Consultation team longevity: Challenges and issues Zoe Otter, Forensic Psychologist

Outline PiC Midlands DBT Timeline The DBT Team – PiC Midlands Current consultation meeting arrangements Consultation agenda Consultation team agreements Consultation challenges Individual (team) impact Positives of our consultation team Future directions

Partnerships in Care - Midlands Calverton Hill 2 Medium Secure wards for women with high levels of challenging behaviours and complex forensic histories 32 beds 1 Medium Secure female Learning Disability ward - 16 beds 1 Medium Secure male Learning Disability ward - 16 beds Annesley House Low Secure and Inpatient Rehabilitation including specialised High Dependency Unit Women only with primary condition of mental illness and/or personality disorder 28 beds Annesley House Low Secure Calverton Hill Medium Secure

DBT timeline 2005 Began to introduce DBT to the organisation (Medium Secure) 2 trained therapists (Psychologists) 1 left & 4 attended DBT training (2 Psychologists, 1 Social Worker, 1 Mental Health Nurse) 2008 DBT programme well established at both Medium and Low Secure sites 3 trained therapists 4 attended DBT training (3 Psychologists, 1 Social Worker – Social Worker did not complete training, completed by psychologist) 2009 7 trained therapists (Psychologists) 2013/14 3 more nurses and four psychologists trained 2015/16 3 more staff trained – 1 psychologist, 2 nurses

Partnerships in Care Midlands Dialectical Behaviour Therapy Team

Forensic Psychologist John Greenacre Staff Nurse Dr Nicola Sutton LEAD Zoe Otter Forensic Psychologist John Greenacre Staff Nurse Dr Nicola Sutton Forensic Psychologist Nathalie McPherson Staff Nurse Jess Townes Acting Charge Nurse Kristy Summers Trainee Forensic Psychologist Sarah Ashworth Trainee Forensic Psychologist Donna Harrison Trainee Forensic Psychologist Dr Natalie Brotherton Principle Clinical Psychologist Emily Goodrick Charge Nurse

Consultation meeting arrangements Weekly meetings 1 hour 12:30-13:30 Business meeting every 5th week 2 weeks: video conference between Annesley House and Calverton Hill 2 weeks: separate consultation meeting at both sites (aim: to encourage use of role-play/practise)

Consultation team meeting: Agenda Mindfulness Apologies and announcements Reflections on the last meeting Behaviour analysis and repair Consultation questions Skills group, referrals Skills training AOB

Consultation team agreements Dialectical agreement (no absolute truth, search for a synthesis by asking ‘what is being left out?) Consultation-to-the-patient agreement (to improve our own skills as a therapist, to not treat each other as fragile) Consistency agreement (accept diversity and change, we have different opinions) Observing limits agreement (observe our own limits and not judge or criticise the different limits of others) Phenomenological empathy agreement (no blaming, we are trying our best and want to improve) Fallibility agreement (we all make mistakes and must help each other to find a synthesis)

DBT Consultation Challenges Establishing consultation Training New staff/changes in team Non attendance Consultation Challenges Working in a dialectical way Cross-site and cross-service working Establishing consultation – in 2005 it was a relatively new intervention – diabolical behaviour therapy – sect! Training – increasingly supported over the years but can be complex to organise and to support staff with New staff/changes in the team – brings new dynamics and new approaches – new elephants (as well as positive opportunities for learning and renewed motivation) Working in a dialectical way – practising what you preach! Is likely to be an indicator of the degree of support that is needed within individual therapy Individual impact – an emotional rollercoaster between some strong negative feelings and some very positive feelings – also reflects individual therapy (Time) commitments – understandably difficult for nursing staff but this has also improved over time and perhaps reflects the good organisational commitment to supporting DBT Organisational commitment – currently the best it has been Cross-site and cross-service working (Annesley House and Calverton Hill & DBT and ICFG) Non-attendance – is an ongoing challenge Individual (and team) impact (Time) commitments Organisational commitment

DBT therapist – individual (and team) impact Feeling: Alone Energetic Discouraged Confident Hopeless Encouraged Depressed Supported Frustrated Competent Angry Valued Incompetent Undervalued Unrealistic demands on self These are just some of the emotional effects… DBT is also a huge time commitment, resource commitment, etc…

Consultation team: Observer tasks Judgmental/non-compassionate comment is made Consultation members are treated as fragile Dialectic goes unresolved Defensiveness arises, forgetting that we are all fallible Non-mindfulness, doing two things at once Solutions are given before the problem is assessed Consultation-to-team intervening, rather than teaching

DBT Consultation Positives (Previous) development of internal training Supportive environment Integration of new members of the team Commitment Consultation Positives Positive outcome data Flexibility Strong support provided by everyone. Email connection Multidisciplinary team Well established Organisational commitment increased Sharing practice

Further progress… Supporting each other with: Consultation to the therapist Following the consultation team agreements Ongoing organisational support of staff training and facilitation by all disciplines involved Consideration of individual and team accreditation in future Research/publication of outcome data Further conferences – sharing ideas and experiences Consultation - Primary functions: 1) to keep the therapist in the therapeutic relationship (with the patient and the team)…(by cheerleading and support of the therapist) 2) to balance the therapist 3) to provide the context for the treatment (DBT = a transactional relationship between all borderline patients and therapists involved)