Talking about Choice

Was doing some supervision today and talking about a case of a very anxious mum who seemed over involved with a dependent and anxious child with a diagnosis of Aspergers.  What she wanted – for any “help” – didn’t seem to match well our understanding that her relationship with the child was a part of the issues that we’d like to think about.

This raised a challenge of how do you get to a Choice point if your mutual understandings are miles apart. The clinician I was talking to had actually booked the family into a partnership as they “clearly needed help” (i agree) but not with any mutually agreed goal.

I think the “honest opinion” step of Choice maybe should have been used a bit more. Comments on how close they seemed. What did she think of that? Asking whether mum thought how she felt affected how the child felt or maybe what was her view of successful development or separation. Do you have any thoughts? I think this is trying to get at mums formulation of the situation rather that her experience of the situation…

Just goes to show that although CAPA definitely helps (we think) it doesn’t always make every situation easy!

Exciting times

Well since I last posted we have been to Holland and Wales! And next is to an international conference in Paris to jointly present a workshop with Folk from the Werry Centre, New Zealand.

But the exciting bit is that Ann and I are just piloting a new measure the CAPA FACE.  This is a more detailed evaluation tool for us and services to get a close look ay how near to full CAPA they are and what steps they need to take to get there. The neat bit is that it is an interactive PDF so you can just click the boxes and it works out all the scores for you. We hope to have it available to all through the website soon.

We are also steaming ahead with the new book. It will have some extended and revised content and we want it to be available in September. Phew!


Our tour down under!

Ann and I have been very privileged recently to do a couple of weeks work in New Zealand and Australia around CAPA. We spent three days in Auckland working with the Werry Center (NZ’s excellent CAMHS change organization) including one day’s masterclass with CAPA champions from cross the country. Then we flew to Wellington, met with the local Adult mental health team in their service (great to visit actual buildings and staff) followed by a CAPA conference for the whole DHB (organization). After that we flew to Sydney briefly and on to Orange (160 miles west and inland of Sydney) doing two workshops there – one for staff and another for clinical leads, planners, clinical directors etc. After flying back to Sydney we had a day off on the Wednesday and then two metropolitan conferences in the city.

So much to talk about but for me the highlights were:

  • the positive feedback from the Christchurch team about how CAPA had increased their team cohesion so they had been able to provide a service through the difficulties and been able to flex choice capacity in responses to waves of referral demand. Humbling experience to hear about them, their situation and their efforts.
  • the discussions with adult consumer advisers (service users) about what they would like the initial appointment to be called. They said they really did not like “First Assessment” as they did not want to be “Assessed” not did they like that the service was counting already! The loved “Choice” as “we wold love to be really able to feel that we had a choice”
  • turning up to Wellington airport to discover our booked flight to Sydney did not exist!
  • the size of some of the patches in the Orange area and especially so further inland, The size of Germany with only 100K people in them. And the challenges of the lone workers in these patches were enormous and their resilience was extraordinary.
  • cycling round the Manly dam cycle track on a hire mountain bike. This was not for beginners to advanced as advertised. Very scary for me anyway!
  • the energy of the Sydney metro conferences
  • and finally arriving at Sydney to come home to discover that our return flights had been unbooked by the airline as we had missed the non-existent plane!

We plan to be back in a year maybe. Thanks to all and to Ann for sharing it all with me.


Choice and Assessment

At a recent consultants meeting in Hertfordshire we spent some time thinking about Choice appointments and, as i discovered, some continuing myths about the role of assessment. First off let me state the myth: that Choice appointments do not contain any assessment – it is just offering a range of Choices. I can see where this myth comes from as Ann and i talk a lot about Choice and the need to work with the users wishes, hopes and wants. As well as our recommendation that we stop calling the initial contact “Assessment” (as we think this word is not collaborative) and to call it something else, maybe “Choice”.

BUT we also say that our job is to “facilitate their choices using our expertise”. In other words we have to do think about both assessment and risk to be able to have conversations with the young person in a collaborative and informed manner. The trick is to move away from an expert assessment that makes the young person and family feel passive to being able to do our assessment and risk thinking in a conversational manner that both gives us the information we need and keeps the young person and family active and engaged.

In fact it is this open and honest conversation with the young person and their family using my ideas as well as their hopes and wishes that I find so rewarding in a CAPA service!

A Team Away Day – Xmas version!

Today we had one of our team away days. These are part of the full CAPA model and should occur at least 4 times a year (see the 11 components). A key part of away days are that they are not set by management but that the content is devised by and delivered by the team – I thought it might be interesting to post about today.

We started with a warm-up. We thought it might be good to do something appreciative so we each took a piece of paper, wrote our name on the bottom, and passed it to our left. We then all wrote an appreciative comment or comments about that person, folded the paper over – so no-one could see what was written — and again passed it to our left. Eventually the pieces of paper returned to their owners. It was quite moving to see what had everyone had written.

Then, up till coffee, we talked about the recent GP audit and thought about ways we could improve the referral process, let them know about the good things we were doing and reflected on the choice letters. The plan is to then meet with the local GP lead and think it through with them.

After coffee, up till lunch, we looked at the CYP-IAPT measures for every session monitoring and tried some out. These changes are going to be HUGE but in the end i think really good.

After lunch we thought about shared decision making and young peoples experience of the service. We thought both about how to make our clinic rooms more welcoming and what posters or positive messages we wanted on the walls. We then went on to think about a user experience project about how young people and their families experience the choice letter.

Tea came and then we had an exercise where we walked round the room looking at 6 Xmas pictures (snowman, mistletoe, Rudolf, present, tree, scrooge) and choose the one we thought best represented our view of the CYP-IAPT process. After we’d all selected we talked in the round why we’d picked them. After that we reflected on the hopes and fears we had written down 3 months ago. Interesting to find we had moved on and were maybe more positive and working together as a team.

Finally to cool down, we had a Xmas quiz run rather madly by Simon. A fun end to a really good day of working together.


CAPA-ccino and other beverages…

We visit and hear about lots of teams who say they are doing CAPA but when we look closely they are doing some but nowhere near all of the 11 CAPA components. Our experience is that this CAPA-lite model really doesn’t work very well! In fact this was a key finding of the Mental Health Foundation of English CAMHS and CAPA, that there were many partial implementations often due to myths about CAPA (MHF report).

At a recent conference a delegate suggested that we should call such a service not CAPA-lite but CAPA-ccino! It has less coffee, is covered with a frothy top and suggests it is more substantial than it is.

More extreme even was when we came across a service that said they were dong CAPA and had merely converted their first appointment into triage, called it Choice and nothing else! As another delegate suggested this should be CAPA Zero.

So if you think your service is meant to be doing CAPA but it isn’t a full and satisfying double espresso, check out the self rating scale…

A CAPA limerick

I have to credit Andrew, a systemic therapist, in my team for this…

Said a CAMHS statistician / clinician
“To end waiting lists is my mission.
With a partnership quota
We’ll be lean – like Toyota !
My ambition will come to fruition.”

Excellent and had to post it!