CLCH NHS TRUST HOMELESS HEALTH COUNSELLING SERVICE A THREE STEPPED APROACH John Conolly October...
-
Upload
blake-holland -
Category
Documents
-
view
216 -
download
0
description
Transcript of CLCH NHS TRUST HOMELESS HEALTH COUNSELLING SERVICE A THREE STEPPED APROACH John Conolly October...
John Conolly October 2015 1
CLCH NHS TRUST HOMELESS HEALTH COUNSELLING SERVICE
A THREE STEPPED APROACH
John Conolly October 2015
The Challenges Of Homelessness
• Time Horizon – Day to Day, • Tri-morbidity: Physical, Mental Health and
Addiction Needs• Competing Priorities – Welfare appointments,
Multiple healthcare appointments• Impact On Healthcare
• Inconsistent Attendance Rate• Inconsistent Treatment – crisis only
2
John Conolly October 2015
Homelessness and Personality Disorder
• It is estimated that up to:
70% of single homeless people may have undiagnosed
personality disorder (Maguire et al, 2009).
• The American Psychiatric Association defines Personality Disorders as:
‘relatively stable, enduring, and pervasively maladaptive patterns
of coping, thinking, feeling, regulating impulses, and
relating to others’. (Bleiberg, Rossouw and Fonagy, 2012).
3
John Conolly October 2015
Complex Causes of PD
PD has complex causes: ‘ multiple biological, psychological and cultural factors contribute to its development’ (Livesely, 2003).
‘ A history of childhood abuse, deprivation, neglect, appears to be associated with the diagnosis of PD (Alwin,2006).
4
John Conolly October 2015 5
DSM V ICD-10Cluster A Paranoid
Distrust and suspiciousnessParanoid
Distrust and sensitivity
Schizoid Socially and emotionally
detached
Schizoid Emotionally cold and detached
Schizotypal No equivalent
Cluster B AntisocialViolation of the rights of others
DissocialCallous disregard of others, irresponsibility
and irritability
BorderlineInstability of relationship, self-
image and mood
Emotionally UnstableA) Borderline type: unclear self-image and
intense unstable relationshipsB) Impulsive type: inability to control anger,
quarrelsome and unpredictable
HistrionicExcessive emotionality and
attention-seeking
HistrionicDramatic, egocentric and manipulative
NarcissisticGrandiose, lack of empathy,
need for admiration
No equivalent
Cluster C AvoidantSocially inhibited, feelings of inadequacy, hypersensitivity
AvoidantTense, self-conscious and hypersensitive
DependentClinging and submissive
DependentSubordinates, personal need, seeking
constant reassurance
Obsessive compulsivePerfectionist and inflexible
AnankasticIndecisive, pedantic and rigid
The PD Challenge - Shocking Figures
– 77% of suicides have PD ( DOH, 2009)
– 73% prison population ( Ministry of Justice 2007)(Mi70% of single homeless (Maguire et al, 2009)
– 67% Mental Hospital population(NIMHE, 2003)
– 4% general population (Coid et Al, 2006) oid et al, 2006).
John Conolly October 2015 6
JC Draft 1JC Draft 1 6
John Conolly October 2015
Complex Problems
• People with personality disorders have increased risks of suffering additional mental health problems, such as:
• Anxiety, • Depression • Addictions• Recurrent deliberate self harm, suicide• Brief Psychotic episodes• Eating Disorders.
7
Treatment Assumptions violated by PD patients
1. Treatment compliance.
2. Access to own thoughts & feelings, and ability to report them back.
3. Responsive to logic & experimentation.
4. Can engage in a collaborative relationship.
5. problems are readily identifiable as targets of treatment.
6. People seek validation and empathy for their suffering rather than learn how to deal with it.
(Young at al, 2003)
John Conolly October 2015 8
John Conolly October 2015 9
HOMELESSNESS & TRAUMA 1.• Most people become homeless after a series of cumulative
trauma• Homelessness itself being a further secondary trauma. • Trauma reactions involve:
– disorientation, – memory loss,– poor focus, attention span, retention and processing of information; – panic, the oscillation between intense, overwhelming emotions
with a sense of numbness and not feeling anything. • Many will turn to deliberate self-harm and/or self- medication in order to
try and regulate these unmanageable emotions, resulting in (secondary) addictions
John Conolly October 2015 10
HOMELESSNESS & TRAUMA 2.
• Trust in the world and people has been lost, and sufferers are ‘hyper-vigilant’, on the lookout for danger and experience heightened levels of physiological arousal,– making them hypersensitive to further triggering
of their trauma responses. • This making the management of contacts and
relationships with others EXTREMELY challenging.
John Conolly October 2015
Change is Difficult• As has been seen there are many CHALLENGES to change
and ….
…. ‘fewer than 20% of a problem population areprepared for action at any given time.
And yet, more than 90% of behavior change programs are designed with this 20% in mind’
(Prochaska et al 2006).
11
John Conolly October 2015 12
Stages of Change 1-2Stage of change Characteristics Interventions To Move On1.Precontemplation -No Intent to change
- Problem behaviour seen as having more Pros than Cons
-DO NOT Focus on Change -Use Motivational strategies( Help person reduce their own Ambivalence)
- Acknowledge problem -Increase awareness of Negatives of problem -Evaluate self-management activities/skills
2.Contemplation -Thinking about changing -Seeking info re problem -Evaluating Pros & Cons of problem -Not prepared to change yet
-Consciousness raising -Self-re-evaluation -Re-evaluation of situation/circumstances
-Make decision to ACT -Engage in Preliminary Action(s) Engage with Peer Support Networks - e.g. Drop In Support & Discussion Group, AA and its offshoots;
John Conolly October 2015 13
Stages of Change 3-53.Preparation -Ready to change in
Attitude and Behaviour -May have begun to increase self-management and to change
-See above 2 -Increase commitment or self-liberation
-Set goals/priorities to achieve change -Develop Change Plan
- Regular Counselling
4.Action -Modifying Problem Behaviour -Learning new Skills to prevent full return of Problem
-Methods of overt Behaviour Change Behavioural Change Processes
Apply Behaviour Change methods for average of 6 months Increase self-efficacy to perform the behaviour change
5.Maintenance -Sustain Changes Methods of overt Behaviour Change ctd.
Ongoing Support e.g. ‘Leavers Group’, ‘Expert By Experience/Peer Mentor Forum’
John Conolly October 2015 14
A THREE STEPPED APROACHTO COUNSELLING
• In response to this the Homeless Health Counselling service has developed a ‘Three Step Model of Support & Counselling’:
1-Crisis Intervention
2-Appointment based interventions
3-Ongoing Recovery and Recovery Maintenance
John Conolly October 2015 15
DROP IN COUNSELLING• ‘Drop in’ individual and group sessions are offered
where people can self-refer and where there is no pressure from expectations of regular engagement.
• Every attention is given to fostering a relationship of trust where people are offered a safe, unpressurized, non judgmental, supportive space– where they can begin to make sense of their experiences
and reactions, – And delineate some possible alternatives. – They are also encouraged to move on to regular appointment
based counselling.
John Conolly October 2015 16
Regular Counselling Appointments • Here, following NICE PD guidelines, no less than
twenty sessions are offered• people are supported to think about how best to start
addressing their trauma, addiction, accommodation, employment, disability issues.
• There might also be a focus on transition management• new crises may be re-experienced in the process and
interventions may well be increased as appropriate. • Great attention will be given to ending the program so
as to avoid a repetition of previous traumatic losses.
17
Recovery and Recovery Maintenance
• Given the early age at which trauma was 1st experienced, homeless people when resettled are left vulnerable to re-experiencing psychological difficulties in the face of new life transitions and challenges, and are at risk of losing the gains made.
• It is therefore vital that some provision be made for them to have ongoing support as and when needed. Therefore the service is considering offering the following:
John Conolly October 2015
18
Recovery and Recovery Maintenance
RECOVERY A Schema Therapy Workshop – where people are taught to recognize their negative perceptions and reactions and to manage them better.
A Life History Workshop – where people are supported to develop the narrative of their past, present and future lives.
Women Only Interventions - It is also recognized that women need women only Intervention and support groups in order to feel safe, heard and validated.
RECOVERY MAINTENANCE
A Leavers Group – where ex service users can share their ongoing difficulties as well as solutions with each other
An Expert By Experience/Peer Mentor Forum - Where those more advanced in their recovery journey, e.g. Peer Mentors, ‘Experts By Experience’, may in confidence share the challenges and opportunities of holding such positions.
John Conolly October 2015
John Conolly October 2015 19
ReferencesAlwin, N., 2006, ‘ The Causes of Personality Disorder’, Chptr 3, pps 41-58, in ‘ Personality Disorder and Community Mental Health Teams – A Practitioner’s GuideSampson, McCubbin and Tyrer, John Wiley & Sons, Ltd.
Bleiberg, Rossouw and Fonagy, 2012, ‘ Adolescent Breakdown and Emerging Borderline Personality Disorder’, Chptr 18, pps 463-509, in ‘ Handbook of Mentalizing In Mental Health Practice’, (Eds) Bateman and Fonagy, American Psychiatric Publishing, Inc. Washington DC, London England.
Coid, J., Yang, M., Tyrer., et al, 2006, ‘Prevalence and correlates of personality disorder in Great Britain’, British Journal of Psychiatry, 188, 423-431.
20
References 2.Department of Health, 2009, ‘Recognising complexity – Commissioning guidance for personality disorder services’,
Livesley, J.W., 2003, ‘Practical Management of Personality Disorder’, The Guildford Press, New York.
Maguire, N. J. et al., 2009, ’Homelessness and complex trauma: a review of the literature’, Southampton, UK, University of Southampton
Ministry of Justice., 2007, ‘Predicting and Understanding Risk of re-offending: prisoner Cohort Study’,, Ministry of Justice, London
John Conolly October 2015
John Conolly October 2015 21
References 3.National Institute for Mental Health in England, 2003,‘ Personality disorder no longer a diagnosis of exclusion’,
Prochaska, Norcross and Diclemente, 2006, ‘ Changing for Good’, HarperCollins, New York.
Young, Klosko and Weishaar, 2003, ‘Schema Therapy’, Guildford Press, New York.