The Acute Therapy Service (ATS) is an initiative that aims to support service users during a mental health crisis by providing an alternative to the existing in-patient model. The ATS is a psychologically led, structured therapy service based upon the principles of Dialectical Behaviour Therapy (DBT). We accept referrals from Crisis Teams, CMHT’s and in-patient services. Referrals from the community are accepted if it is to avert a hospital admission and likewise those from in-patient services are accepted if the person would otherwise have to remain on a ward. DBT is based on a dialectical and bio-social theory which emphasises the role of emotion and behavioural dysregulation (over and under control) which can be evidenced in patterns of instability in affect regulation, interpersonal relationships, impulse control and self- image.
What We Did
The Acute Therapy Service (ATS) is an initiative that aims to support service users during a mental health crisis by providing an alternative to the existing in-patient model. The ATS is a psychologically led, structured therapy service based upon the principles of Dialectical Behaviour Therapy (DBT). We accept referrals from Crisis Teams, CMHT’s and in-patient services. Referrals from the community are accepted if it is to avert a hospital admission and likewise those from in-patient services are accepted if the person would otherwise have to remain on a ward. DBT is based on a dialectical and bio-social theory which emphasises the role of emotion and behavioural dysregulation (over and under control) which can be evidenced in patterns of instability in affect regulation, interpersonal relationships, impulse control and self- image. Given the cohort of people expected to attend the service, which is not limited to those with a diagnosis of BPD, it was felt that DBT was a model of care that provided the best fit for this challenging group, whilst also having the best evidence base.
Consequently the ATS is staffed by DBT trained staff who ensure that the principles and strategies of the model are applied to service, the staff group and then to the service users. The rolling 6 day programme is structured to provide group work based upon DBT skills groups with the central aim being to help service users cope actively and effectively with their problems through skill acquisition whilst remaining in their home environment. In addition, the service is supported by a multi-disciplinary team who promote these functions and provide social, occupational and recovery focused input.
The main benefit of the ATS Model and what contributes to its effectiveness is that it focuses on enabling and empowering service users to assume greater control and responsibility for their own recovery. It actively encourages them to learn to manage crisis situations independently rather than looking towards the wider environment to help them regulate their distress. It does this by offering a containing, structured environment where service users are able to acquire skills that are known to increase self-management and self- regulation, whilst remaining in their own home (and possibly the very environment that has triggered the crisis).
EXAMPLE OF SERVICE USER FEEDBACK:
Sarah: ‘I feel the techniques, such as mindfulness and self-soothing are fantastic tools to use when feeling over emotional. This is a great service and I much prefer this service than a hospital admission’.
Given the level of risk, complexity and challenges in treating this group of service users it would be understandable for the staff team to at times feel overwhelmed, discouraged and ineffective. However, staff report that the DBT philosophy and the principles of care applied within the ATS allows them to feel contained and better able to tolerate the demands placed upon them. This is further demonstrated in high morale and low staff sickness.
Wider Active Support
The ATS works closely with the In-Patient Units, Home Treatment Teams, CMHT’s and the Assessment and Treatment teams. These partner organisations are responsible for gatekeeping assessments for inpatient services and ensuring that patients are discharged into the community. Utilising ATS prevents admission and facilitates early discharge so is integral to the gatekeeping process. ATS also has DBT therapists embedded in the community mental health teams, these therapists will encourage and support their colleagues to consider ATS when their service users are in crisis. This allows the service user a choice in treatment and empowers them to gain greater control and responsibility for their own recovery whilst avoiding an admission.
ATS professionals regularly promote the benefits of ATS via team business meetings, governance, presentations and liaison with commissioners. We also involve the community Recovery and Restart teams who provide in-reach work whilst service users attend the programme in order to facilitate engagement with their local community following discharge from the ATS.
We are currently in the process of developing a “Leavers” group, facilitated by former servicer users and supported by the staff team so that the skills gained during their attendance at ATS can be reinforced and embedded once discharged.
As part of the ATS model staff meet every morning to reflect on the previous days programme and how it impacted upon them and the service user experience. lessons learnt from this process are then shared and help inform staff’s behaviour for the remainder of the day. Within the morning meeting staff practice mindfulness which helps them to regulate their own emotional reactions and makes them less reactive and more responsive.
Staff receive clinical supervision on a one to one basis and via their weekly consult meeting. This ensures that they continue to apply DBT principles and strategies and they report that it is this that contains them emotionally. However, it is the direct service user feedback that maintains their motivation, this information is given verbally at the “end of day meeting” and this informs how the team individualise the following days care. We also obtain service user feedback upon discharge as part of our outcome measures which is used to update group and programme content.
Looking Back/Challenges Faced
This service was initially piloted in West Lancashire and was established very quickly, in a matter of 3 months. One of the first challenges was to convince the wider teams that a psychologically led service could manage this level of risk and for this to be done whilst the service returned to their home environment each evening and over the weekend. There were also issues around who would be the RMO, given that this service sits outside the medical model and the existing structures and care pathways. There was also the problem of ensuring that the most appropriately trained staff were available to work into it and that there was a good staff mix.
Our experience has taught us to introduce new ATS services in a more measured manner, ensuring that the facilities are fit for purpose, the staff group in place and inducted into the programme. What helped in West Lancashire was the close working relationship between the clinical lead and the service manager. Both were also respected within the wider teams and with the commissioners. This helped to build confidence and trust. A lot of time and energy was spent liaising and negotiating with other stakeholders to reassure them and to provide a clear operational policy (one which can also evolve as we learn). We used our relationships with colleagues to promote the service and encourage them to refer. However, it has been the effectiveness of the programme that has ultimately won referrers over. We have also made referral to our service as easy as possible, with no paperwork involved from the referrer, we do all the 48 hour follow ups, which is helpful to provide a seamless service when teams are under such pressure.
The service originally came about following discussions between West Lancashire Clinical Commissioning group, an LCFT Service Manager and the PD Network Clinical Lead in response to the in-patient bed crisis which was and remains an issue at a national and at a local level. The intention was to pilot a day programme that would be psychologically orientated and which would accept referrals from Crisis Teams, CMHT’s and in-patient services. This pilot was closely scrutinised with regular audits and evaluations; the findings were positive in terms of service user satisfaction, reduced crisis contacts and contact with other parts of service. This data allowed Lancashire Care NHS Foundation Trust and relevant stakeholders to gain a clear picture of the effectiveness of ATS which encouraged them to support future service planning and development. As a result we have moved from one ATS in Central Lancashire to 3 across the network.
The ATS Clinical Lead ensures that the ATS Team Leaders are model adherent via supervision which ensures that in her absence the team will be able to deliver the model effectively. We are also currently investing in staff training and recruitment to promote and embed the model.
Evaluation (Peer or Academic)
The ATS was evaluated in January 2017 by Dr Charlotte Ingham, Clinical Psychologist ATS North and Angela O’Brien, Consultant Clinical Psychologist, Clinical Lead, Personality Disorder Managed Clinical Network & ATS Services.
The Evaluation explores the effectiveness of ATS. The project specifically hoped to explore the longer term impact of ATS on service involvement. The following research questions were identified : what impact does ATS have on admission rates, length of admission, and service use for service users over a 12 month period, and what is the financial impact of this? To complement and provide context for this data, the following additional research questions were asked: what impact does ATS have on service users’ emotional wellbeing, and what is the service users experience of the ATS?
In the year following their intervention, ATS was found to prevent further admissions in around 85% of service users included in the sample. Of the 15% who were admitted in the 12 months following ATS, all had admissions in the 12 months preceding ATS and had lengthy involvement in services (an average 5 years and 5 months in services).
To assess and monitor the therapeutic benefits of the ATS, psychological outcome measures are used on admission to ATS and upon discharge.On average scores for the GAD-7 (Generalised Anxiety Disorder Screen) changed from ‘’Severe Anxiety’’ to ‘’Mild Anxiety’’, and the scores for the PHQ-9 (Patient Health Questionnaire) changed from ‘’Severe Depression’’ to ‘’Moderate Depression’’ Staff working in ATS report satisfaction in their work and sick days are low.
The evaluation and the model has been shared via a number of conferences and presentations within Lancashire including,West Lancashire Commissioning Group, GP’s, Police, Children & Adolescent Services, Voluntary sector, Psychological Services, and external Trusts. We are in the process of promoting secondments into the ATS from the wider service to help improve staff knowledge base.