Combined Therapy and the Costs of Complexity

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Combined Therapy and the Costs of Complexity

• Dr C S Mizen
• Consultant Psychiatrist in Psychotherapy

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The Vision Tiers of service

• Tier 0 Self help / user network support
• Tier 1 Generally available services at primary
  care level.
• Tier 2 Community services for people with
  moderate needs
• Tier 3 Generic secondary services for people with
  complex and severe needs.
• Tier 4 Intensive and specialist treatments
  generic inpatient admissions crisis
  support/resolution
• Tier 5 Secure and forensic services
• Tier 6 Services for people with dangerous and
  severe PD.

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Survey of Psychotherapy referrals - Risk. (n123)
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Survey of Psychotherapy referrals - Service use.
(n123)
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Resources currently used in non-specialist
service provision

• Inpatient bed usage
• CMHT
• Psychiatric Day Hospital
• Psychological therapies
• CAMHS

• NIMHE 36-67
• London/Exeter 25
• 7 (research study)
• Devon figures
• 25
• 50-60
• 9

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Planned service development for a rural catchment
area

• Tier 5 Medium secure /low secure PD service in
  conjunction with forensic services
• Tier 4 Five day a week therapeutic community day
  programme with 14 places with a specialist
  supported accommodation placement alongside.
  Trust wide resource and income generator
• Tier 3 Hub and spoke model outpatient service
  available Trust wide offering a single point of
  entry PD service in each locality with three
  streams or therapy
• Group and Individual therapy
• DBT
• CAT.
• Tier 2 Develop a training for care co-ordinators
  in work with PD patients, nursing patients in
  groups.
• Tier 0 A nursed user network.

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The Costs of ComplexityThe most costly
presentations of PD.

• Physical illness presentations
• Consequences of the Physical/Mental health divide
• Social services
• Fund assessment not therapy.
• Police and the Criminal Justice System
• Forensic placements

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The new clinical hub meeting Redeploying IPP
resources locally.
Referrer
IPP Application
Trust IPP Panel
PD Hub Psychological Therapies Experts
group IPP managers
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Income generation

• From neighbouring Trusts purchasing Tier 4 and 5
  services
• From Physical Health Care services
• From Social Services
• Payment by results

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The Combined Therapy Project
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Reasons to do it

• Can be set up for patients with PD within a
  generic psychotherapy service without additional
  resources.
• An adaptation of the therapeutic community model
  optimise the therapeutic use of a general
  psychiatric service.
• Highly purchasable by many agencies.
• Strategically useful.

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The Combined Therapy Model

• Therapy
• Twice weekly therapy.
• One individual psychodynamic session weekly
• Analytic Group weekly.(with two therapists.)
• Liaison meetings
• Monthly (Approx.)
• Three year therapy programme.
• Sign up to all three parts of the model.

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Theoretical Perspectives

• Transference to the whole psychiatric/psychotherap
  eutic team.
• Opportunities for splitting and integration
• Transference to buildings, concrete aspects of
  containment.
• The significance of admission
• Containment of anxiety for staff and patients
• Maintenance of adult functioning in the face of
  the regression in therapy.
• Patients encouraged to participate in each
  others treatment and take responsibility for
  their own.

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Theoretical Perspectives Linking

• Linking function.
• Transference of non-psychotic aspect of the
  personality, symbolic functioning to the therapy
• Transference of predominantly psychotic, acting,
  concrete aspects to the psychiatric service.
• The importance of liaison meetings.
• Symbolically for the patient
• Practically - optimal use of resources to maximum
  therapeutic benefit.
• Strategically Treating severely disturbed
  patients

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Supervision

• Joint supervision of group and individual
  therapists
• Held fortnightly
• Functions
• Integration of splitting
• Linking function
• Counter transference
• A culture of honesty.
• Information sharing
• Management of risk containment of anxiety.
• Staff Group

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Liaison Meetings

• Practicalities
• Teams refer themselves as well as the patient.
• Meetings held monthly (average).
• Undertaken by consultant psychotherapist. (Nurse
  Specialist)
• Twenty minutes with professionals,
• Forty minutes with patient and professionals.
• (Oedipal issues and depressive position)
• Other agencies invited
• Housing support, Social Services, CAMHS, Liaison
  Psychiatry, Crisis Resolution, Substance Misuse,
  Eating Disorders.

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What are liaison meetings for?

• Professionals
• Good communication with care co-ordinator.
• Good communication about acting out for
  therapists.
• Integration of splitting.
• Optimising the use of the care co-ordinators
  relationship to support the therapy.
• Managing regression using the care-coordination
  role to foster/support/ develop adult
  functioning.
• Management of risk
• Patients
• Increase the sense of containment so they make
  best use of their therapy.

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Strategic importance of liaison meetings

• Working with other agencies
• Out of area teams, the RDE, Social Services and
  CAMHS, probation. This makes the service very
  Commissionable.
• Working with severely disturbed patients
• Negotiating
• Clinical Flexibilty
• Useful to colleagues
• Good relationships with teams

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Training

• Developing a culture
• Awaydays
• Leaflets
• Reviews
• Supervision
• Psychosocial nursing training
• Training of analytically oriented therapists to
  work in an interdisciplinary way.

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Outcome Negotiating position in the past year.

• Out of area commissioning
• brought money into our service.
• Demonstrated it could be done
• Shift of the Psychotherapy service to the
  Specialist Services Directorate.
• Business case supported by trust management
• To be operational within two years.
• Business case supported by cost savings and
  income generation
• PD Hub reducing 2.8M spend out of area.
• Income generating capacity from
• Out of area referrals
• Purchase from other agencies.
• Bringing patients back from out of area
  placements
• Funded an expansion of the service