – Service user aspects 8 Making Inpatient Environments more Dissociation Friendly • Environment Quiet, calm, cosy single sex, Own room & facilities As many choices as possible within presenting risk Clear expectations & boundaries Outside space animals • Staffing high ratio staff:patients Characteristics – warmth, empathy, compassion,accepting, validating & curious stance Personable Ability to be consistent and work to appropriate boundaries 9 Making Inpatient Environments more Dissociation Friendly • Programme • MHA / MCA Underpining relational framework evident across the team Individualised & group Approaches to assist with difficulties Skills training & promotion of recovery focus Integration of any trauma work –collaborative working Ongoing Training and supervision to support this Consideration to the supportive role MHA can play in assisting adult to regain control / manage risk within system Difficulties of capacity framework in state shifting especially adult self state presentations Protections within the MHA framework. • Medication Judicious and appropriate use – little evidence. Relational support should be first line Treatment of comorbidities Role to review & take off meds 10 Making Inpatient Environments more Dissociation Friendly • Service User Single sex How to manage history of violence / aggression & create safe environment – can you mix those with Flight / freeze vs fight responses? Motivation to engage & recover? Level of understanding / acceptance of system? • Others Active risk history & agreement on how to manage 11 Making Inpatient Environments more Dissociation Friendly • Training – What training to do? • What training do you think most staff (including doctors) have had in trauma and dissociative presentations? • What do you think staff understand about the symptoms and difficulties these patients might experience? • What skills training do you think staff will have had around support to these symptoms? • How do you match training across the different staff groups? 12 Making Inpatient Environments more Dissociation Friendly • What Training? What is available? • • • • ESTD 4 day foundation training PODS new clinician training courses In- house around PTSD etc. Other general training – Attachment, Structured clinical management, KUF • Clinical Skills Coaching training – flashback management, grounding, chain analysis, interpersonal skills (relationships, mentalising, communication), emotions management (allowing experience, identification, tolerating, managing) 13 Making Inpatient Environments more Dissociation Friendly ESTD Foundation Course • This four module ESTD-UK Foundation course developed and delivered in collaboration with First Person Plural. • It takes place over four days, usually as 2 x 2 consecutive days scheduled about 1 month apart. • The course as a whole is primarily for qualified counsellors, psychotherapists, clinical psychologists and other professionals working therapeutically with chronically traumatised clients who have a (diagnosed or not yet recognised) complex dissociative disorder. • Participants attending all four modules will have gained a solid foundation on which to build their continuing professional development in a critical knowledge and skills set for recognising and working effectively with the many highly dissociative chronically traumatised individuals who present in NHS mental health and other therapy settings. 14 Making Inpatient Environments more Dissociation Friendly • Module 1: Understanding dissociation & complex dissociative disorders Trainers : Melanie Goodwin & Kathryn Livingston (First Person Plural) • Module 2: Developmental origins of dissociation in childhood Trainer: Dr Renee Marks, Consultant therapist specialising in children & adolescents • Module 4: Resources & resourcing: using a body-centred approach to working with trauma and dissociation Trainer: Lyn Terry-Short, Chartered Psychologist with 20 years’ experience in NHS • Module 3: Assessment & Treatment Approaches Trainer : Dr Mike Lloyd, Consultant Psychologist 15 Making Inpatient Environments more Dissociation Friendly • The Kemp Experience • 8 bedded • Homely modified risk environment • All women, Focus on C-PTSD / Dissociation / PD / Cormorbidities including eating disorders & OCD • Specific exclusion to antisocial PD / history of violence or aggression to others in last 6 months • High staffing ratio to allow for relational psychological approaches as first step • Underpinning model to the unit – Structured Clinical Management – Generalist – Relational & attachment based (1:1 key worker) – Curious & validating stance – look beyond the behaviour to understanding the reason for it – Focus on risk reduction & skills & resilience building 16 Making Inpatient Environments more Dissociation Friendly • The Kemp Experience • Programme aspects – SCM problem solving, Emotions Group, CFT Compassionate mind Group, IPT – Interpersonal Skills Group, Life Skills • Recruitment – focus on relational interaction & attitudes alongside experience, service user involvement in recruitment • Training & Supervision – Training package before opening • • • • • Intro aspects – PD, PTSD, Eating Disorders, Skills works – IPT / CFT / DBT / CBT ESTD 4 days SCM 2 days KUF Personality disorder Boundaries, Risk assessment & management – Ongoing weekly skills coaching – Weekly case formulation meetings – Weekly group supervision 17 Making Inpatient Environments more Dissociation Friendly • Service User & Staff Video 18 Making Inpatient Environments more Dissociation Friendly • The Kemp Experience What has gone well? • • • • • • • • Environment (with one exception…..) Attitude and approach of staff Upskilling of staff Ability to hold difficult experience Ability to retain a curious, non judgemental, validating stance Appropriate & low level use of medication Collaborative Use of the MHA Positive Risk Taking Extremely positive response from service users & positive outcomes measures 19 Making Inpatient Environments more Dissociation Friendly • The Kemp Experience What has not gone so well? -Staff turnover Marmite speciality area – learning as to recruitment Risk management aspects – high stress Unit & Organisational operational aspects Job progression offers -Suspicious & negative response from other clinicians -Organisations comfort around risk given CQC reports etc -Lack of contained outside space -Lack of large kitchen / diner to allow for self catering 20 Making Inpatient Environments more Dissociation Friendly • Questions? 21