Right Place, Right Time

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A stressful year is giving rise to a fresh approach to mental health at Phoenix Futures, as DDN reports.

DDN article on mental health‘People in treatment are keen to say they’re ok, but a significant amount of people have really struggled over the past year,’ says Phoenix Futures’ chief executive Karen Biggs of more than 12 months in lockdown.

Phoenix Futures’ chief executive Karen Biggs
Phoenix Futures’ chief executive Karen Biggs

‘Our residential services are where we’ve traditionally seen those with the most complex needs and where they will have an opportunity to engage with the appropriate medical help and psychological support,’ she says. So Phoenix made two key decisions, and the first was to stay open throughout, ‘because I knew the need was out there and if there was ever a time people needed access to rehabs it was during the pandemic.’

The second key decision was that ‘we were not going to take our foot off the pedal in our mental health work’. There were two important strands to this – a refresh of clinical interventions, and a specific look at what else they could be doing to make sure people could access the right interventions at the right time.

‘People with substance misuse and mental health conditions get passed from pillar to post, struggling to engage with substance misuse services and then mental health services at the same time,’ she says. With the expertise of the team’s psychologist and senior mental health nurse, the plan was to develop the team’s skills to ‘hold’ people and start to address their issues while they were in treatment – then to improve links with other services, ‘so there’s a really good pathway of support when they move out’.

Nothing has stalled over the past year – quite the opposite. Biggs is ‘terrified’ of what’s to come on drug-related death statistics as ‘there’s so much we don’t know about the experience of people in treatment over the last year’. Add to that the stigma, not just in the media but in the ‘everyday decisions made by professionals in the healthcare system’, and there is much to do. ‘Stigma is preventing people from accessing help,’ she says. ‘It prevents people from accessing substance misuse services and put together with a mental health condition it’s so hard. We need to speak out about it and support health professionals to understand the impact of their decisions.’

As the pandemic escalated, Biggs was acutely aware that her staff had support needs of their own, whether out on the frontline or adapting to the challenges of virtual support from home. Half of Phoenix’s staff continued to work face-to-face in the pandemic, in residential and housing services, and there was ‘a lot of fear’ to begin with, facing risk, adjusting to new protocols to keep everyone safe, and fighting for PPE, testing and access to the vaccine. (A particular challenge, says Biggs, as while residential rehabs are registered care homes, they were not viewed as priority.)

The decision to stay open was a ‘massive ask’ of team members and redoubled her commitment to staff welfare. She recognised that ‘there was a very real need for the staff to decompress’, particularly without the usual opportunities to get together, laugh, cry, hug, and share the load, so a much-valued wellbeing programme was introduced and has been extended indefinitely. ‘We have to continue to recognise that staff have been going into work and risking their lives every day,’ she says.

Phoenix has also taken the opportunity to learn from the pandemic by beginning a research partnership with Liverpool John Moores University. The aim is to study the impact of COVID on residential rehabs through surveying staff and service users, and results will be interpreted in June and fed into the organisation’s review of practice.

The other area for development – and something Biggs feels hopeful about – is the prospect of addiction services becoming part of the wider health and social care sector, post PHE restructure. ‘The pathways into and out of addiction services and how we are able to support alongside our health and social care partners should be made easier,’ she said. But she adds a strong note of caution: that we must not allow the specialism of addiction to get lost ‘within the broader health and social care tent’ – a real risk. ‘We’ve got to be braver and more confident as a sector in our communication on it,’ she says.

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As head of clinical interventions, Gabrielle Epstein is at the forefront of the revitalised mental health strategy and clinical review.

Gabrielle Epstein, head of clinical interventions.
Gabrielle Epstein, head of clinical interventions.

People working in substance misuse manage people with mental health issues really well whether they realise it or not,’ she says, and we should be building on these strong skills.

An experienced psychologist, she talks of the ‘whole person’ arriving in treatment with various issues to address and is very keen to move away from the label ‘dual diagnosis’. Mental health needs were identified in 60 per cent of people admitted into Phoenix’s residential services – 66 per cent were found to have depression and/or anxiety, 7 per cent had PTSD and 12 per cent were diagnosed with a personality disorder/affective disorder.

People with mental health needs are ‘our bread and butter, this is who we’ve always treated’, says Epstein, but it’s not always straightforward. ‘Some substances are very good at masking the positive signs of mental illness… So heroin for example is quite good at dulling down the psychotic symptoms of schizophrenia, which is sometimes why people use it. If the substances are masking the symptoms, when you detox they will emerge.’

Many diagnoses were identified by GPs and mental health services before admission, but other people had mental health needs that had not been formally diagnosed. With a system of ‘dynamic assessment’ in place, their needs are reviewed regularly and the treatment plan adjusted to bring in the relevant expertise. Referrals are made swiftly and incorporated into risk assessment and care planning – an approach that’s working. Data on completion shows that those with a mental health issue are as successful as anyone else in completing the rehab programme.

The registered mental health nurse (RMN) is an important member of the team and a key to keeping the door open between substance misuse and mental health. Training for the entire team includes a full set of skills to recognise and manage mental health issues, and some of the nurses are dual qualified as CBT therapists. Everyone is switched on to helping people engage in treatment, explains Epstein, and that might mean clinical supervision, medical interventions or cognitive behavioural therapy (CBT) at different points in their journey. Anxiety, for example, ‘yields very well and relatively quickly to CBT interventions’ and a few sessions usually enable the person to engage in treatment.

The other major part of staff training is in trauma-informed care, because, says Epstein, ‘we know that nearly everyone who comes into residential treatment has an experience of trauma’. This has to include supporting staff to recognise their own triggers, as well as being fully aware of the risks of retraumatising people in their care.

Read more on mental health from DDN

The team is looking at some very promising (and cost-effective) interventions such as eye movement desensitisation and reprocessing (EMDR) – ‘evidence based and economical, because it’s a brief intervention with very good outcomes’, according to Epstein. While the intervention itself is brief, she adds, there’s a ‘long preparation period where people have to be stabilised enough to be able to engage in it’, which once again shows the need for close-knit working within the multi-disciplinary team and beyond.

The community mental health team form another essential link in the chain of care, and Epstein is hopeful that changes within the Department of Health and Social Care will give greater capacity for the multi-disciplinary team approach, including joint case conferences that support residents beyond discharge from rehab. It makes all-round (including financial) sense, she says. ‘People who come into residential treatment may have had frequent contact with the police and be frequent flyers with A&E. But we know that if you’re successful with your treatment and continue with your aftercare, those presentations to A&E will decrease and there’s an overall cost benefit to the health system.’ DDN