The

Complex Cases
Service
Rochdale
Presents:
‘NICE start, but is it time to get
nasty?’
A synopsis of how we have implemented and audited
NICE Guidelines, and attempted to use them
10/02/2009
for the optimal benefit of our clients!
 First a case study,
about Millie: Millie has a
diagnosis of BPD and
has been in and out of
psychiatric hospitals
since the age of 14!
 Millie’s parents were harsh and
neglectful. From the outset they
were not interested in Millie. She was
just their possession; not a person in her
own right. When she was tiny, they left
her crying in hunger and distress. They
did not interact with her and would hit
her if she protested too much about her
discomfort. For Millie, this had 2 direct
consequences:
 (1). Millie learned that the world was hostile and
unpredictable and that people are cruel and not
to be trusted; this left her feeling continually
anxious and fearful.

(2). The development of Millie’s brain was compromised,

because poor attachment between an infant and its
primary caregivers, leads to poor attachment between the
brain’s emotion production centre and its emotion
regulation and problem-solving centres. In practice, this
meant that Millie experienced extreme and rapidly
changing emotions, without being able to exercise control
over them or problem-solve her way out of the crises that
triggered the emotions.
 By the time Millie went to school, she felt
unlovable and struggled to have normal
relationships. Her rapidly changing and
extreme moods made her unpopular with everyone, as
she would either lash out at other children or cut herself
off and refuse to play with them. She wanted to fit in, but
had no idea how to make others like her. She ended up
being bullied by her peers. The teachers were highly
critical, accusing Millie of having temper-tantrums. Her
parents continued to be cruel and abusive towards her
and, by the time she reached her mid-teens, Millie had
already tried to take her own life three times. Just being
alive was so emotionally painful, she used alcohol,
drugs, cutting and overdosing to try and block out the
hurt.
 • Millie isn’t a real person
• But she may just as well be
• Because she represents so many
of the women & men I’ve worked
with over the years
• Not only has she been neglected
and rejected by her family, peers
and teachers, Mental Health
Services have continued to treat
her in this manner…….
Who would
choose to
have a life
like
Millie’s?
Yet historically, the
attitude of mental
health services has
been to blame
people like Millie for
their own situation!
 Millie, like so many others with
‘Personality Disorder’, has been a victim of:

Diagnosticism!
“They’re just messing
about aren’t they”
“It’s not like schizophrenia is it;
“They’re not really ill People can’t help having that!
are they”

“If there’s two people on the ward
saying they’re going to kill
themselves, who are you going to go
to, the person who’s really ill, or the
one who’s just p-----g about?”
“They should pull themselves
together and stop wasting
precious time and resources”
 Racism
Sexism
Ageism
‘Diagnosticism’

They’re about:
• injustice
• unfairness
• intolerance
• discrimination
• misuse of power
 …and about excluding
people from their right
to a fair share of
society’s resources!
And until 6 years ago ‘Diagnosticism’
was used to deny people with PD the
treatment they needed and deserved
 But research during the 1990’s
and early 2000’s, sewed the
seeds for a change in attitude;
evidence began to accumulate
about the biological,
psychological and social causes
of personality disorder and about
its treatability. People with PD
who wanted help, could no
longer be ignored!
And came up
with some
bright new
ideas
 Let’s make
Personality Disorder:
No longer a diagnosis
of exclusion
2003
‘NICE’ People
 With a set of
Guidelines for BPD

Which, together with

the NIMHE document,
created the impetus
for NHS Trusts to set
up dedicated P D
Teams

To address the following key priorities   

 Provision of Assessment &
longer-term, treatment for the
evidence- most complex &
based high risk clients
therapies
Consultation &
advice to other
teams
Oversee the
implementation of NICE
NICE guidance Help in the
Guidelines management
for BPD of individual
cases
Develop & provide
training programmes

Facilitate good
Networking with other communication &
agencies, including, forensic, information
CAMHS, Social Care sharing
 2007 - Remit to develop a specialist PD Service (with
limited resources):

Rochdale
Complex Cases
Service
Pennine Care NHS Foundation Trust
Fully operational since April 2008
 The ‘Hub’ Team
• Clinical Lead / Consultant Clinical Psychologist
• Operational Manager / Senior M H Nurse
• Clinical Psychologist
• Psychology Assistant
• Skills Therapist / M H Nurse
• A&C
 So what do
we do and
what have we
achieved?
 Client Group
Adults of working age, who are care co-ordinated
& meet the following criteria:

• ENDURING mental health / personality-based problems

• SEVERE impact on everyday functioning (relationships,
work/education, social & leisure, etc)

• COMPLEX presentation (e.g. history of neglect,

trauma/abuse, attachment disruption, etc)

• High RISK to self and/or others (violence & aggression, self

harm, suicidality, neglect, child protection issues, etc.)
 Role of Hub Team
• Comprehensive Psychosocial Assessment

• Individual Complex Formulation

• Formulation Driven Management Plan

• Evidence Based Skills interventions

• Insight Based Therapies

• Supervision, teaching/training of ‘Spoke’ Teams

• Consultation/liaison
 The Importance of
Validation
• We recognise that most of our clients
have experienced invalidation
throughout their lives, even at the hands
of mental health services
• Therefore, we want them to know from
the outset that we genuinely value and
respect them
• We try to send out this message in a
number of different ways……..
Therapy rooms are made to feel welcoming and relaxing
 We have placed maximum effort
into developing high quality
information leaflets taking advice
from service user representatives
 The same applies to our Skills-Based
Therapy handouts which have been
carefully thought through and made as
accessible and user-friendly as
possible
 • We take our time in getting to know our
clients (typically assessment = 3 sessions)
• We ensure that we explain all aspects of what’s
on offer in a clear, unambiguous manner so our
clients are empowered to make decisions
about their own treatment
• With their consent, we make sure that we track
down and review all their available mental
health, health and social care records
• All of this information is combined into a
biopsychosocial formulation, which draws
on theoretical models to form the basis for
appropriate evidence-based interventions
 Our FORMULTIONS are all UNIQUE to the
INDIVIDUAL CLIENT

Individual Genes
Biology
Neurochemistry
Neuroanatomy
+
Attachment
Social Opportunities
Environment Socio-Economic
Circumstances
Culture & Religion
Cognitive Style
Personal
Psychology Emotional Responsiveness
Learned/Conditioned
Behaviours
 We believe it is hugely
important to tailor our service
to each individual client, and to
work collaboratively with them
to try and make sense of their
journey through life, and how it
has resulted in them being
stuck in patterns of self-
defeating thoughts and
behaviours
 That’s why,
everything we do
is driven by the
formulation and
NOT a diagnostic
label
 • Working within the Care Programme
Approach (CPA), we aim to bring all other
member’s of their care team on board,
with a unified ‘Multi-Agency Management Plan’ (a
M-AMP), based on the formulation
• This approach places the client’s needs at the
heart of the intervention and is designed to
promote consistency and safe containment from
the care team
• We monitor the implementation of the M-AMP via
the CPA process as well as MDT meetings,
consultation sessions and clinical supervision of
the remainder of the care team
 Therapeutic Interventions
Skills Enhancement Programmes:
• Taught skills to replace unhelpful ‘coping’ strategies
• Tailored to the needs of each individual client
• To help them manage their distress in a safe manner
• All founded on therapies with a strong evidence base (e.g.
DBT, CBT)
Insight-Based Therapies:
• Longer term evidence-based therapies to promote more
fundamental change (at a thinking and feeling level)
• The aim is to increase self-awareness and empower the
individual to have real choice about how to live their lives
in the future
 Client and Staff Feedback
Questionnaires
Have been administered to clients and MDT staff
members with the following results:
Clients: Staff:
• Information – 12/15
• Environment – 15/20 • Involvement 4/5
• Clinicians – 25/30 • Formulation Feedback – 17/30
• Information – 12/15 • M-AMPs – 17/20
• Therapy Handouts – 18/20 • Consultation & Supervision – 9/10
• Other Comments: • Effectiveness of therapy – 8/10
“Very helpful, but hard” • Other Comments:
“Too much noise in the “Provides a safe, accountable framework
corridor” for managing risk in the community”
“A brew would help” “Needs more clinicians”
 Training Events
• By helping other professionals to understand the
biological, psychological and social origins of personality
and personality disorder, and by supporting them in their
involvement with our joint clients, we aim to increase their
interest and enthusiasm for working with people with
personality-related mental health difficulties
• We want staff to feel greater confidence and
competence to work with clients with complex
presentations
• Above all, we aim to increase compassion and empathy
for our clients, so that they feel valued and listened to
Training Outcomes
We are in for the long-haul,
interested in providing
quality services to our
clients, but this high
intensity approach requires
justification if we are to
survive in the current
economic climate!
 So we are
M H admissions auditing level of service
Contacts with Care use before,
during and after involvement
Co-ordinator with our team
In-patient days Visits to A & E

Planned psychiatry Number / type of medical

appointments admissions
Unplanned Psychiatry Police contacts
appointments
Number of contacts with CRHT Incident reports
 Clinical Outcomes (Client **)
TARGET
BEHAVIOURS
To reduce:
• Staying in bed
• Drinking binges
• Brief, intense
relationships
• Episodes of self-
harm
• Social Isolation
• Angry, aggressive
outbursts
**’s CORE:

Standardised
measures like
the CORE are
proving less
useful with
this client
group.
 Inevitably, it will take time
for us to demonstrate the
full economic benefits of this
‘invest to save’ approach;
but if we are given the
opportunity to survive long
enough, you can be sure
that we will do so!
 Why do I say that?
• Because, in spite of all the evidence
suggesting that personality-disorders
are deserving and treatable
• And a growing body of evidence
demonstrating that treating PD leads
to financial savings across all public
sector services
• We are still the ‘poor relation’ of M H
services!

• In Fact, when it comes to allocation of

resources we’re as poor as church mice!
Now I can set up a
Complex Cases
Service!
We’re a dynamic bunch of people
and we keep battling on!
 With the help of NIMHE & DoH we’ve made a
promising start in breaking down the barriers to
P D exclusion, but is playing it NICE going to be
enough?

BUT
• As long as the gains aren’t immediately observable
• And scarce resources must be competed for
• And it’s all about guidelines rather than targets
Will Trusts support this development?
And will Commissioners invest?
 OK guys; it’s
Complex time to get
Cases tough!
Team
 TNT
Trinitrotoluene ?

Trusts Need Teams

and maybe…… Trusts Need Targets to encourage them to
keep the P D agenda at the forefront of their minds!
 julie.machan@nhs.net

Dr Julie Machan
Consultant Clinical Psychologist
Complex Cases Service
Birch Hill Hospital
Rochdale
OL12 9QB