Reflective practice in homelessness services: A CBT approach 20 th June, 2014 Nick Maguire University of Southampton Reflective practice Staff reflection on: • Experiences with service users • Experiences with services – Emotions related to behaviours – Enabling change 1
Structure • Training followed by reflective practice • Training – Cognitive model – Complex trauma – Service issues • Reflective practice – Reflection on skills learned – Learning through experience of others Kolb’s Learning Cycle Reflective Abstract observation conceptualisation Concrete Active experience experimentation 2
Relating thoughts, feelings and behaviour Specifics • Six basic emotions (evolutionary perspective; Ekman, 1992) – Anxiety – Anger – Sadness – Happiness (including love) – Surprise – Disgust 6 3
Random thoughts... The Cognitive Model 4
Identifying Beliefs: The ABC Model (Ellis, 1966) Antecedent event Belief Consequence Emotion: Behaviour: Metacognition... 5
“Is what I’m thinking about what they’re doing absolutely true?” “Are they doing it for the reasons that I think that they’re doing it?” “If the thought about another’s behaviour isn’t totally accurate, could I do do something different?” Choice . 6
Maintenance of the problem - cognition • Selective attention (Posner, 1988) • Thinking changes with stress levels (Interactive Cognitive Subsystems (ICS); Barnard & Teasdale, 1991) Thinking and burnout Thoughts • ‘Nothing’s changing’ • ‘It’s my fault’ • ‘I’m no good at this’ Emotions • Anxiety, low mood Behaviours • Blame • Disengage • Leave 7
Evidence Measures • Maslach Burnout Inventory (MBI; ; Maslach, Jackson & Leiter, 1986). – Measure of staff burnout in the helping professions. • Effective Working with Complex Clients (EWCC; Maguire, 2007). – Novel questionnaire designed to assess staff confidence with using CBT techniques with complex clients. • Staff Attitudes and Beliefs – 42 (SAB42; Clarke et al, 2005 ). – Novel questionnaire designed to assess negative beliefs about complex clients. • CORE-OM (CORE Project Group, 2003). – Services users’ general mental health functioning 8
Staff training and reflective practice • Around 350 staff trained nationally • St Basils, DePaul, Westminster CC, St James, TwoSaints, Exeter CC • Pre-post (T1-T2) training improvements in • Burnout • Negative beliefs • Confidence in effecting change • Reflective practice further increases improvement • Numbers much lower for T3, still significant Staff burnout Maslach Burnout Inventory 70 30 28 65 p < .05 60 MBI Score 12 55 Maslach Burnout Inventory 50 45 40 Time 1 Time 2 Time 3 9
Beliefs about effectiveness of facilitating change Effective Work With Complex Clients 50 49 5 Effective Working Score 48 28 47 46 Effective Work With 30 45 p<.05 Complex Clients 44 43 42 41 40 Time 1 Time 2 Time 3 Negative beliefs about the client group Staff Attitudes and Beliefs 140 30 130 28 SAB-42 Score 120 110 Staff Attitudes and Beliefs p < .05 5 100 90 80 Time 1 Time 2 Time 3 10
Mediation analysis Effective working beliefs -.287* -.382** . 438** Negative Burnout beliefs • n = 62 * p < .05 ** p < .01 11
Reflective practice in homelessness services: A CBT approach End 12
Inclusion Health Continuing Professional Development Day 1 BSMS 20 th July 2014 WELCOME! • Housekeeping • Tea , coffee, food • Timetable • Thanks to Pathway for funding the catering 1
Aims of the day • Theme is excellence • Multidisciplinary and interdisciplinary education • Setting and maintaining high standards • Start of Inclusion Health speciality education • Meeting like minded people (aka networking) • Mutual education, mutual support • Reducing isolation, preventing burnout • Chance to influence developments Introductions • Name • Role • Where you are from (service, location) AND Either a ‘top tip’ for working in Inclusion Health OR something you would like to see develop OR one thing working in IH has taught you 2
First steps towards a speciality of Inclusion Health • Dr Chris Sargeant • GP Pathway Homeless Team BSUH since 2012 • Senior Clinical Lecturer • GPwSI Substance Misuse • Previously GP at BHH Morley St 1998-2008 One thing IH has taught me is that we have more success when services change to suit people, rather than expecting the opposite. Introductions 1 • Name • Role • Where you are from (service, location) Either a ‘top tip’ for working in Inclusion Health OR something you would like to see develop OR one thing working in IH has taught you 3
Inclusion Health Where Did we Come From? Primary Care Specialist Services • Doing a ‘bit extra’ - e.g. • Disease specific e.g. covering a hostel TB/mental health/sexual health • Part of generalist role • Voluntary / faith based • Working in day centres services • Urgent care • Street outreach services • Being in ‘right’ place • Mainly large cities • Special funding • Local funded initiatives • One off/special interest e.g. Christmas Who is included in Inclusion Health? • Hard to reach/easy to ignore groups • Those poorly/not served by mainstream/traditional services • Homeless People • People with addictions • Asylum seekers • Gypsies and travellers • Sex workers 4
Legislation in late 1990s • Allowed PMS services and salaried GPs • PCTs, Trusts, other GPs could employ deliver Primary Care services (GMS/PMS) • More specialist services started for those not served by mainstream • Developed along different lines depending on local focus, funding, needs Which services do we need to help educate and include • Emergency Services • Mainstream Services • E.D. • In-patient facilities • Primary care • Out-patients • OOH Primary Care • In-reach to hostel/day centres • Ambulance Services • Outreach to street 5
Introductions 2 • Name • Role • Where you are from (service, location) Either a ‘top tip’ for working in Inclusion Health OR something you would like to see develop OR one thing working in IH has taught you Where are we now? • Faculty of Homeless and Inclusion Health London based with North,South,East Hubs and West coming • Increasing number of services developing-Pathway services and others • Faculty Standards published • Pathway trial of in-patient intervention to be published soon • Discussions with RCP re specialty accreditation (more later!) • CCGs tasked with reducing health inequalities 6
Where are we now ? cont Specialist education programme for IH under development To include: On-line/distance learning modules Stand alone educational modules Full MSc programme for IH Continuing Professional Development (started!) What do we do? • Support and enable (patients and each other) • Educate each other • Fill in the gaps • Influence to change attitudes • Get the best from other services for our patients • Stick with people 7
What do we do that is different? • Truly multidisciplinary • MDT meetings • Making services work • Bringing in social care better together earlier • Filling the gaps • Outreach /in-reach • Pushing boundaries • Advocating for rehab • Staying with patient • Community teams • Increasing support • New services in TA • Acting for patient • Representation/advocacy • Bottom up and top down • CEOs, administrative staff, and influencing the managers middle! Introductions 3 • Name • Role • Where you are from (service, location) Either a ‘top tip’ for working in Inclusion Health OR something you would like to see develop OR one thing working in IH has taught you 8
Where do we want to go? • Recognised as specialty within our professions • Fully networked and connected to each other • Supporting each other • Educational programme and training programme for out/ in-reach workers, social workers, nurses, doctors and medical students • Maintaining agreed standards of excellence • Growing services (and influence) • Now Pathway Plus Team in hospital Local example in Brighton Follow up for patients discharged to TA or street homeless Pre-1998 Session of GP and 3 sessions of DN in Hostels team of nursing+OT, plus nurse and local day centre outreach worker for discharged patients Post 1998 Weekly Pathway MDT and hostel MDT Specialist NP and GP services Education programme for medical students Specialist primary care care, gradual additions of substance misuse, mental Medical student homeless society health, midwife services,alcohol • Future services. Shared MDT with MH Homeless Team Bid to scale up above programme-increase Outreach to street and day centres outreach to hostels/TA and street Plans for Homeless Hub for all services Plans for purpose built premises 9
The end • Questions and discussion 10
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