Outcome Orientated-CAMHS: A whole service model for … OOCAMHSevidencepractice61.pdfeducation, social capital).! ... • MTA study: 14 month stimulants, BT, ... OO-CAMHS" Partners

Sami Timimi

Outcome Orientated-CAMHS: A whole service model for CAMHS

Dangers of Commodification •  “Branding” leads to abstraction, alienation and short

termism.

•  Mental health always in danger of approaches being ‘commodified’.

•  Need to struggle to remain reflective, curious, grounded, and transparent.

•  Difference between resistance to change and critical engagement.

•  Adoption of OO-CAMHS or similar should be adapted to each clinician and each team.

Which has the largest impact on outcomes?

A.  Extra-therapeutic factors (such as Socio-economic status, level of education, social capital).

B.  Matching treatment to diagnosis.

C. Therapeutic alliance.

Do any of you use outcome measures to inform in an on-going

way treatment decisions?

Do you think feedback on progress effects outcomes?

A. Yes.

B.  No

Which model?

•  Since the 60’s, the # of models has grown from 60 to over 400, multiplying like…

•  Each claims superiority in conceptualization and outcome

•  The result is a fragmentation along theoretical and disciplinary lines

•  Now over 100 so called evidence based treatments-effectiveness not increased in 40 years, and…

Evaluations of Treatment Models���

•  With few exceptions, partisan studies originally designed to prove the unique effects of a given model have found no differences -nor has recent meta-analyses.

•  Termed, the “Dodo Verdict”

•  “Everybody has won and all must have prizes.”

Meta-Analytic Research

•  Client/ extra-therapeutic factors biggest effect

•  54% of treatment effects due to alliance factors

•  8% of treatment effects due to model and technique

The dodo wars ESTs v CFs

•  Little disagreement that overall Common Factors (CFs) convincingly defeats Evidence Supported Treatments (EST)

•  Continuing debate about specific ‘problems’ e.g. Trauma, panic.

•  Debate about client characteristics e.g. Do we need to be more selective about psychodynamic therapies?

•  Onion v garlic problem. Who wants change? E.g. involving parents in working with childhood behaviour problems/ eating disorders.

•  Many treatments (e.g. NLP, gestalt) have not been subject to proper outcome research, should we trust them?

Dodo bird verdict holds for children

•  Meta-analysis of treatments for childhood MH problems finds meagre differences (.2 ES) between approaches.

•  Behavioural approaches in direct comparison to other bona-fide child treatments offer no advantage.

•  There is little differential efficacy between approaches to marriage and family therapy.

•  Aug 04 “Depressed Adolescents Respond Best to Combination Treatment” TADS. Compared Prozac, Placebo, CBT, CBT+Prozac. Lack of advantage of placebo, 6v2 suicide attempts. Follow up 6 months – group differences disappear but increase risks with medication.

•  MTA study: 14 month stimulants, BT, BT+stimulants, comm care. 1999 “treatment with stimulants should be first line for ADHD”. Differences disappear by 3 years, but increase risks with medication.

Therapy for children and families!•  Better outcome found when parents/carers included,

particularly for behavioural problems.

•  Therapeutic alliance with parents AND children additive. Maybe more important in behavioural disorders.

•  Group therapy for young people with behaviour problems can make it worse.

•  Extra-therapeutic factors have largest impact on outcome.

•  Poverty, parental mental health problems/criminality, single parent status, callous/unemotional child all predict poor response to parenting programmes.

So that’s what the research says - so what?

OO-CAMHS"

Partners for Change Outcome Management Systems (PCOMS)

•  Michael Lambert first used client feedback systems in late 1990s. Using the Outcome Questionnaire 45.2, Lambert has conducted five RCTs and all five demonstrated significant gains for feedback groups over treatment as usual (TAU) particularly for clients at-risk for a negative outcome.

•  The development of PCOMS included research, and publications in peer reviewed journals to establish the psychometric validation of its instruments. The ORS and SRS scores exhibit good internal consistency and test-retest reliability despite the ultra-brief nature (four items) of these measures. PCOMS has been shown in a number of randomized clinical trials to significantly improve engagement and effectiveness in real clinical settings (community mental health, marital counselling).

•  Community Health and Counselling Services provides community-based home health and mental health services to adults and children in Maine (over 750 clinical staff): Reduced the number of patients seen for more than one year from 655 (pre-PCOMS) to 321 (post-PCOMS). Reduced the number patients seen more than two years from 227 (pre-PCOMS) to 94 (post-PCOMS). Reduced number of ‘No Shows’ by 30%.

•  Southwest Behavioral Health Services provides comprehensive behavioural health services in Arizona (over 400 clinical staff): Decrease in the average length of an episode of care in children’s’ services from 315 days to 188. Adult services length of stay decreased from an average 322 days to 158. No shows decreased by 47%.

•  Center for Family Service of Palm Beach County, Florida provides counselling, early child education and homeless services (over 100 clinical staff): Reduced ‘drop outs’ by 50% and ‘no shows’ by 25%. Using 40% fewer sessions to achieve program goals. Use of fewer resources without sacrificing client satisfaction. Decreased by 80% the number of long term therapy cases where no benefit was being achieved. Decreased the number and frequency of client grievances and complaints to almost zero.

OO-CAMHS"

What else is out there? •  John Weisz: “the very real-world factors that experimentalists might view as a nuisance (e.g., child comorbidity, parent pathology,

life stresses that produce no-shows and dropouts, therapists with heavy caseloads) and thus attempt to avoid (via exclusion criteria) or control, are in fact, precisely what we need to understand and address to make psychosocial treatment protocols work in real clinical practice”

•  Len Bickman: Fort Bragg and Stark County studies “in both studies the amount of treatment did not affect outcomes. Supported by other reviews of community-based treatment, the evaluators concluded that there was no evidence that the treatments as provided in the real world were effective for children and adolescents.”

•  Peter Fonagy: “UK bottom of the league table for most indicators of childhood emotional well-being in developed countries, yet top spender per head of population on CAMH services”

•  Bury IAPT: Using SDQ and CORE-OM session by session.

•  Hertfordshire: Using SDQ and 3 goals session by session.

OO-CAMHS"

OO-CAMHS: A whole service model for CAMHS Listening to patients and optimising outcomes

OO-CAMHS"

A whole service model for a culture change

•  CONSULTATION: Extra-therapeutic factors: Professionals meetings to avoid duplication and address external factors before starting therapy. Involve family in reviewing social circumstances.

•  OUTCOME: Monitor outcome session-by-session to alert early to poor response. If no change by session 5, review with patient and MDT.

•  RELATIONSHIP: Monitor the alliance session-by-session.

•  ETHICS OF CARE: Whole team ethos. Like patients, clinicians need to feel listened to, respected and supported. Helps improve each clinician’s therapeutic ‘potency’.

New Paradigms Move  away  from  

• A  focus  on  matching  a  treatment  plan  to  a  diagnosis.  

• Focusing  on  what  is  wrong.  Suffering  must  be  validated,  but  an  emphasis  on  dysfunction  can  distance  from  resources  and  resilience  factors.  

• Thinking  in  terms  of  ‘pathology’.  Instead  use    the  potentially  less  stigmatising  ‘problems’.  

• Blaming  and  berating  people  for  the  problem.  Self-­‐blame  and  self-­‐loathing  are  unlikely  to  lead  to  positive  action.  

• Acting  the  ‘expert’.  Patients  are  more  likely  to  maintain  changes  they  experience  as  being  down  to  their  doing  something  to  change.  

• Creating  patient  dependency  on  services.  Help  patients  Cind  resources  in  themselves  and  their  communities.  Recovery  is  a  journey  rather  than  ‘treatment’.  

• Paperwork  and  bureaucracy  that  has  no  evidence  base  that  it  improves  patient  outcomes  or  safety.  

.  

New Paradigms Move  toward  

• Recognising  that  our  treatments  are  not  as  important  as  extra-­‐therapeutic  factors.    Understand  the  real  life  context  that  people  live  in.  

• Fostering  on-­‐going  partnerships  with  patients.  Our  most  important  task  in  treatment  is  to  learn  about  each  person’s  unique  belief  system  and  treat  it  with  respect,  paying  particular  attention  to  their  cultural  models    

• Believing  that  everyone  is  capable  positive  change.  

• Allowing  patients  to  make  choices  and  to  be  responsible  for  those  choices.  

• Structuring  treatment  around  patients’  goals  and  expectations.  

• Believing  that  patients  know  what’s  best  for  their  own  lives  and  have  the  motivation  and  capacity  to  reach  their  goals.  

• Understanding  the  complexity  (and  messiness)  of  mental  health  work.    

OO-CAMHS"

Consultation •  Rationale: 40-85% of variance of outcome accounted for by extra-therapeutic factors such as social support, parental mental

health, socioeconomic status and motivation. This should make us take seriously the de-centring of our (and our treatments) importance to the process of change.

•  Before embarking on treatment think about the external factors/system around the child.

•  No more than one agency working on any one problem at any one time.

•  Who already has an attachment or important relationship with the young person particularly when that person already has other agencies involved in their care.

•  Who has the motivation to change?

•  Establish whether there is a stable predictable set of circumstances before embarking on treatment.

•  Families in crisis: avoid over-intervention.

OO-CAMHS"

Outcomes •  Rationale: Session by session monitoring of outcomes. Regular feedback to the patient on their progress can by itself improve

outcomes. If the outcome is showing no signs of improvement after 3-6 sessions, there is a high risk of a poor outcome. Change as a result of an intervention usually happens early in treatment. Matching the treatment model to a diagnostic category has a clinically insignificant impact on outcome.

•  Patient Related Outcome Measures - PROMs. The measure should be simple and feasible otherwise it won’t engage clinicians.

•  Keep the service focussed more on providing treatment to improve outcomes (rather than assessments).

•  If the young person or their parents rate above the cut off for clinically significant impairment at first session, discuss.

•  Use the PROM actively to help shape the intervention.

•  Keep a record of the outcome score session by session and plot a graph that is discussed at the beginning of each session.

•  If no improvement has occurred after 5 sessions discuss with the young person and/or their parent/carer and/or the Multidisciplinary team.

•  Maintenance of change after therapy is associated with patients ascribing change to something they did.

•  Once the young person and/or their parent/carer are scoring above the cut-off for clinical significance for 2 sessions discuss discharge.

OO-CAMHS"

Relationship

•  Rationale: Alliance as rated by the patient is by far the strongest factor, from those within treatment, associated with improved outcomes.

•  Measure the alliance at the end of each session. Make sure the measure is simple and feasible otherwise it will not engage clinicians.

•  From the first session create a culture of strong interest in patient feedback.

•  Building strong alliances is important particularly early in treatment.

•  Look for any minor variations on alliance feedback.

•  Address and discuss alliance issues before the young person and/or their parent/carer leave every session.

OO-CAMHS"

Ethics of care

•  Rationale: Team effects are often found in outcome studies. Using the database associated with the PROM, means there is clinician by clinician outcome data available. If this is not handled sensitively it can become a source of anxiety for clinicians rather than a source of empowerment. A clinician anxious about their place in a team is more likely to perform poorly.

•  Putting patients’ strengths, abilities and choices in the centre of the therapeutic process needs clinicians who similarly feel empowered by having their strengths, abilities and therapeutic choices noticed and respected.

•  Strong team relationships makes it easier to ‘fail successfully’ as a clinician and pass the patient who is not improving to another clinician in that team.

•  Each clinician is different. Team consultants, managers and supervisors have an important role in noticing and re-enforcing each individual clinician’s strengths and helping them develop their therapeutic skills through that clinician’s choices.

•  Good therapy sees positive value, strengths, acceptance, and abilities in their patients. Good teams see positive value, strengths, acceptance and abilities in their clinicians.

Database of outcomes

OO-CAMHS"

Evidence base everything! •  Data for each patient, each clinician, each team.

•  Constant feedback helps think about practice, areas for improvement and how well we are doing too.

•  Team can publish its outcomes, helping patients understand what they can expect.

•  Any new initiative (e.g. Multi-Family group, Nurtured Heart Approach group) can be evidenced.

OO-CAMHS"

Professor Sami Timimi: Consultant Child and Adolescent Psychiatrist and Developer of OO-CAMHS

Dianne Tetley: Assistant Director of Research and Effectiveness and OO-CAMHS NHS management support.

Gill Walker: Nurse therapist and OO-CAMHS project facilitator.

Dr Amulya Nadkarni: Consultant Child and Adolescent Psychiatrist and clinical director providing support for roll out/implementation trust wide.

Thank you for listening The OO-CAMHS Team-