Model of Care
Care in Mind provides safe and clinically effective residential care. Our model, underpinned by attachment theory, brings together a number of evidence-based interventions that have been adapted to meet the specific needs of our young people and the staff who support them.
Our innovative approach includes:
- The Boundary See-Saw model, which supports teams and young people in understanding and managing boundaries in relationships
- Structured Clinical Management (SCM) adapted for use with our adolescent population (SCM-A), supporting skills development and problem-solving
- Safewards for Safe Homes (SSH), our therapeutic risk management and skills model, developed in collaboration with Safewards specifically for our therapeutic residential homes
- In addition, we offer specialist psychological therapies, family therapy, medication and other interventions based on the individual needs of our young people
Structured Clinical Management is an evidence based systematic approach for mental health clinicians working with clients with complex needs, that involves both individual and group sessions. Care in Mind is the first organisation to adopt SCM for use in an adolescent client group as SCM-A (Structured Clinical Management for Adolescents) and it is the dominant intervention and guiding model for all clinical work undertaken with our service.
SCM-A is delivered by trained clinicians through individual and group interventions. SCM is, at its core, an attachment based model with an evidence base for people with Borderline Personality Disorder. However, we believe that the principles underpin good consistent effective care for all mental health presentations.
Group sessions run with 6-8 young people at any one time and with two clinicians supporting the process. These groups focus on core skills in the areas of problem solving, understanding emotions, managing emotions and developing healthy relationships. These sessions involve psycho-education – to learn about the skills – as well as looking for creative ways to explore and practise them.
Individual sessions take a problem solving approach, where the young person is supported to identify and understand the core problem affecting them at any given time. This stops others from assuming or deciding what problems are and what should be worked on! In these sessions young people and their nurse will also think together about how to apply and use the skills being developed in the SCM-A groups.
The Spine of SCM-A
- Clear boundaries and mutual expectations
- Consistent planned and structured group and individual sessions
- Detailed safety plans and clear goals and aims for treatment and placement
- Collaborative care planning and goal setting
The Aims of SCM-A
The aims of SCM-A are to help service users to:
- Use services more effectively
- Develop better understanding of their internal states of mind
- Learn and practice skills to help them manage their emotions, impulses and relationships
- Develop vocational activities outside of mental health services and work toward independence
Specialist Psychological Therapies
All service users within Care in Mind work within the core SCM model. However, many of our young people have more specialist psychological therapy needs. Young people arriving in our service have received varying levels of previous psychological therapy, but our clinical psychologists have excellent skills in engaging young people who are difficult to engage and help them to begin to work on core issues. All our young people in service are able to access individual psychological sessions that will help them to develop a better sense of their difficulties through formulation-based work and then work on issues such as emotional regulation, self-identity and past trauma, as and when they are able to do so and using a model that best suits their needs. Within our team of clinical psychologists and psychological therapists, we are able to offer the following therapeutic approaches:
- Schema Therapy
- Mentalisation Based Treatment (MBT)
- Cognitive Analytic Therapy (CAT)
- Compassion Focused Therapy (CFT)
- Cognitive Behavioural Therapy (CBT)
- Acceptance and Commitment Therapy (ACT)
- Family Therapy
- Art Therapy
Our Staff Are Our Most Valued Resource
At Care in Mind, we recognise the value of all our staff in delivering therapeutic care to the people we support. We believe that it is by valuing our staff highly that they will, in turn, provide the high-quality care and support for young people that we expect them to receive. We also realise, however, that many of the young people we support have complex and often relationally based needs which make them challenging to engage with and to support. We, therefore, consider it essential that we provide a high level of support and training to staff, based on specific approaches that we believe will equip them to work with our complex and challenging clients.
The Boundary See-Saw Model
We use an approach called the Boundary See-Saw Model in a number of settings in supervising staff and during team reflections. The model helps teams and individual staff to reflect on relational boundaries, exploring the roles that staff, young people and carers can adopt in the difficult processes that arise around finding a balance between the need for care versus the need/wish to control (security). The model creates a shared language between staff and service users, to help everyone to understand the inevitable dynamics and boundary issues that arise all the time between carers and clients, particularly where there are significant risks and interpersonal difficulties.
The model helps individuals and teams to develop a heightened awareness as to when there are significant shifts away from the expected ethos of a comfortable balance between the Care and Control domains in relating positions between carers and young people. In turn, it provides a useful and non-threatening structure to support discussions and shared understanding and responsibility for shifts that may be identified and the development of collaborative plans to redress the balance in a healthy manner.
Team Support Structures
- Staff Support Groups
- Reflective Practice Sessions
- Post-incident Debriefs (with young people and staff)
- Clinical Supervision
CIM Training Academy
The Academy was developed to ensure staff are well equipped with the appropriate knowledge and skills to carry out their duties effectively and to support the aims and objectives of the Care in Mind Model of Care. All staff complete Mandatory and Statutory Training as a norm but are free to enhance their studies by completing NVQs which takes their training to the next level and supports their personal development and opportunities for career progression within the organisation. Successful candidates are invited to attend an annual Awards Evening when, along with members of their family as well as colleagues, we can all celebrate their achievements.
Effective risk management is essential to our work. We approach risk in a collaborative way, with the young person at the centre of their care and risk management.
Therapeutic risk management encourages a young person to take increased responsibility for their risks over time and to develop healthier ways to manage their distress.
Care in Mind operates a non-restrictive policy, whereby the use of physical intervention and restraint is avoided wherever possible. This allows for more respectful and thoughtful relationships with clients and encourages alternative relationship-based approaches to risk management. It is our firm belief, backed up by evidence, that this approach reduces, rather than increases, risk and promotes safety for all. We have had considerable success in helping young people to reduce their levels of risk using these techniques and our outcomes are shown here. To ensure the consistent use of the model and ensure that restraint is only used in exceptional circumstances, all restraint incidents are reported to senior management in order that the necessity can be validated.
Care in Mind recognises that there are occasions when staff need to respond to life-threatening situations by utilising minimal restrictive holds for the shortest time possible. All staff at Care in Mind are trained by qualified instructors in TRUSST (Therapeutic Risk Underpinned by Safe Supportive Techniques), which lays out an approach to crisis management that promotes a culture of learning and growth and sees crises as opportunities for positive outcomes.
The TRUSST approach separates crises and crisis interventions into five distinct phases:
- Understanding Behaviour: Formulation of Risk
- Primary Prevention Phase: ABC Charting, Environmental Conditions
- Secondary Prevention Phase: Assertive Strategies, De-Escalation Strategies
- Physical Intervention Phase: Legal Framework
- Restoration Phase
Effective Risk Assessment and Management
- Effective assessment and management of risk is essential to our work with young people and young adults, given their complex mental health difficulties
- All clients have detailed risk assessments that are undertaken jointly involving care staff, clinicians, clients and carers or other professionals where appropriate
- These risk assessments consider risk factors and triggers that are important to build into risk management plans so as to reduce the likelihood of risk incidents
- We approach risk management in a collaborative way with the service user at the centre
- We support service users to gradually increase responsibility for their own risks and to develop more healthy strategies to manage their distress
- The Safewards Model, developed by Professor Len Bowers for inpatient settings, has been adapted by Care in Mind for the residential care setting
- The Safewards for Safe Homes (SSH) model applies the evidence-based least restrictive principles of Safewards to the community setting and specifically to the needs of young people with complex mental health difficulties
Safewards for Safe Homes (SSH)
SSH identifies factors that may lead to conflict and containment, which could place service users at risk of serious harm. SSH interventions support service users by considering mediating factors that may influence a containment dynamic.
Core interventions are:
- Clear and Mutual Expectations
- Know Each Other
- Mutual Help Meetings
- Calm Down Methods
- Soft Words
- Talk Down
- Positive Words
- Bad News Mitigation
- Discharge Messages
Safety plans to manage risks are developed between care staff, clinicians and service users, involving parents, social workers or other professionals where appropriate.
These plans will take into account early warning signs and triggers for risks, proactive approaches to prevent risk behaviours and agreed strategies as to how staff will respond to risky behaviour.
These may include the involvement of police or other agencies to maintain the safety of the service user, peers, staff or others.
All young people and young adults in Care in Mind placements are under the supervision of our Consultant Psychiatrist. Many of our clients will arrive from hospital settings on considerable amounts of medication. At the first psychiatric review, this will be discussed and a plan will be developed based on whether it appears that the medication has been helpful or not. It is important not to destabilise a young person by stopping medication during the period when they are settling into a new home and potentially arriving in the community after a long period in hospital. However, no medication is without its risks and we take the view that it is important to work toward reductions in medication where possible and particularly to discontinue the medication that has not made a positive difference.
Our approach to the use of medication in Care in Mind is to use it to treat symptoms that are distressing or difficult for a young person, but that it is the psychological interventions that are the core focus of Care in Mind’s treatment and this will be what leads to the most meaningful and enduring change.
Medications that we may prescribe at Care in Mind include:
- We will use these medications where we are persuaded that there is a Depressive episode present or where a young person struggles with Anxiety or OCD type symptoms.
- We will avoid the use of these medications in patients where mood is not low in a sustained way and their mood pattern is more of ‘affective dysregulation’ as they are not shown to be helpful in this client group and can increase impulsivity
- Antipsychotics are used at times to reduce high levels of emotional arousal and distress so as to assist the young person in engaging with the team to manage their risks better
- They are also used to treat psychotic-type symptoms such as ‘hearing voices’ and ‘unusual beliefs’ that can be distressing and difficult for a young person to manage
Antihistamines and Benzodiazepines
- These medications can be helpful in reducing agitation and distress. However, Benzodiazepines can lead to tolerance and addiction so we would always aim to use these drugs for as short a time as possible and then to reduce and stop them
- Often young people will have been taking this medication for a long time before they arrive at Care in Mind. However, we do find that at times, particularly in girls, this diagnosis may have been missed, in which case we may commence treatment
At times we may consider the use of other medications, such as mood stabilisers or medication to help sleep (in conjunction with a sleep hygiene plan)
Physical Health Monitoring
Our clinical nurse specialists will work with young people and residential staff to monitor physical health during medication usage and to identify any adverse effects that may need attention. Adverse effects may be monitored using standard tools such as LUNSERS.
We take the physical health of our clients very seriously. We have the facilities within the organisation to monitor:
- Blood Pressure
- Oxygen Saturation
We work in close cooperation with GPs around the need for routine and urgent blood investigations and the prescribing of medication and we develop Shared Care agreements when required.
Some medications and conditions require regular physical health monitoring and blood investigations and we will follow protocols to ensure that these are completed as required.