20 minute read
TRAUMA FOCUS
Placing trauma at the heart of neuro-rehab
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From a realisation that case management needed more focus on emotional rehabilitation, particularly with regard to client trauma, Psychworks Associates was born.
NR Times meets the founders of the fastgrowing venture and learns how their desire for change extends beyond neuro-rehab and into their passions of diversity and sustainability. Through recognising a lack of focus on emotional responses experienced by clients among case managers working with clients with life-changing injuries, Dr Shabnam BerryKhan established a business that continues to push for positive change within the neurorehab sector. Having moved into case management in 2010, clinical psychologist Shabnam quickly identified that the variety from her doctorate level clinical skills were being used even outside of the boundaries of treating therapy, and were hugely relevant to supporting clients in their everyday lives - but this was not a view shared by everyone. “My experience was - certainly back then, when case management was still finding its feet in terms of holistic support - that it was medically-driven in the main, with physical rehabilitation goals as the main focus. The concept of understanding trauma and how that actually gets in the way of rehab seemed to be missing to me,” she recalls. “For a long time, I thought ‘Am I missing a trick here? Have I missed out on where trauma has been talked about for clients, family and care/therapy teams, or where we address the concept of adjustment and think about the grief journey systemically?’ “I remember a senior case manager saying to me ‘What can a psychologist really do to help a two-year-old with brain injury?’ I was honestly speechless. “But while there were some people who just didn’t get it, others did, and I got a bit more confidence to talk more about what I knew. It did seem to resonate with solicitors and case managers, and I started getting referrals.” And from there, PsychWorks Associates was born - a unique and brave medico-legal focused business which delivers treating psychology services and case management support to serious and catastrophically injured clients, as well as training to personal injury lawyers and those working within a InterDisciplinary Team (IDT). The fast-growing venture, run by Shabnam and husband Gabriel, has become an established presence in London and the South East since its foundation in 2014, and is seeing ongoing expansion across the country. But with its growth comes responsibility, and its values of sustainability and diversity are central to the PsychWorks Associates operation. And at the heart of its service delivery is the focus on trauma, to actively challenge the situation Shabnam faced and make positive difference to clients’ rehabilitation experience and the impact professionals and the IDT can make. “We are all about focusing on the trauma, for both the client and their family, and how that then looks to the professional network supporting them,” she says. “The family involvement is hugely important, and it doesn’t make sense to me when people don’t see that especially as there is so much literature supporting this idea. “How can you not see that having a system around the family to address their trauma, to deal with the sadness of what has happened to their family member, could be helpful to the client, who is trying to engage with rehab and relies heavily on the people around them? “It's about working within an IDT, and helping an understanding of the emotional response to the injury filter through these different layers, and then communicating that in such a way that not only makes sense to the clients and those that we're working with, but also to the solicitors who instruct us.” To deliver a multi-systemic service that serious personal injury work is effectively, Shabnam and her team of litigation-informed treating psychologists adopt a formulation approach, which they are committed to delivering differently to the vast majority of other nonspecialist psychology providers - in the client’s own environment. “I would say at least 95 per cent of independent psychologists are set up to be run from a clinic of some description, the idea being that a client would go to them,” says Shabnam.
“But immediately, you can see that doesn't work with the serious and catastrophic injury cohorts of client that we work with – it is simply not appropriate or helpful to understand a client need outside of their complex contexts. “If you do not consider incorporating the family and professional network into the work you offer, you are not going to be able to answer the psychological questions posed to you to be able to help quality of life and the rehabilitation outcomes that need to be worked on. “Because of the way we work at PsychWorks Associates, we use the full breadth of clinical skills we were trained in from observing the care team, talking to key players in the professional network so they understand a little bit more about what's going on, communicating with the case manager regularly to help inform the coordination of the role, inter-agency working with schools and attending meetings, as required. “When seeking a treating therapist, case managers and solicitors need to look beyond the role and registration, and to look for a psychologist who has the capacity to work right in the community, where the client is. And that’s what we are committed to delivering at PsychWorks Associates.” Also working under the PsychWorks Associates umbrella are traumainformed case managers, putting trauma at the heart of its approach in a way that remains absent in large areas of case management. “When a case manager comes in at the beginning, it’s often about the physical rehabilitation” says Shabnam. “But we aren’t addressing the fact that this life-changing situation has just happened to them, and it’s going to get in the way if we don’t talk about the elephant in the room. “It’s what we informally call ‘baggage’ - and the heavier it is, the harder it becomes to engage with everyday life. And if you’re working with people who have had traumatic experiences, which is pretty much any client or family who has been affected by catastrophic injury, then that is going to weigh heavily and a lot of support is needed to offload the weight. “And rather than saying ‘I had a conversation with them about it, tick the box, let’s move on’, we need to create the foundation to allow ongoing conversations to happen around how it feels and how difficult it must be, and be able to signpost them to resources or services that are going to help. “If you do this, then the impact is often indirectly felt. Suddenly communications are a use simply do not fit,” says Shabnam. lot easier with the client or family members for “There are a disproportionate number of all involved, because there’s somewhere non-white and non-English clients in personal to go with all about emotion. And the way injury, particularly in the South East and forward becomes easier to talk about and London, and other bigger cities where we are clearer for everyone involved.” beginning to work with our service, and it’s Through Shabnam’s near-20 years of working very important that any professional has an in client-focused psychology work, and the understanding of their world as that will impact expertise of the growing team, PsychWorks on their rehabilitation. Associates has also begun to deliver training “We work in people’s private homes with their to other professionals working in the field. families often, which is a massive intrusion “It’s mainly for case managers and solicitors, anyway, and suddenly there are rules that may but is also relevant to others in the IDT,” or may not fit the lifestyle they would choose to says Shabnam. have and so difficult conversations are needed. “We’re looking how to get the best out of your And these may or may not happen depending on care team, thinking about how to conceptualise how empowered clients feel. Those conversations the client case that you’re working on, and even might be about how they want people to respect how to promote self-care and avoid burnout, a dress code in their home, understanding which is a huge issue in care. different food habits, how religious practices happen, without facing judgement and without being ignored. This is the
We are all about backdrop many minorities have focusing on the trauma, experience of, making these moments potentially feel like ‘micro-traumas’. for both the client and “With the longitudinal context of trauma, their family, and how pretty much anyone you speak who is non-white will talk about racial trauma that then looks to the in some way - we need to acknowledge professional network and understand how this can be triggered in our communications and practices in supporting them the name of rehabilitation.” Its commitment to sustainability is another issue which runs deep, and “We need to be doing everything we possibly in which PsychWorks Associates are keen to can to look at how we can get the very best for lead the way. the client and what is probably going to work Gabriel, who has worked extensively in or not at the case may be, while also thinking sustainability, says: “This fits with us personally, about the professional need in the medico- as directors, and with me from my career legal context.” background. But also, it fits with the general And while helping to transform traditional agenda of social responsibility that companies practice through the focus on trauma, increasingly now have, and we certainly have PsychWorks Associates is also leading the way as a business. in helping to shape the future of the industry Over the next year, we want to introduce a way with its deep-rooted commitment to diversity of reducing formal plan to reduce our impact and sustainability. on the environment in a way that's going to The clinical teams collectively speak over 15 be sustainable within itself, and be appealing languages, and the service is proud of its to clients looking for conscious responsibility ethnic representation to support their clients, throughout our operation. a significant proportion of whom are from Psychworks Associates is embodying in its diverse ethnic background. business focus the positive change it wants to “Case management and psychology are see in the world of personal injury rehabilitation. clearly white English, female-dominated However, its referrers and clients know it best professions, and the concepts we are taught as simply a reliable service offering high in mental health alone are very Euro-centric quality and cost-effective case management - and we therefore need to acknowledge that and treating psychology support. someone of colour may experience things very differently to someone who is white www.psychworks.org.uk English and sometimes the models we 07942 691070
How positive behaviour support can deliver life-changing outcomes
Mark Henry, head of behavioural support and mental health at Exemplar Health Care, discusses how bespoke interventions can enable people who display behaviours of concern to thrive, and shares the stories of three service users who have been supported by its specialist team to achieve this
Where people have complex health conditions, this can result in behaviours which can make safely caring for them a challenge. While many people who display behaviours of concern are able to live in ‘mainstream’ residential homes or supported living, others thrive in care homes that specialise in care for people with these complex behaviours.
Behaviours of concern can have a range of causes, often involving damage to the brain or a mental health condition. People can experience such behaviours due to: • dementia • a brain injury, such as from trauma, or medical insult to the brain such as a tumour, haemorrhage or infection • a disability the person was born with, or genetic conditions • stroke.
At Exemplar Health Care, the people we support usually display behaviours which have made it difficult for them to interact with others safely or effectively, such as physical or verbal aggression or offensive language. Many of them have been deemed to have behaviours that are considered ‘too complex’ for mainstream nursing and care services. Our community-based homes and OneCare services provide person-centred care and rehabilitation that focuses on maximising independence, building everyday living skills and empowering people to live their best lives. Through our specialist care, many people are able to find new coping strategies and learn skills to manage their feelings. Our approach to behaviour support focuses on how we can prevent the need for restrictive practices and reduce the frequency and intensity of behaviours of concern, so that people can live a fulfilling life and integrate with society without their behaviour restricting what they can do. Our trained teams work with individuals to understand the reasons for their behaviour, to learn the skills to manage their own behaviour, to identify, remove and reduce any trigger factors and implement strategies to reduce the frequency, duration and impact of incidents of behaviours of concern. We look at psychological methods of distraction and diversion before other methods are considered. Our care homes have high staffing levels which enable us to work at people’s own pace and build trust. Our homes also have in-house Activities and Life Skills Teams that support people to take part in everyday activities that are meaningful to them, which helps to reduce feelings of frustration for people who display behaviours of concern. All of our care and nursing colleagues complete our Exemplar Positive Behaviour Support (EPBS) training which has been certificated by the British Institute for Learning Disabilities Association of Certified Trainers (Bild ACT). This confirms that the learning meets the Restraint Reduction Network (RRN) Training Standards 2019. The certificated EPBS training includes up to five days of learning – two of which cover PBS theory, psychological support, self-protection skills and break away techniques, and up to three days of level two training which covers restrictive practices. The training provides colleagues with the skills and knowledge to protect people’s fundamental human rights and promote person-centred, best interest and therapeutic approaches to supporting people when they’re distressed. We also have a central team of Mental Health and Behaviour Support Specialists who support our colleagues and service users who display behaviours of concern, including crisis or rapid intervention when a person’s behaviour is escalating. The team is made up of Behaviour Support Specialists who take the time to observe the individual, understand the reasons for their behaviour and suggest strategies to reduce distress or discomfort which might be causing the behaviour. Through dedicated, bespoke support, our team - working closely with our service users - are able to deliver outcomes that truly change lives.
Wayne lives with central pontine myelinolysis (CPM), a neurological condition that happens in the pons area of the brain. When he moved to Dearnevale in 2016, he was told he only had 12 weeks to live. When Wayne first moved to Dearnevale, his behaviours of concern were due in large part to the frustration of his situation and very short life expectancy. Our high staffing levels have enabled Wayne to progress at his own pace and build trust with the Care Team, developing strategies to recognise when he’s experiencing anxiety, and to manage these symptoms before they escalate. Over the past few years, the number and duration of incidents of behaviours of concern have reduced dramatically.
Rebuilding mobility
When Wayne first moved to Dearnevale, he was at high risk of falls and received one-to-one support to mobilise safely. Regular sessions with the in-house Physiotherapy Team have supported Wayne to stand and improve spasticity in his hands and arms. He’s now able to make small movements independently, such as turning in bed and lifting his legs when getting dressed.
In 2018, John experienced a thin acute subdural hematoma and contusion following a fall. This led to an acquired brain injury, dysphasia, poor short-term memory, epilepsy, poor vision and Bell’s palsy. Before John experienced his injury, he owned a building business and worked seven days a week - his only rest time was Sunday afternoon when he went to the local working men’s club for a rest and a pint. John’s spare time was spent with his young daughter or playing football. He coached the local pub football team. The team at Dearnevale has helped John to develop strategies to recognise when he’s experiencing periods of agitation that could escalate to behaviours of concern. He can now vocalise when he is feeling this way, and recognises when he is about to experience seizure activity. Our high staffing levels enable John to progress at his own pace and build trust with the Care Team. During his time at Dearnevale, the number and duration of incidents of behaviours of concern have reduced dramatically.
Improving nutrition
Wayne has received input from Dieticians to support him to eat orally again. He’s had his PEG feeding tube removed and is able to eat and drink thickened fluids orally. Wayne only uses his PEG for top ups. Wayne has also been supported by Speech and Language Therapists to enable his speech again, which has supported his independence and reduced feelings of frustration.
Getting a passion for life back
Wayne prefers spending time on his own, which staff respect. He enjoys supporting Liverpool FC and watching other sports such as snooker and tennis. He occasionally joins in group activities – especially when karaoke is on! Wayne enjoys a good relationship with family, and now sees them more than he ever did. He has a wicked sense of humour and wants to write a joke book to send to all Exemplar Health Care homes and spread some laughter.
Over the past few years, John has enjoyed sessions with the in-house Physiotherapy Team to build his body strength and range of movement. Now, he enjoys walking in the local community with colleagues and goes to football training and plays on a local team. He’s just started jogging with a coach to build his fitness. Being active and staying fit has improved John’s wellbeing and reduced feelings of agitation.
Rebuilding mobility
When John first moved to Dearnevale, he was at high risk of falls and received one-to-one support to allow him to mobilise safely.
Developing life skills
John enjoys regular sessions with the inhouse Life Skills Team at Dearnevale, and has developed his hand and eye co-ordination and enjoys completing the Rubix cube. He asks staff to mix the cube for him and has successfully completed the puzzle 423 times! John has also developed his level of concentration and has begun playing the keyboard, as he did before his injury. He’s completing self-taught lessons that he accesses online, with the aim of performing at the Christmas talent show. With the support of the team, John has begun preparing his own meals in the therapy kitchen. He loves helping out in any way he can, and volunteers to clean the therapy kitchen and hoover the training every Monday.
Meet Karen, resident at Tyne Grange care home in Newcastle upon Tyne
Karen had a spinal cord injury eight years ago which resulted in quadriplegia. She also has a personality disorder and displays behaviours of concern. Karen moved to Tyne Grange in 2020. She has complex needs in terms of her physical condition, and displays behaviours of concern with regular selfharm and emotional dysregulation. Karen has had many previous placements that have broken down, mainly due to the complex behaviours of concern that she displays. With 1:1 support from our Care Team, and input from the Therapy Team at Tyne Grange, Karen now enjoys a good quality of life.
Physiotherapy
Karen has a session with the home’s in-house Physiotherapist twice per week. These sessions have improved her upper body and hand dexterity, strength and range of movement in her legs and her transfer and mobility practice. Karen’s movement has improved significantly and she has progressed from requiring a full hoist to using a stand aid to being able to walk using a walking frame. She's achieved 54 metres of independent walking with a walking frame. We’ve set a goal for her to be able to walk across the Millennium Bridge from Newcastle to Gateshead independently.
Occupational therapy
Karen works on preparing food and baking, increasing independence with personal care, accessing the community, building self-esteem and managing her emotions through sensory/ self-soothing work. Karen really enjoys her time spent accessing the community. Her goal is to find a local class to start a new hobby and meet other people.
Behavioural support
Our high staffing levels have enabled Karen to progress at her own pace and build trust with the Care Team. This has reduced the number of instances of behaviours of concern. Her selfharming behaviours have dramatically decreased. Karen’s built a great rapport with the staff at Tyne Grange who have got to know her well and have learned how to manage her emotional needs. Karen has also explored a variety of activities and interests. She loves doing arts and crafts, going shopping, making friends and is the home’s Service User Ambassador.
Wiltshire Farm Foods and The BDA Collaborate On ‘Ready, Steady, Blend’ Challenge to Raise Awareness of MDT Approach
For those living with swallowing difficulties, there are several considerations and challenges that can arise when cooking nutritious meals to the correct texture. To demonstrate these, Wiltshire Farm Foods and the British Dietetic Association (BDA) have combined forces to produce a video that launched during Dietitians Week. The aim of the video is to raise awareness of the practical implications of dysphagia, and to ensure that healthcare professionals (HCPs) – particularly Speech and Language Therapists (SLTs) and Dietitians – have takeaways they can then put into practice. Since the adoption of the IDDSI (International Dysphagia Diet Standardisation Initiative) framework by the BDA and RCSLT in 2019, there has been significant focus put on helping HCPs understand descriptors and how each texture can be achieved in a health or care setting. However, there has been less emphasis placed on supporting those with swallowing difficulties at home. The BDA and Wiltshire Farm Foods together recognised there was an opportunity to further explore this topic, with this ‘Ready, Steady, Blend’ exercise resulting from the collaboration. The ready meal provider challenged SLT Lindsey Collins and Dietitians Laura Clarke and Alison Smith to create a Level 4 puréed meal from a Wiltshire Farm Foods Roast Beef Dinner. During the ‘Ready, Steady, Blend’ practical session, the HCPs were given blenders, thickeners and various cooking utensils to ensure the meal was the correct consistency to meet IDDSI Level 4 guidance. The IDDSI framework provides a common terminology to describe the characteristics and consistencies of various texturemodified foods and drinks. Specialist meal providers, such as Wiltshire Farm Foods, have expertise in supplying meals developed in alignment with IDDSI guidance; these are always designed with dietetic input, to ensure the needs of more nutritionally vulnerable service users are met. Clinical Specialist SLT, Dr Lindsey Collins, was invited to discuss the diagnostic phase of dysphagia, also stressing the importance of collaboration between HCPs in the video: “It’s about recognising what we know and what we don’t know. SLTs have our specialist knowledge, as do Dietitians. It’s really important to not assume that the other already knows something. We’re not the final say on our service user’s eating and drinking needs, and it’s about working together as a MDT. Discussion and ultimately, collaboration, is key.” Resulting discussion amongst the HCPs demonstrated the learnings taken from the challenge and, moving forward, how consultations with those with dysphagia could be improved to achieve more open dialogue, safer outcomes, and better access to a wider range of appetising and nutritious meals. The video launched during Dietitians Week (20th – 24th June) and is available to view on the BDA’s website. In the spirit of collaboration, Wiltshire Farm Foods is also encouraging HCPs to attempt their own ‘Ready, Steady, Blend’ challenge at home and share the images across their social channels.
To watch the video, visit: specialistnutrition.com/blog.
