Dr Keith Bowden Programme Director - Psychology (Learning Disabilities) NHS Education for Scotland 6 th September 2017 keith.bowden@nes.scot.nhs.uk
Context NES (Psychology) providing training in a range of psychological therapies, but nothing specifically for people with a learning disability NES (NMAHP) has commissioned and provided training in PBS and on psychological care (with collaboration from psychologists) Development of (initially) a one-year (part-time) post to develop a training strategy for psychological interventions in learning disability services joint appointment with Dr Sharon Horne-Jenkins NES (Psychology) has two major areas of responsibility: Training of psychologists for NHS Scotland Upskilling the existing multi-professional workforce in psychological care
Scope Timescale for initial project led to decision to focus on Adults with learning disabilities Health professionals However, Should inform child and adolescent services Should be applicable in social care settings
Need for service improvement in psychological interventions for people with a learning disability Failure to recognise mental health needs Risk factors for the development of mental health difficulties Biological factors Psychological factors Social factors Prevalence of mental health problems Prevalence of challenging behaviour Challenge to local services in meeting the needs of individuals Hidden population who may, or may not, be accessing generic services? Limited evidence base specifically relating to people with a learning disability
Initial workplan Liaison with groups of specialist LD health professionals Psychology, nursing, psychiatry, OT, Arts Therapies, Dietetics, Physio, SALT Liaison with colleagues in NES Nursing, psychology, implementation sicence Liaison with Scottish Government Literature Review Analysis of relevant documentation Surveys of health professionals Two conferences/consultations psychology & multi-disciplinary
Influential documents
The Matrix There should be multi-disciplinary delivery of psychological interventions and therapies at a variety of levels in both mental and physical health settings. Training and accreditation in therapeutic approaches should be competence-based. IMPLEMENTATION WELL-FUNCTIONING PSYCHOLOGICAL THERAPIES SERVICES SHOULD OPERATE WITHIN THE FRAMEWORK OF A CLEARLY ARTICULATED AND WELL GOVERNED MATCHED/STEPPED CARE SYSTEM.
The Matrix Tiers of Care Although there will be some variation among services, which should be configured to best meet local needs, the well-functioning service will have levels of service delivery corresponding to the following: HIGH VOLUME INTERVENTIONS aimed at those experiencing stress or other forms of psychological distress, and may include provision of information, psycho-education, prescribed exercise, counselling or the use of psychological principles within another healthcare context.
The Matrix Tiers of Care LOW INTENSITY EVIDENCE-BASED TREATMENTS these are most commonly accessed through GPs, and would cover doing well advisors/self-help coaching, problem solving therapy, guided self-help, behavioural activation, some computerised CBT packages, structured anxiety management groups etc. The interventions are aimed at mild/moderate mental health problems with little complexity, are time-limited and normally last between 2-6 sessions.
The Matrix Tiers of Care HIGH INTENSITY INTERVENTIONS PSYCHOLOGICAL THERAPY these are normally based in secondary care, and comprise traditional, standardised psychological therapies (CBT, IPT, etc), delivered to protocol. The therapies are aimed at moderate/severe common mental health problems with significant complexity and effect on functioning, and normally last between 6 and 16 sessions.
The Matrix Tiers of Care SPECIALIST PSYCHOLOGICAL THERAPIES these are most commonly accessed through secondary care and specialist services. Essentially they are standardised high intensity psychological therapies developed and modified for specific patient groups. They are delivered at the same level as High Intensity therapies, but in a specialist context. Specialist therapies are aimed at moderate/severe mental health problems with significant complexity and effect on functioning e.g. substance misuse, eating disorders, bi-polar disorder and normally last between 10 and 20 sessions.
The Matrix Tiers of Care HIGHLY SPECIALIST PSYCHOLOGICAL THERAPIES AND INTERVENTIONS HIGHLY SPECIALIST, INDIVIDUALLY TAILORED INTERVENTIONS BASED ON CASE FORMULATIONS DRAWN FROM A RANGE OF PSYCHOLOGICAL MODELS - these are normally accessed through secondary, tertiary and specialist services. Aimed at service users with highly complex and/or enduring problems, and usually lasting 16 sessions and above.
Survey of health staff Most frequent psychological referrals were for common emotional issues, such as anxiety, depression and anger, challenging behaviour and trauma. Interventions with a behavioural origin or mechanism (i.e. Applied Behaviour Analysis or Positive Behavioural Support) continue to be the most commonly delivered psychological intervention across the LD workforce Cognitive Behavioural Therapy (CBT) and to a lesser extent Systemic Psychotherapy were commonly delivered by psychologists on a regular basis. A small number of other health professionals reported providing these.
Survey of health staff Other models, with an emerging evidence base such as mindfulness and acceptance based approaches appear to be available to varying degrees with a range of professions involved. A very small number of staff reported using other psychological interventions such as Cognitive Analytic Therapy (CAT), Dialectical Behaviour Therapy (DBT) and Solution Focused Brief Therapy. Psychodynamic psychotherapy was mainly provided by arts therapists.
Survey of health staff A number of challenges were highlighted. In particular: Variable adoption of the matched care model in learning disability services, including problems with appropriate leadership protected time to deliver interventions skill mix access to and capacity for psychological supervision. External and internal (NHS) expectations of the availability of psychological interventions for people with a LD varied Concern that a rigid matched care approach could under-value the eclectic psychological and multi-agency approach often adopted when promoting and supporting the emotional and behavioural needs of people with a LD.
Workplan To develop a framework similar to those for dementia and ASD Design explored at conferences/consultation events Critical friends recruited for consultation on details To develop a training plan alongside this to assist identification of What should be available locally What should be developed nationally Development and commissioning of training
Framework initial consultation with psychologists Originally planned structure showing distinction between: Psychological interventions for challenging behaviour and Psychological therapy in relation to meeting emotional and mental health needs but,
Psychological therapies and people who have intellectual disabilities (2016) There are a number of theories regarding the relationship between mental health and challenging behaviour. These include: that challenging behaviour may represent an atypical presentation of mental health difficulties; that challenging behaviour may be a secondary feature of mental health difficulties that mental health difficulties may act as establishing operations for operant-maintained challenging behaviour that challenging behaviour and mental health difficulties co-occur due to an underlying biological pathway; and that the presence of challenging behaviour increases risk factors for the development of mental health difficulties.
Development of Framework Integrated PBS and other psychological interventions and therapies Built explicitly on Equal Health framework Strongly influenced by PBS Coalition (now Academy) document The Matrix Psychological therapies and people who have intellectual disabilities (BPS & RCPsych) Reviewed by critical friends
What is the framework? It s a functional structure
in progress
Design of Framework - levels Informed Practice (8 indicators) Skilled Practice (15 indicators) Enhanced Practice (22 indicators) Specialist Practice (24) indicators)
Informed practice level The Informed Practice Level on psychological interventions for practitioners working with adults with learning disabilities outlines the baseline knowledge and skills required by all practitioners working with adults with learning disabilities and their families and carers. For example, staff working in primary care, secondary care, generic social work, education and community health and social care settings who work with adults with learning disabilities on an occasional basis.
Skilled Practice level The Skilled Practice Level on psychological interventions for practitioners working with adults with learning disabilities outlines the knowledge and skills required by practitioners who have direct and/or substantial contact with adults with learning disabilities and their families and carers. For example, staff working in learning disability services (including residential and day services), staff in other health and social care services who regularly come in contact with adults with learning disabilities (which will include acute services with high usage by people with learning disabilities). Staff at this level will most often apply/support psychological interventions designed by others.
Enhanced practice level The Enhanced Practice Level on psychological interventions for practitioners working with adults with learning disabilities outlines the knowledge and skills required by practitioners who have more regular and intense contact with adults with learning disabilities and their families and carers, provide specific interventions, and/or direct/manage care and services.
Enhanced practice level For example, appropriately qualified professional staff and first level line-managers in services that specialise in working with adults with learning disabilities who present with significant challenging behaviour and/or specific emotional or mental health needs. These are staff who will be taking an active role in the development of treatment design and implementation (in the absence of complex presentations). Some will be in a position where they can lead on the creation of environments and opportunities that provide a recovery focus for adults with learning disabilities and associated mental health needs or challenging behaviour. Line managers will provide guidance and professional supervision to skilled practice staff as appropriate to role.
Specialist Practice Level The Specialist Practice Level on psychological interventions for practitioners working with adults with learning disabilities outlines the knowledge and skills required by practitioners who, by virtue of their role and practice setting, play a specialist role in provision of psychological interventions and therapy with adults with learning disabilities and their families and carers. It is recognised that some levels of intervention at this level may be considered to be Highly Specialist, due to the level of complexity and risk involved.
Specialist Practice Level challenging behaviour For example, for challenging behaviour, this will include staff who have received specialist training in the development of PBS and associated interventions, (i.e. applied psychologists or other professionals with appropriate additional qualifications)...
Specialist Practice Level challenging behaviour This level will also include appropriately qualified professional leads/ senior managers of specialist challenging behaviour services as there are two elements operating at this level: 1. Staff who are responsible for assessment, formulation, development and monitoring of individualised Behaviour Support Plans for adults with learning disabilities who present with complex challenging behaviours. 2. Staff who are responsible for service design and ensuring that environments and lifestyle opportunities are managed appropriately to reduce the likelihood of challenging behaviour and that staff are managed to apply Behaviour Support Plans effectively...
Specialist Practice Level challenging behaviour Some staff will fulfil both of these roles. Staff in these roles should also be responsible for supervision commensurate with the role. Provision of highly specialist psychological intervention for challenging behaviour for people with very complex needs or whose behaviour is very high-risk is most likely to be provided by applied psychologists who specialise in working with people with learning disability.
Specialist Practice Level psychological interventions For other psychological interventions, this will include staff who have received training in the provision of specialist psychological therapies (i.e. applied psychologists, arts therapists or other professionals with appropriate specialist qualifications). Provision of highly specialist psychological therapy for people with very complex needs, or whose associated behaviour is very high-risk, is most likely to be provided by applied psychologists who specialise in working with people with learning disability
The Framework can potentially be used in a number of ways, including by: individual practitioners, by themselves, (in conjunction with the appropriate generic and/or professional Frameworks and guidance) to help them understand the values base, knowledge and skills they require to deliver optimal assessment, care, support and treatment with adults with learning disabilities to support psychological wellbeing
The Framework can potentially be used in a number of ways, including by: individual practitioners, alongside their managers/supervisors, to identify their strengths and any gaps in knowledge and skills in relation to the role they are performing, which will allow both to identify and take action to address any development needs to deliver the aspirations set out in this Framework
The Framework can potentially be used in a number of ways, including by: organisations, to ensure staff have the necessary knowledge and skills to support psychological wellbeing in adults with learning disabilities and to plan staff development activities to reflect the aspirations set out in the Framework
The Framework can potentially be used in a number of ways, including by: organisations, to shape the design and delivery of future-focused vocational and professional undergraduate and postgraduate education and training
The Framework can potentially be used in a number of ways, including by: adults with learning disabilities, their families and carers as an information resource to ensure they are aware of, and can exercise their rights in relation to achieving appropriate levels of assessment, care, support and treatment to promote psychological wellbeing
Areas covered in Framework Assessment Communication Relationships Care Plans Preventative strategies Reactive strategies Behaviour Support Plans Therapeutic Strategies Monitoring & Evaluation Supervision & Training Referring on Competencies
Design of Framework - levels Each indicator specifies Outcome What practitioners know (knowledge) What practitioners are able to do (capability/skill/ability) Particularly relevant elements from Equal Health are crossreferenced in the Framework in italics
Design of Framework Each level defines the knowledge, skills and behaviours specific to the practitioner s role in relation to supporting psychological wellbeing for people with learning disabilities The skills outlined at each level are constructed in an incremental way where each levels builds on the previous one: for example, practitioners working at Skilled Practice Level would also possess the knowledge and skills described at Informed Practice Level and practitioners working at Specialist Practice Level would possess the knowledge and skills described at all preceding levels.
Examples from Framework
Appendices 1. Critical readers 2. Structure of PBS Coalition PBS Competencies Framework Headings 3. Psychological interventions for people with learning disabilities in The Matrix 4. Examples of adaptations that can make therapy more accessible from IAPT Learning disabilities positive practice guide Thinking about me
Next steps - you? Consider framework in relation to own role in relation to promoting psychological wellbeing What level are you working at? Identify development needs and opportunities Consider framework in relation to own service Identify development needs and opportunities Consider framework in relation to other services you work with How can you assist their development, or learn from them?
Next steps - us? For further discussion today but likely to lead to Further development of training plan in collaboration with SG (see Q. 10 on evaluation form) Some developments in the pipeline (hopefully) online training for BEAT-IT programme Adaptation of IAPT training programme for therapists in Scotland NES Trauma courses & adaptations for adults with learning disabilities
Aspirations