1. New Beginnings with START: Experiences of piloting a manualised intervention for carers in a secondary care mental health service
Dr Rachel Wenman
Bedfordshire and Luton Mental Health and Wellbeing Service. Provided by ELFT.

2. STrAtegies for RelaTives (START)
Coping with caring intervention
Developed by Livingston et al (2013)
8 sessions using a leaflet/manual
Individual sessions (not group)
Based on Cognitive Behavioural approach

3. www. ucl.ac.uk/psychiatry/start

6. Evidence base RCT 2:1 intervention vs Treatment as usual 260 carers
8 sessions with graduate trained by research team.
Outcome
end of therapy lower HADS, better QoL
2 years – 7x less likely to be depressed
Cost effectiveness

7. Key issues/Questions How does START fit? Who can deliver START?
What resources do we have?
Who can deliver START?
Tailoring training to needs
Who is eligible? When?
How to measure outcome?
Ethical issues
Motivating the system

8. IAPT – primary care talking therapy
Service context
4 CMHTS – severe and enduring mental health problems. Complex needs, difficulties engaging with services
4 Memory Clinics – MDT diagnostic process + signposting and support
Prescription clinic
3rd sector: carer support, information, cognitive stimulation groups, activity groups (music, singing, walking football etc)
CST programme
IAPT – primary care talking therapy

9. IAPT – primary care talking therapy
Where to offer START?
4 CMHTS
Memory Clinics
IAPT – primary care talking therapy
Prescription clinic

10. Who can deliver START? Low intensity therapy
Delivered by non-clinicians/therapists
Specialist training and supervision
Pre-requisites
Experience with people with dementia/PSI
Core skills – listening, person-centred, empathic
Interested

11. Training 2 day training + self directed Dementia
Understanding challenging behaviour
Stress – models and coping
**Therapeutic interactions differences and boundaries,
Delivering interventions – role plays, practice, discussion
Ethical and risk issues

12. Training 5 CMHT staff (OT, nursing, CSWs) 3 Assistant psychologists
3 Trainee Clinical Psychologists
more self-directed learning

13. Treatment Preventative Criteria To All Who and When? Pilot
1-2 referrals per psychology staff
CMHT – offer within existing caseload

14. Measuring outcomes PHQ-9, GAD-7 for anxiety and depression
Relative stress scale
Self ratings:
Understanding of dementia
Level of stress
Ability to cope with behaviour
Satisfaction with coping strategies
Ending – feedback open questions and ratings:
How helpful (what was and wasn’t helpful, improvements), how well it fits with CMHT input, timing of intervention being offered.

15. Ethical issues
Case and activity recording
Confidentiality
Risk issues

16. Status 1st wave of training
Pilot of psychologists and 1 CMHT delivering intervention
13 referrals and 9 appropriate
1 non-psychologist begun intervention
Unintended outcomes

17. Moving Forward Review Pilot Staff support Training 3rd Sector partner
Drivers

18. Key issues/Questions How does START fit? Who can deliver START?
What resources do we have?
Who can deliver START?
Tailoring training
Who is eligible? When?
How to measure outcome?
Ethical issues
Motivating the system

19. References
Greene et al (1982) Measuring Behavioural Disturbance of Elderly Demented Patients in the Community and its Effects on Relatives. Age and Ageing, 11:
Knapp et al (2013) Cost effectiveness of a manual based coping strategy programme. BMJ 347: f6342
Livingston et al (2013) Clinical Effectiveness of a manual based coping strategy programme. BMJ 347: f6276
Livingston et al (2014) Long term clinical and cost effectiveness of psychological intervention for family carers of people with dementia. The Lancet: 1:
Somerland (2014) START… Qualitative Study of participants views about the intervention. BMJ; 4e
Ulstein et al (2007) The Relative Stress Scale, a useful instrument to identify various aspects of carer burden in dementia. International Journal of Geriatric Psychiatry. 22: 61-67