Susie: I.D. and Behaviour Problems

Meeting

2011-09-28T16:34:00.000+10:00

Meeting was great. Ethel has now taken on Sue's case, it was Ethel that told the CJP they could not move Sue to Montrose. I am so pleased that she listened to our concerns and acted on them. Ethel you rock.

She explained why Sue is on the CJP books and why she will stay on them and it is to do wiht funding. How hard was that fot the CJP to explain to us, let see not very but they chose not to.

So the hunt is on for accommodation for Sue and she may move as far away as Orange, but if the placement is right i do not care if i have to travel further to see her.

Ethel has said that Sue will never be placed in a surbian model that she will be placed in either the Riverside, Westmead or one of the other two models that are more like where she currently lives.

We also discussed Sue's rapid aging and she said she had noticed that and will ask to get Sue assessed as to whether the aged care placement at the Central coast may be on the cards for Sue at some stage.

So all in all a good meeting

SUE ISN"T MOVING

2011-09-16T16:51:00.000+10:00

YIPEEEEEEEEEEEEEE
WOOOOOOOOO HOOOOOOOO

doing little happy dance

shit i must be happy i don't dance

ADHC compliant

2011-08-31T16:14:00.001+10:00

ok, the head of ADHC is organising a meeting time with me. Hopefully we'll get some answers. She is really good and was instrumental is getting Sue placed at Kanangra.

ADHC complaint response form ADHC

2011-08-30T14:21:00.001+10:00

ADHC fowarded on my complain to Kanangra. Bad move, very bad move, Kanangra are wonderful and I will not let them get caught up in the complaint about the CJP.

So this is my reply back to ADHC

"First of all this is highly inappropriate because my complaint is not with Kanangra it is with the CJP and two workers at the CJP. Secondly it is a great delaying tactic to refer it onto someone not involved in the complaint.

So I have told Kanangra to reply back to ADHC saying that I have refused to meet with Kanangra and the CJP to discus how to communicate better with me as that avenue has already been explored before that that is why the complaint was submitted.

Secondly I said they should let ADHC know that I think it is highly inappropriate to contact Kanangra because my complaint is not with Kanangra it is with the CJP and two workers at the CJP. I have no issue or complaint with Kanangra or their staff or their communication with me. Kanangra staff are wonderful and Kanangra has been the best placement Sue has ever had."

It almost feels like the CJP are trying to cause a rift between Kanangra staff and myself by referring the complaint to them.

So I am going to add this to my complaint with the ombudsmen that the CJP inappropriatly referred this complaint to Kanangra.

Not only are CJP no good at keeping family informed they clearly can't read either for the complaint to end up at Kanangra.

Commonwealth Ombudsman’s office

2011-08-29T14:49:00.002+10:00

Our ref: 2011-115685
Dear Ms Patterson
Thank you for your email of 25 August 2011 in which you complain about the Department of Ageing, Disability and Home Care (ADHC).

We cannot help you with this matter. The Commonwealth Ombudsman’s office investigates complaints about the actions of Australian Government agencies (that is, ‘Federal’ or ‘Commonwealth’ Government agencies). As ADHC is a state government agency, we cannot investigate your complaint.

The NSW Ombudsman can investigate some complaints about ADHC. You might want to contact them to see if they can help.

Yours sincerely

ADHC compliant

2011-08-25T10:28:00.002+10:00

Dear Ms Patterson,

The Hon Andrew Constance, Minister for Ageing and Minister for Disability Services, has asked me to acknowledge receipt of your email.

A response will be sent in due course.

Office of the Hon Andrew Constance MP

Minister for Ageing

Minister for Disability Services

ADHC compliant

2011-08-25T07:57:00.000+10:00

Ok so seeing ADHC complaints department have not repleid to me I have taken the next step. Below is an email i sent to the Ombudsmen, The Hon. Andrew James CONSTANCE, MP
Minister for Ageing, and Minister for Disability Services and The Hon. Barbara Mazzel PERRY, BA, LLB MP Shadow Minister for Disability Services. Why not just answer my emails, why ignore someone it makes no sense to be this rude and incompetent or does it just come down to plain old arrogance.

"Hello,

I have lodged a complaint with ADHC (Ageing, Disability and Home Care) about the CJP (Community Justice Program) Parramatta office on the 11.8.2011. I have not heard back from them.

The initial complaint about CJP was about why the workers assigned to my sister case (Sue Patterson) do not reply to my emails, why I seem to be excluded from very important updates to her situation (such as workers refusing to work with her) and why I have not been receiving my weekly updates. The CJP talk about making sure family are kept informed of what is going on but in reality it is merely lip service.

Now I want to know why ADHC has ignored that complaint.

Now that this has got to the point of me sending a complaint to the Ombudsmen I would like an investigation as to why the CJP are moving Sue at all. They tell me it is because she is on their books but in reality should she still be? She has served her sentence, she has housing, she is settled. They tell me it is because she is one of their clients but in their own mandate they state that: “This program is funded by the NSW Government for the provision of accommodation and support services for people with intellectual disability exiting the criminal justice system. Clients exiting correctional centres undergo a comprehensive assessment to determine the level of support required by the person. Etc.”

My sister is not exiting prison, she has been out of prison since 2004 I think, so how long will she be treated like an offender? As you can see CJP is meant to deal with people exiting prison, she is not. The CJP should be helping people who need a placement, especially if their parole depends on suitable housing. Sue served a much longer sentence than originally handed down to her simply because there was no housing for her and DADHC were refusing services at that stage. It was my partner and myself who fought for Sues accommodation.

Sue has housing now, furthermore it meets all of her very complex needs. The housing that the CJP are offering does not, clearly, as they are having problems finding staff able to cope with Sue's very high and complex needs. Sue has had seven previous DAHDC housing models that have failed.

Kanangra where she currently is has everything that Sue needs and is not scheduled to close until 2018 and will never close while Morisset hospital is open so why the rush to move her?

Thanking You

Julie Patterson"

Discrimination

2011-08-23T16:55:00.000+10:00

A friend just pointed out something to me.

Sue has served her time, she is no longer on parole, so why are the CJP treating her like a criminal. If she did not have a disability then she would not be in this situation.

She in not a criminal, she has served her time, the CJP is for "This program is funded by the NSW Government for the provision of accommodation and support services for people with intellectual disability exiting the criminal justice system.

Clients exiting correctional centres undergo a comprehensive assessment to determine the level of support required by the person. Support may range from specific consultations or interventions to intensive accommodation support. Specialist assessment and support is provided by clinical and case work staff. A range of accommodation options is available, from intensive group home support to drop-in models.

The program aims to reduce the incidence and impact of offending behaviour by people with an intellectual disability."

She is not exiting jail she has been out for 7 years. So leave her alone and help the people who are leaving jail.

Ignorance is not bliss

2011-08-11T20:59:00.002+10:00

Complaint:

CJP wants to move my sister Sue from Kanangra to Montrose. This complaint is about their lack of communication with me as Sue's advocate and family. Example: I was the only person not told that Dr Kavarah, the psychiatrist, refused to work with Sue. Also i was not told that the RN had been removed from the plan that was orignally proposed to me.

And even though I am supposed to get weekly updates this information about staffing was not told to me by the CJP. I found out from other sources and when I emailed CJP about how these issues are going to be addressed they igonre me unless I lose my temper.

The main point is if they kept me informed on everything I would not have found out from other sources and this would never have got to complaint stage.

Sue does not know about the move yet so it wouldn't be a good idea to mention it to her.

I want from CJP, and in relation to this complaint, everything via email because I believe we all need to be accountable.

Thank you

latest email to CJP

2011-08-09T08:44:00.000+10:00

Hi

I'm wondering how you are going to deal with Sue's lack of hygiene when she moves. I know I have said before that she will not use a shower properly. That she does not care if she smells, Kelly you have first hand experience on this. But her space only has a shower.

In Sue's lastest ISP they say they use a "Daily plunge bathing for personal hygiene and relaxation"(pg 6 Health care section).

How are you going to manange this very important issue.

Julie

weekley updates

2011-08-05T16:58:00.000+10:00

haven't had one since the 6th July 2011. Bad, very bad, cause i reckon lots is happening.

Email to Kelly

Hi Kelly
I haven't had a weekly update in a while. Can you catch me up in regards to Sue's move and her service providers, Dr's, psychs etc.

Julie

my reply to Kelly

2011-08-03T15:41:00.001+10:00

Hi Kelly

Your reason for why I was not contacted about the recent changes in Sue's plan are unacceptable. If your firm tells everyone else involved about the Psychiatrist not wanting to consult with Sue then in reality I should have been informed at the same time because if I find out from elsewhere it only causes more problems. Does your firm not see that as being rude and just adding to the issue of bad family communication further. Regardless of what the CJP say you DO NOT keep family informed. Actions speak louder than words and your actions clearly show a lack of keeping family informed. First the RN, now the Psychiatrist, who else has decided not to work with Sue?

I expect better, Sue deserves better and in a lot of ways it's better for your firm if I know what's happening. I do not like being excluded and my patience ran out a long time ago with this situation.

I still do not understand why the rush to move her after all Kanangra is not due to close until 30th June 2018 and while ever Morisset Hospital is open so is Kanangra (Stronger Together pg 24-25)

I really think you should leave Sue where she is. She has everything she needs on site and clearly the industry outside of Kanangra do not feel they can deal with Sue and her very complex needs. All the talk of research and appropriate training don’t seem to have a clear result at all, and instead the work has been farmed out on contract.

If CJP do decide to move her then you should at least move her under the temporary leave move policy so that if/when it all falls apart she has a spot she can go back to at Kanangra.

As of yet I have not heard of any clear direction the CJP have except the “we'll make it work” line which doesn’t seem to be in line with the academic research and training line touted at meetings. So far this move is not working for Sue. You have to start seeing Sue as a person and not a case file to fill a vacancy and funding/political volleyball.

Julie

CJPs reply

2011-08-03T07:26:00.000+10:00

Hi Julie,
unfortunately I haven’t had a chance to get to my emails the past couple of days until now.

Your correct Dr Kavarah has declined to see Sue when she moves, we were only notified of this early last week. Given she is already consulting with one of the other ladies at Montrose we were attempting to clarify why she was prepared to see one person and not the other. Unfortunately we haven’t been able to clarify this, but her office has confirmed that she will not be able to take Sue on.

Katelynd & Lifestyle Solutions are busily attempting to identify other appropriate Psychiatrists to refer to, once we have confirmed the Psychiatrist I will ensure you are informed asap. Im sorry I can not give you a specific date as we are at the mercy of the Psychiatrist.

Thanks
Kelly

Now i saw Sue on Thursday, If they could let others know why not me? They do not keep family in the loop.

CJP's reply

2011-08-02T17:08:00.000+10:00

Good morning Julie,

I will have Kelly follow up on this.

Regards Katrina

So I fowarded this email onto Kelly myself, I'm making sure she gets it, tic tic tic.
My paitence is gone. tic tic tic, this is getting very old and annoying.

time for a shake up tic tic tic

weekley updates

2011-07-31T09:12:00.003+10:00

21st feb 2011
7th March 2011
18th March 2011
5th April 2011
12th April 2011
21st April 2011
30th May 2011
18th June 2011
30th June 2011
6th July 2011

For Katrina if she looks at this blog. You said to Julanna on the: "We give her weekley updates."

We'll there's a few gaps and in reality your weekly updates are not very informative. wonder why none of them metioned the RN not being employed afterall you like to keep family imformed don't you. Most times the weekley updates went like this;
"Hi Julie,
Progress over the past couple of weeks, has been significant from a staffing prospective. Katelynd along with a couple of other members of CJP conducted 2 weeks of training for the Staff recruited for Montrose. The training was very successful and all staff participated well.

Kelly"

Not very informative afterall I now know some of what was going on with not finding a Dr, a pschy the rn being cancelled funny how none of that was in the "weekly updates"

Mmm in reality it's only on the things you feel we need to know or the lip service you give us and that way we won't cause a fuss. Afterall can't have family knowing too much.

Susie

2011-07-29T17:05:00.001+10:00

In the last 13 months sue has had 118 incidents of challenging behaviour

I do not know how the Montrose model will work. I am worried about the quality of care and support she will get there.

Also she has had to be physically restrainted 31 times. Now i know it can take 5 staff to be able to safely restrain Sue, how are two going to do it at Montrose. Will the rn help, will the onsite psch help? It's still one less than needed. Yet another question not explained by the CJP.

I think they are to worried about money and not about safety and quality of life for Sue and a safe and well support work place for staff.

I do not understand how you could read Sue's notes and decide the best thing for her is to move her to somewhere with less. It has less than what she needs.

CJP

2011-07-29T15:21:00.000+10:00

no reply yet, my god they are hopeless, even if they could not answer my question hows about an email back letting me know that.

it's not hard it could go something like this

"I'm sorry Julie but at this point we don't have a time frame as we are still looking to source a pschy for Sue."

easy isn't it

what is really going on though is the CJP are rude, arrogant and have their head soemwhere it should not be. And they wonder why i get angry with them.

Susies visit

2011-07-28T20:35:00.000+10:00

Good visit today she was in a good mood, cheeky. She even ddin't mind me taking some photos. She ate al the treats then told me I could leave but it was in jest, so i stayed almost half an hour. The third time she said "you can go now" she meant it. She looks real good and has blonde hair at the moment and it really suits her. Told her she looked really cool with her, the blonde hair brings the colour of her eyes out.

Well I'm tired so I'm gonna go I wonder how long till the CJP email me?

Dr pulls out of treating Sue when she moves

2011-07-28T20:31:00.000+10:00

I was visiting Sue today and found out once again how bad the CJP are at contacting me. Th psych that they lined up for Sue has pulled out of being her Dr.
Now you'd think that would mean i would get an email form them to keep me up to date. But nope didn't get one, how rude is that. And they have the hide to tell Julanna that they do keep me informed, yeah right. So here is the email i sent Katrina:

Hi
I was visiting Sue today and was told the pschy (name omited for privacy reason) has decided not to work with Sue when she moves.

It would have been nice if yourself or Kelly sent me an email on this, but communication with family is not a strong point with the CJP.

Do you have a idea of how long it will take to find a replacement? Do not call me as per our agreement at the meeting email your reply.

Julie

Sue's move postponed

2011-07-25T06:54:00.000+10:00

Will update blog with Sue's new move date as soon as I know.

CJP's reply

2011-07-25T06:53:00.000+10:00

Good evening Julie

Will consult regarding new the new date for Sue’s transition given the delay in staff recruitment.

Yes re the walks will ensure that you receive a recreation planner which details staff attached to various activities for Sue, will discuss this with Lifestyles?

The Sykpe idea is brilliant, that would also be great for the other 2 women as well. I will discuss the implementation of this with Life styles also Kanangra.

Chat during the week re the various updates.

Cheers Katrina

Reply

2011-07-25T06:52:00.000+10:00

Hi Katrina
Thank you for the email reply. In regards to Sue's walks at the first meeting the original proposal was: "Montorse staff would drive her to a park where she can walk. With two staff supervising her." Is this what you are envisioning, that two two staff would drive Sue to a park and walk with while the other staff remain behind. It's a bit unclear in your reply, presumably the other clients don't need the same supervision level as only one staff would be staying behind.

Due to the delays caused by the employment of new staff do you have the ammened move date for Sue?

Have you thought of Sykpe video calls as a means for Sue to maintain her contacts at Kanangra I believe it is very cost effective.

Julie

got my reply

2011-07-22T17:31:00.006+10:00

Dear Julie,

I hope this clarifies some of you concerns. I would like the opportunity to talk with you again regarding the current issues also to try & reassure you that we will do all that is necessary to make Sue’s new move very positive and rewarding for her, I will ensure that all appropriate levels of staff resources for Sue and the other 2 women at the program are adequate at all times.

Is the Rn still going to be employed?
The Executive Director, Office of the Senior Practitioner, in consultation with Lifestyles Solutions has approved 14 hours per day for a registered nurse to be on site based at the Montrose program for Sue’s care only. This is not a shared staffing resource with the other 2 women who currently reside at the program.

The Community Justice Program has also funded Lifestyle Solutions to appoint a Psychologist full time 5 days per week based on site at Montrose.

There are also 2-3 disability support workers per shift (3 shifts per day).

What are the day activities for Sue, how often and who will do them? Is it separate staff to her staff?
As far as possible we have tried to replicate Sue’s daily activities as it currently is at Kanangra. The house staff on shift will be able to support Sue and participate with her in those activities. In addition, CJP has also funded another service provider (PSA) who can be utilised for day program activities. This is provided by Sunshine Homes.

What is the ratio of staff to Sue to the whole centre?
When Sue moves in she will be the third person living at Montrose. There will be 3 staff on shift during the day and 2 staff on shift overnight.

The housing/funding model changed, what funding is left?
Ageing, Disability and Home Care fund Lifestyle Solutions to operate the Montrose program as an Intensive Residential Service. Funding benchmarks are not for public disclosure. Lifestyle Solutions are funded for placements not individuals as per benchmark regulations.

How do you propose that Sue will do her daily walks?
Sue can exercise on site. There are also 3 parks close to the property where Sue could go walking with staff. Discussions have also occurred in relation to having a treadmill in the Recreation Area that Sue would have supervised access to.

How is Sue going to visit her friends at Kanangra? How is Sue going to maintain contact her friends both staff and other clients at Kanangra?

We have documented plans for Sue to visit Kanangra to maintain those relationships e.g. attending concerts and Christmas parties. Her friends are also welcome to visit her. Regular contact can also be maintained with phone calls and mail. We also have the contact details of her friend that lives in the community so that arrangements can be made for the monthly catch-ups to continue. Montrose staff and vehicle will be available to facilitate these visits.

Regards Katrina

Email sent to CJP after they have not replied to any of my emails today

2011-07-22T16:02:00.002+10:00

ok you're forcing my hand by not replying. I'm going to have to go public with this. Maybe see a minister or two or the reporter who covered the Watagan Centre story.
Next move is yours
you have until five
it is not hard to relpy to an email.

Julie

Katrina CJP

2011-07-22T10:20:00.000+10:00

Hi
couple of questions
Is the Rn still going to be employed?
What are the day activites for Sue, how often and who will do them? Is it seperate staff to her staff?
What is the ratio of staff to Sue nto the whole centre?
The housing/funding model changed, what funding is left?
How do you propsoe that Sue will do her daily walks?
How is Sue going to visit her frinds at Kananagra?
How is Sue going to maintain contact her friends both staff and other clients at Kanangra?

I want direct answers. Sick of the policy waving.

REPLY
Good afternoon Julie,
Could you please make a time to catch-up with me ASAP, regarding the various ongoing issues re Sue Transition?
I’m more than happy to schedule a meeting with you tomorrow.
Many thanks Katrina

REPLY BACK
Hi
Surely you can answer the questions in an email.

Julie

SECOND REPLY BACK
Hi Katrina
I am actually busy today. You will have to email me. I forgot the CJP have already told me it is Sunshine Homes that will provide day activites for Sue, I found the info in my notes. But I would still like to know what they are offering her. I do expect an email back with answers by the end of the day.

Julie

email to gaurdain

2011-07-22T10:18:00.002+10:00

Hi Peter

I have sent you now 4 emails and left three mesasages. The duty manager yesterday said he would put a pop up on your computer when it was started up this morning telling you to call me.

So either email me about where you satnd on Sue's move now the RN is not being employed. Or call me on my mobile 0434885800.

I expect to hear back from you today it is now 5 days since I first contacted you.

Come Monday if I haven't heard form you I will lodge a complaint.

Been patient enough i think.

Julie

OPG complaints

2011-07-21T09:24:00.000+10:00

so they tell me staff can not remotely access their email or voice mail, in this day and age how archaic is that.

So in a job where it requires you to be out of the office you have to be in the office to get your message, stupid just plain stupid.

OPG (Gaurdian)

2011-07-21T09:11:00.000+10:00

is not in the office today. This is frustrating beyond belief. no replies to my email and no replies to my voice message. What the hell use are you.

CJP

2011-07-20T16:23:00.001+10:00

no reply to email so far, two days since i sent it. They are also making me mad, they should know by now DON'T PISS JULIE OFF

OPG (Gaurdian)

2011-07-20T16:21:00.000+10:00

ok two messages left and an email for the Gaurdian no reply so far.

What is going on. Making me mad, not a good thing to do?

Watagan Centre

2011-07-20T13:35:00.004+10:00

WATAGAN CENTRE FORMER RESIDENTS

The Hon. PATRICIA FORSYTHE: In relation to funding for the support of former Watagan Centre residents did the Minister for Community Services, Minister for Aged Services, and Minister for Disability Services last week tell the media that they would always receive the level of funding necessary to support their needs? Did he also tell the media:

Naturally as the level of support they require lessens, the funding necessary to maintain them in their group homes can be reduced accordingly.

What assessment process was carried out to determine the level of revised funding to support these people? Is it a fact that no new assessment was carried out, and that service providers merely received a "Dear Provider" letter?

The Hon. R. D. DYER: As I have said before in this House, a proud achievement of the Government is the devolution of the Watagan residents to group homes in the community. I was the first member of Parliament to ever bother to visit the former Watagan Centre, which was earlier known as Carynia Oaks, and I described it as a valley of the lost souls. I was shocked and dismayed at what I discovered when I visited with my colleague the honourable member for Lake Macquarie, Mr Jeff Hunter. I made a promise to myself then that if I ever had the opportunity, I would remove residents from that place. One of the first things I did as Minister was to honour that commitment.

I am pleased that the Treasurer helped to achieve that objective by funding the necessary 80 places to relocate those people in the community. The Treasurer informs me that today he has given me more money. I am not sure what for, but I assure the House that whatever the Treasurer gives me will be gratefully accepted and very well spent. Thank you, Treasurer. I move on to what is happening with the Watagan Centre residents. When they moved out from Watagan to group homes in the community they were assisted at considerable public expense - more than might ordinarily be the case - given the extreme levels of disabilities and low levels of functioning occasioned by the many years they had spent at the Watagan Centre with practically no day programs, therapy or anything else.

In relocating the residents I was assisted in particular by the Hunter Mission, which did an excellent job, and by the Ageing and Disability Department. That department prepared individual service plans that were fashioned to suit the individual needs of each resident relocated from the Watagan Centre to group homes in the community. I not only said to the media but probably said in the House as well in response to an earlier question, that some of these 80 people are functioning at a greatly improved level, to such an extent that some no longer require permanent supported accommodation from the Government. Some who are living in ordinary homes in the community are receiving drop-in assistance. I have endeavoured to ensure that residents continue to receive the support they require.

On 21 November 1995 I gave a guarantee that when residents move from large residential establishments into the community, they will receive the level of care and support they need. All consumers have received that guarantee; the Government has been honouring that guarantee and will continue to honour it. It remains the case that funding for these people is monitored. I do not particularly care whether the Hon. Patricia Forsythe believes that, but these people have individual service plans and are provided with funding packages commensurate with their individual needs - full stop. Page 11102

WATAGAN CENTRE FORMER RESIDENTS

The Hon. PATRICIA FORSYTHE: I ask a supplementary question. Is the Minister currently reviewing and reducing the amount of money available to services providing accommodation and support to former residents of the Watagan Centre? Is he putting at risk the progress of those people? Can he guarantee that the programs aimed at improving the integration of those people into the community will not be cut?

The Hon. R. D. DYER: I will always ensure, and this Government will always ensure, that adequate resources are made available to care for people with disabilities who are in permanent supported accommodation places, including former residents of the Watagan Centre. It is true to say, though, that as time passes and as the level of functioning of certain clients increases, the support levels previously warranted can in some cases be reduced. That is a matter of individual judgment regarding particular clients.

afterthought, Email sent to the Gaurdian

2011-07-19T15:02:00.001+10:00

Hi Peter

The other thing that is of concerns is that the house is not sound proofed and the ammount of noise that Sue can make will surely lead to complaints from neighbours. The CJP have not addreesed this concern, even though it has been raised with them at least twice.

Also has anyone considered the fact that at the rate Sue is aging, she is aging quite fast due to her genetic disorders, that by the time Kanangra offically closes she may not need this high level of securtiy. She may just not be physically able to be a threat anymore. I think because the current model is so far away from the original propasal you need to rethink giving permission for the CJP to house Sue.

Ta
Julie

email to the two K's at CJP

2011-07-19T14:32:00.002+10:00

email to the gaurdain

2011-07-19T14:31:00.002+10:00

The gaurdian is out of the office today I'veleft message and emialed hi.

Hi Peter

I have grave concerns about the changes in the model for Sue's housing at Montrose. I have been told the the CJP are out of money for the matiance of the house and that any cost would be incurred by Lifestyles. So far the CJP have nto told me how this occurs.

I beleive there is not goign to be an RN employed anymore so how is Sue goign to get her IMI's?

The day activites seem to be slipping away as well.

I do not think she should be moved as the Montrose of today is not what they promised for her.

Thanks
Julie

my reply back

2011-07-18T13:11:00.007+10:00

Hi Kelly,

Just remove the shelf, as I have said three times now the tempered glass does not solve the problem as such, if she breaks the shelf Sue may decide to ingest the glass fragments if she cannot cut herself.

You really have not listened to anything anyone in the consultation process has told you. Sue does not have anything other than plastic or paper options in her own space at Kanangra. She will break crockery and she will inflict harm on herself or others but in the end that is your problem I guess seeing you do not listen to anyone has told you. And as the plates etc only being used in times of necessity (she will have at least three meals daily) well it doesn't take long for a plate to be broken once it's in her hands. You think I'm angry you would be right. I don not understand why the CJP seem intent on not minimising known risk factors.

"The unit has been funded by the CJP and there is a purchasing and planning team that continues to work with the service provider around the funding parameters" That really doesn't answer my question. I was told the money was all spent for the unit and that maintenance would have to come out of Sue's lifestyle funding. Now is there separate funding for the property and her day activities, massage et or is it all one lump amount?

In the end if things go wrong then the CJP will have to wear it. As there have been numerous attempts on my part to open your eyes to potential problems, which you chose to ignore.

Julie

CJP's reply

2011-07-18T13:11:00.005+10:00

Hi Julie,

Thankyou for your correspondence on the 14.07.11, please find to follow information in relation to the issues you raised in your email below.

· The glass shelves in the refrigerator are tempered safety glass and should be a safe option for Sue in her unit. Alternatively the glass shelving could be removed from the refrigerator as an immediate solution if needed. Sue’s fridge will also initially be locked at all times with access provided only during staff supervision.

· All units are equipped with locked cabinets for storage and security. The kettle and toaster in Sue’s unit will be placed in these lockable cabinets until they are required and will be returned and locked after each use. Procedures are in place so that staff check unit cabinets and locked areas, when she accesses these items, prior to leaving Sue’s unit. Sue will also have access to the kitchen within the common area and staff unit. This space will only be used when staff are present, the kitchen in this space has been modified to ensure safety for all and kitchen equipment such as toaster, kettle etc will also be locked away.

· Plates and cutlery were purchased with staff and client safety in mind so are for example shatterproof and less likely to inflict serious harm if used for purposes other than those intended. All cutlery and plates will also be in lockable cabinets and be used only during times of necessity.

· The service provider has already purchased linen and towels and these are available on site. Sue’s unit will have her linen and towels ready when she moves.

· The unit has been funded by the CJP and there is a purchasing and planning team that continues to work with the service provider around the funding parameters.

· Options to make the fencing higher on the side of the property are being considered and progress on this will be provided when available. There are unit procedures in place for staff to monitor and physically check the property perimeter on a regular daily basis and the unit is staffed around the clock to provide appropriate support to clients.

· Sue’s shutters will be operated only by staff and after further consultation with all stakeholders plans will be put in place for Sue to learn to operate and access them independently.

Thanks for the email.

Kelly

Email sent to CJP after visit to property

2011-07-14T15:55:00.000+10:00

Hi Katrina
I meet with H*** at Montrose today. Ok now for my concerns there is still glass in Sue's space. There is a glass shelf in the fridge and he is pretty sure the mirror in the bathroom is glass. This was asked to be rectified last visit I suggest you fix this now.

Also you should remove the kettle and toaster from Sue's space. As I said before she has no access to the kitchen at Kanangra. Or ask them how to manage this new situation. Also what are you going to use for cutlery, plates, mugs etc for her?

What linen, bedding and towels are going to be provided for her? And by who?

H*** told that the CJP funding for the house has been used up. What funding does the CJP have left for Sue? Can you give me a monetary break down of Sue's allocated funding?

It is nice to see the screening suggestion and the need for higher fencing I had for the front entrance has been taken on board. Disappointing that the access to the side of the property is still not rectified but it seems everyone bar me see this as a non issue because of the drop where as I see the fact that it has a drop off the side of the property as a reason to secure it.

Heihena said that my suggestion to grow some climbing plants is also going to be used. Also good to see that privacy. shutters for Sue's space. How will she get access to use them?

Julie

reply to my email about Sue case plan

2011-07-07T07:38:00.005+10:00

Hi Julie,

Thankyou for your emails of 01.07.11 and 04.07.11. Please find to follow additional information in relation to the issues you raised in your emails. The updated Case Plan has also been attached for your reference. The Plan is a working document and as such the term incomplete has been used within the Plan to identify key areas where work is currently in process but not finalised as yet. These items are being worked on with the view to them being finalised as far as is possible prior to Sue moving to Montrose.

Julanna’s involvement in Sue’s life not documented: this has been rectified and the Plan now includes Julanna’s involvement.
Sue’s belongings: This section has been included to document Sue’s possessions and to ensure that they are ALL moved with her. It has been left blank at this stage and will be completed on the day of Sue’s move. The Plan has been amended to make this more clear.
Reactive Strategies in place of IMI: This remains incomplete at this stage until the completion of Prevention and management of violence and aggression training. The strategies discussed will be embedded into the response strategies.
Community based Psychiatrist: Community based Psychiatrists have previously been contacted and indicated that they would not be in a position to take Sue on as a client. We are currently placing a referral with a community based Psychiatrist who is taking on new referrals at the moment and has recently seen one of the other ladies currently living at Montrose.
Community based GP: there were some difficulties with the local GP’s not being in a position to provide the services we needed. This has been rectified with the identification of an appropriate GP, more details are in the Plan.
Briefing the local Mental Health Team: Based on discussions with Kanangra, a 3 tiered mental health plan has been developed with the local mental health team being the 3rd tier. Consequently the mental health team can be briefed once we have engaged the services of a community based Psychiatrist and at the direction of that Psychiatrist.

Tier 1 – Montrose Staff

o Implementation of positive programs

o Implementation of Psychiatrist's recommendations

o Monitoring of symptoms

- repetitive hand movements

- repetitive touching of nose

- decreased enjoyment of preferred activities

- decreased participation in daily activities

- persistent low level of mood

- changes to sleep patterns

- changes to eating habits

- loss of skills

o Data collection

Tier 2 – Sue’s Psychiatrist

o Regular review

o Monitoring, review and prescription of medication

o Recommendations for intervention

o Referral to local Mental Health Team

Tier 3 – local Mental Health Team

o Support with management of major episodes of mental illness e.g. major depression

o Support with management of emergency situations

Clinical Indicators that Sue is not coping: This item is to acknowledge that Sue’s transition needs to be person centred. The clinical indicators have been documented and therefore the item is complete. (See Tier 1 descriptors, developed by Kanangra staff) If there is clinical evidence that Sue is ‘overwhelmed’ or not coping (as observed through the clinical indicators) then decisions will be made at that time in order to support Sue more effectively.
Day Activities: are currently marked as post transition given they will commence after Sue has moved. A daily schedule has been developed based on Sue’s current activities at Kanangra. Day activities such as music and dance are already available through LS Community Justice Performing Arts Programme. There are 3 local parks that have been identified. Options for Sue to exercise on the premises are also being investigated. Risk assessments need to be completed for community access e.g. the parks. CJP has also funded a organisation to provide activities for CJP clients. This service will be available to all Montrose clients.
Appropriate staffing levels: As you’re aware Sue’s levels of support in Kanangra vary through out the day from no direct support when in her unit to the highest level of staffing being 2:1. Montrose plan to duplicate this level of support.
PMVA Training: This will be completed before Sue moves into the unit.
Mental Health First Aid Training: This training has been added to Montrose training calendar; this specific training is not required before Sue’s move. Staff will however have client related training around Sue’s mental health needs prior to her moving in and will have access to plans and strategies.

My Respone

2011-07-06T07:51:00.000+10:00

Hi
Two thing i noticed on a quick read through is there is no mention of Julanna's involvement is Sue's life, please rectify this. Julanna see's Sue regularly. Also there is no mention of Sue's items beig taken with her, in fact it's blank. She has posessions, music, dvd's clothes etc you neeed to make it clear that all her posessions including personal itmes such as photos and Sarah's artwork go with her.

I'll read it in full later.

Julie

Second Reply sent to the CJP
Ok
I have read this document.
In action objective/rationale you have an incomplete in the "Develop appropriate and effective Reactive Strategies to be used in the place of PRN - IMI" when will that be complete? It should have been by now.

Also in action objective/rationale "Handover from current Psychiatrist to community based Psychiatrist: Incomplete" Do you have a communtiy based Psychiatrsit in place?

Also in actions objective/rationale "Handover from current MO to community based GP who is able to provide home visits: incomplete" So does Sue have doctor lined up?

Also in action objective/rationale "Brief local community mental health team (Blacktown): Incomplete. When will this be done. All of these vital resources should be in palce and finalised by now. You have got to be kidding that a month before she moves things like this are incomplete. Hopeless and in a lot of ways disrespectful and neglectful.

Now in objective/rationale actions you have a complete that i don't know how you've done it "Document key clinical indicators that Sue is ‘not coping’ with the transition. The transition can then be modified accordingly based on Sue’s needs e.g. increase / decrease the speed of the transition into the community if there is clinical evidence that Sue is ‘overwhelmed’" Explain?

Now do you have Sue's day activites organised, where she can go walking worked out, her massage and music therapy set up, dances, etc, becasue all it says is post transition can you clairfy what you have in place for her in this area of her life?

Now in actions objective/rationale staffing: "Appropriate staffing levels not less than 2:1 (Staff:Sue) with additional back-up staff in immediate vicinity incomplete." Explain in detail?

Also in actions objective/rationale staffing: "Restraint/Escort Training e.g. PMVA (Graham Davies) or similar: incomplete" When will that be completed?

Also in actions objective/rationale staffing: "Mental Health First Aid Training incomplete." When will training be finsihed?

You have a lot of incompletes, when will these all finalised?

Also i would like to see the space again before you tell Sue of the move.

Regards

Julie

2011-07-06T07:46:00.000+10:00

Version 2.1 (27.06.10)

Client Name: Susan ‘Sue’ Patterson D.O.B 28.11.69 CIS # 875718
CJP Staff: Katelynd Turner CJP Staff: Kelly Fishburn
Annual Review and new plan development date:
Formulation statement:
Ms Patterson is a 41 year woman with an intellectual disability and Phelan-McDerrid Syndrome. Her level of disability has been assessed over time from borderline to moderate, with later assessments indicating declined functioning. Ms Patterson was an adoptive child who witnessed significant violence by her adoptive father towards his natural children and was sexually abused by him. While expressing high levels of aggression as early as primary school, Ms Patterson witnessed further violence at her boarding school, where two teachers were stabbed to death. These teachers were part of Sue’s dormitory and worked with Sue. Sue is able to recount the details of these murders so it is likely that she witnessed some aspects, if not all of these events. She also experienced significant violence and sexual assault in her accommodation upon leaving boarding school and experienced a great number of accommodation changes. From reports, it appears her level of disability, genetic disease, frequent loss of relationships, poor attachment history and traumatic and possibly neglectful early environment interacted to result in severe emotional dysregulation and fears of abandonment. This is consistent with her diagnoses of Intermittent Explosive Disorder and more specifically Borderline Personality Disorder. Her poor emotional regulation stemming from her BPD, in combination with the traumatic losses, such as the loss of her daughter also explains her periods of Major Depressive Disorder with Catatonic Features. Her reported psychotic features are also consistent and common in those with BPD.

Ms Patterson currently resides at Kanangra Centre in Unit 4. Ms Patterson lives by herself in a self contained unit but has the ability to interact with other clients of Unit 3 during the day. Ms Patterson has recently experienced a period of generally positive mental health and behaviour following a number of sessions of Electro-Convulsive Therapy subsequent to a period of catatonic depression. Apart from the ECT, which alleviated the depression, it is suspected that her improved functioning revolves about her environment and pharmacotherapy, which includes the use of mane, nocte and pro re nata psychotropic medication.

A number of environmental factors at Kanangra appear to have been instrumental in Ms Patterson’s improved functioning. Kanangra provides clear physical boundaries to Ms Patterson. This includes the ability to socialise and have day activities without leaving the grounds. It also includes reinforced fixtures which reduce risk of property damage, injuries to self and staff and absconding. These reduce risk of criminal justice involvement, relationship breakdown and consequential service breakdown, (which has historically reinforced some of her Borderline thinking and coping styles). A key element to the success of Kanangra has been the experience of staff in supporting people with severe challenging behaviour. This expertise revolves about their ability to quickly de-escalate critical incidents using distraction, environmental manipulation, communication strategies, PRN medication (including IMI) and applying effective and safe restraint procedures. Of great importance has been their non-dramatic appraisal of incidents which can reduce the function of the behaviour and thereby reduce the reinforcing value of the challenging behaviour. Staff have also been very consistent, with most having been there the entire time Ms Patterson has been at Kanangra. This has provided a degree of stability in her relationships that undermines her core belief about abandonment.

To ensure Ms Patterson does not regress or have the progress she has made squandered, it is imperative that she be supported in a model where there is a clear validating environment with stable, secure staff and other clients she relates well towards. These and the service recommendations from the SNRG assessment are strongly reflected in the accommodation and support model identified at Quakers Hill.

Relationship /Position Name Relationship /Position
Katelynd Turner Casework Specialist CJP Carol Tranter Nursing Manager
Kelly Fishburn Team Leader Case Management Julie Patterson Sister
Ellie Cave RUNM Kanangra Peter Wilson Legal Guardian, OPG
Janine Woods Psychologist Kanangra

1 Family
Objective / Rationale Actions Responsibility
Timeframe

Liaise with Julie and Sue’s mother regarding Sue’s transition into the community through invitations to meetings and the provision of regular updates CJP
Kanangra Ongoing

Maintain current schedules regarding contact and parcels (this includes food parcels to be reviewed by staff and provided to Sue in stages)Lifestyle Solutions Post Transition

Provide opportunities for visits between Sue and her family Lifestyle Solutions Post Transition

Assist Sue to display her photographs etc in her unit CJP Kanangra Lifestyle Solutions Incomplete
Memory book to be developed for Sue about her life at Kanangra Kanangra Incomplete

2 Physical Health
Objective / Rationale Actions Responsibility
Timeframe
Continue to monitor Sue’s weight Lifestyle Solutions Post Transition
Utilise ‘Light n Easy’ or similar to maintain her healthy eating as well as a means of meal preparation Lifestyle Solutions Post Transition

Regular Dietician review Lifestyle Solutions Post Transition
Provide regular schedule of physical activity to support a healthy weight range Lifestyle Solutions Post Transition
Identify suitable location where Sue can continue to enjoy walking Lifestyle Solutions Identified

Need Risk Assessment

Handover from current MO to community based GP who is able to provide home visits Kanangra Lifestyle Solutions Incomplete

Ongoing GP reviews Lifestyle Solutions Post Transition

Completion of CHAP tool (as necessary) Lifestyle Solutions Post Transition

Develop appropriate and effective Reactive Strategies to be used in the place of PRN - IMI CJP Lifestyle Solutions Psychiatrist Incomplete

Handover current Webster Pack Kanangra At Transition
Fill new prescriptions Lifestyle Solutions As needed

Mental Health
Objective / Rationale Actions Responsibility Timeframe

Identify appropriate community Psychiatrist CJP Lifestyle Solutions Dr Sophie Kavanagh

Handover from current Psychiatrist to community based Psychiatrist CJP
Kanangra Lifestyle Solutions Community Psychiatrist Incomplete

Develop mental health response plan based on identifying early warning signs and providing appropriate early intervention CJP Lifestyle Solutions Complete

Monitor mental health status through ongoing data collection Lifestyle Solutions Ongoing

Re-engage services for ECT/other appropriate treatment as indicated in mental health response plan Lifestyle Solutions As Required

Brief local community mental health team (Blacktown)CJP Lifestyle Solutions Incomplete

Accommodation Objective / Rationale Actions Responsibility Timeframe

Sharing Information consistently:
o1 Meeting with Sue’s family
o2 Meeting with OPG
o3 Meeting with Kanangra staff
o4 Meeting with Sue
CJP Kanangra Lifestyle Solutions Sue and her family OPG Ongoing

Transition to community accommodation:

o1 Staff buddy shifts at Kanangra Lifestyle Solutions Kanangra Ongoing

o1 Photographs of new home and discussions with Sue Lifestyle Solutions Incomplete
(Proposed for: 25.07.11)
o2 Visiting new Unit at Montrose Kanangra Lifestyle Solutions Incomplete (Proposed for: 02.08.11)
o3 Pack belongings
o4 Farewell Party at Kanangra Kanangra Sue and her family Incomplete (Proposed for: 03.08.11)
o5 Move into new Unit at Montrose CJP Kanangra Lifestyle Solutions Sue and her family Incomplete (Proposed for: 04.08.11)
o6 House warming party Lifestyle Solutions Kanangra Sue and her family Incomplete
(Proposed for: 05.08.11)
o7 Document key clinical indicators that Sue is ‘not coping’ with the transition. The transition can then be modified accordingly based on Sue’s needs e.g. increase / decrease the speed of the transition into the community if there is clinical evidence that Sue is ‘overwhelmed’ CJP Kanangra Complete

5 Education Objective / Rationale Action Responsibility Timeframe

Investigate formal adult learning opportunities for Sue if interested Lifestyle Solutions Post Transition

Continue informal learning opportunities through Activities of Daily Living (ADL’s) Lifestyle Solutions Post Transition

Continue with literacy and numeracy ‘lessons’ (1/2 hr/wk) that Sue currently enjoys Lifestyle Solutions Post Transition

7 Recreation Objective / Rationale Actions Responsibility Timeframe
Follow similar structure as current daily planner as far as is possible Lifestyle Solutions Post transition

Ensure Sue continues to have the opportunity to enjoy current preferred activities e.g. music therapy, walking, concerts Lifestyle Solutions Post transition

Continue structured community access activities Lifestyle Solutions Post transition

Provide Sue with the opportunity to develop new recreational activities Lifestyle Solutions Post transition

Maintain opportunities to visit peers and staff at Kanangra Lifestyle Solutions
Kanangra Post transition

8 Religion/Cultural beliefs Objective / Rationals Actions Responsibility Timeframe
Sue has attended Church at Kanangra of a Friday. She enjoys the music and the singing. Investigate ongoing contact with Church if Sue wishes to continue attending Church Lifestyle Solutions Post transition

9 Social Relationships Objective / Rationale Actions Responsibility Timeframe

Maintain Sue’s peer relationships at Kanangra with regular planned visits e.g. attending concerts Lifestyle Solutions Kanangra Post Transition

Maintain Sue’s relationships with Kanangra staff e.g. phone calls, staff visits Lifestyle Solutions Kanangra Post Transition

Provide opportunities for ongoing development of social interactions with peers in the community setting Lifestyle Solutions Post Transition

10 Functional Skills Objective / Rationale Actions Responsibility Timeframe
Continue to provide opportunities for informal learning regarding functional skills Lifestyle Solutions Post Transition

Utilise Individual Planning process to identify specific functional skills to target formally Lifestyle Solutions Post Transition

Consider skills assessment Lifestyle Solutions Post Transition

Develop skills development plans accordingly Lifestyle Solutions Post
Transition

Staff to assist with ADL’s as required in periods of depression Lifestyle Solutions
If and as required

11 Decision Making Objective / Rationale Actions Responsibility Timeframe

Liaise with OPG regarding Sue’s transition into the community CJP Kanangra
Lifestyle Solutions Ongoing

Provide documentation to assist in consent for move process CJP Complete

Obtain consent from OPG
Consent for Services, Exchange of Information etc (17.11.10)
Consent for Move (05.01.11)CJP Complete

12 Behaviour & Risk Management Objective / Rationale Actions Responsibility
Timeframe

Update current behaviour support and risk management plans in light of community accommodation and DBT model in collaboration with Kanangra CJP Ongoing

Review incident reports and data CJP Kanangra Ongoing

Provide staff training (see Section 13)(see Section 13)

Staff to have practical working knowledge of above plans Lifestyle Solutions
CJP Ongoing

Implement data collection and collation Lifestyle Solutions Ongoing

Regular review of plans as per policy (i.e. quarterly) Lifestyle Solutions Post Transition

13 Staff Provision & Training Objective / Rationale Actions Responsibility
Timeframe

Employ skilled staff Lifestyle Solutions Complete and Ongoing

Roster regular and stable staff Lifestyle Solutions Complete

Appropriate staffing levels not less than 2:1 (Staff:Sue) with additional back-up staff in immediate vicinity CJP Lifestyle Solutions Incomplete

Training recommended for staff working with Sue:

o1 CJP Establishment Training CJP Complete

o2 Client specific Training CJP Complete
o3 Restraint/Escort Training e.g. PMVA (Graham Davies) or similar Lifestyle Solutions Incomplete
o4 Buddy shifts with Kanangra staff Lifestyle Solutions Kanangra Ongoing
o5 Dialectical Behaviour Therapy Training (ongoing commitment) CJP Ongoing
o6 Behaviour Support Training CJP Ongoing
o7 Risk Management Training Lifestyle Solutions Ongoing
o8 First Aid Training Lifestyle Solutions staff Ongoing
o9 Mental Health First Aid Training Lifestyle Solutions Incomplete

14 Services Current Service Name / Contact Details Last Review / Attendance Date Community Based Service Complete Review Date
General Practitioner Dr Eric Fraser
Kanangra Centre
Hunter Residences
Department of Family and Community Services
Locked Bag No 3
Morisset 2264 Annual physical – 27 June 2011

Psychiatrist Dr Bruce Chenoweth 4 November 2010
Dentist Dr Wong 14 June 2011
Neurologist
Ophthalmologist
Psychologist Ms Janine Woods 27 April 2011
Pharmacist Bowens Pharmacy
Podiatrist
Dietician Ms Wendy Dear
Stockton Clinic 5 July 2010
Massage Therapist Mr Hedley Neal 22 June 2011
Day Program Services Dilkara
Kanangra Centre Daily
Financial Services Leanne Harrison
Assistant Client Service Officer
Client Service Team 5 – Long Term
NSW Trustee and Guardian 27 May 2011
Outstanding Bills ? Pharmacy

15 Furnishings and Possessions
Indicate items, and actions by who and when Client Register Updated signed and dated by current manager

16 Clothing Register
Quantity: Date of
Purchase Item Description Signature

Transportation Company: Booked Date for Transport:

17 Clothing Register
Document Document Date Handover Date
Individual Plan (signed and endorsed and the resident/carer/family member and/or Guardian/Advocate) 4 July 2011
Health Care Plan (signed and endorsed by a doctor and the resident/carer/family member and/or Guardian/Advocate) 4 May 2011
Epilepsy Management Plan N/A
Nutrition and Swallowing Plan 15 June 2011
Oral Health Assessment/Management Plan
Comprehensive Mealtime Management Plan 5 July 2010
Asthma Management Plan N/A
Client Annual Health Review 24 June 2011
Key Health Issues 24 June 2011
Client Health Care Plan As above
Cumulative Medical History Ongoing
Client Risk Profile 4 May 2011
Client Risk Management Plan 4 May 2011
Client Manual Handling Plan (Mobility Management Plan) 15 June 2011
Transport of Clients Risk Review 15 June 2011
Guardianship Order for Banker arrangements and Financial Plan from NSW Trustee Estate managed since admission
Financial Plan – 27 May 2011
Person Responsible Public Guardian
Medical/Dental Consents 23 May 2011
Guardianship Orders 10 May 2011
Behaviour Support 27 April 2011
Behaviour Assessment December 2004
Comprehensive/Incident Prevention & Response Plan 27 April 2011
Lifestyle Review 27 April 2011
Skills Development Plan 27 April 2011
Communication
Communication Profile 15 June 2011
Communication Plan
Financial Plan 4 July 2011
Recreational Activity Preference 15 June 2011
Day Programme Assessment 6 July 2010
Client Profile 15 June 2011
Personal Belongings Inventory At transition
Personal Clothing Inventory At transition
Pension Card 30 Nov 2011
Medicare Card August 2011
Calender of forward medical appointments
Current funeral arrangements

11.2.2011 Update

2011-02-18T07:31:00.001+11:00

Hi Julies,

This weeks update is as follows:

*
Lifestyles continue to attend Kanangra 3 days a week, no issues reported.
*
Interviews for staff commenced today.
*
All property modifications have been completed.
*
Keys to unit will be handed over to Lifestyles early next week.

Let me know if you have any questions, also can you please flick me a brief email to confirm you are getting these emails?

Enjoy your weekend

Kelly

weekely update 3.2.2011

2011-02-18T07:25:00.002+11:00

Hi Julies,

How has your week been?

This weeks update is as follows:

*
CJP had a meeting with Kanangra on Monday. Kanangra reported that Sue has been travelling well. Sue has responded very positively to the Lifestyle staff.
*
Lifestyles continues to attend Kanangra 3 days a week
*
Recruitment - Adds close on Monday. Staff interviews will be conducted over the next few weeks.

If you have any questions please don't hesitate to ask

Have a good weekend

Kelly

weekly udate from the 28.1.2011

2011-02-18T07:24:00.002+11:00

Hi Jules,

This weeks update is as follows:

* Lifestyle's staff continue to work shadow shifts at Kanangra 3 days a week. 2 staff members have been sharing these shifts up until now, given the transition is going to be longer than originally expected, it gives us an opportunity to slowly rotate other staff with the 2 existing staff, allowing more staff to have observed Sue in Kanangra, staff interaction styles & behaviour management strategies on-site. A third staff member will be introduced over the next couple of weeks.
* Recruitment for Montrose staff is on going, Nurses add closes over the next week or two.
* As discussed, Sue's proposed move date will need to be delayed in order to get all staff on board & trained. At this point its looking like late April early May.
* Katelynd returns from leave next week.

Hopefully I haven't missed anything from this week, have a great weekend

Kelly

my reply to the guardian

2011-02-18T07:20:00.001+11:00

"Hi Peter
I do understand your concerns but I tend to think you moved a little fast on signing off on Sue's move. Kanangra isn't slated to close until 30th June 2018 and it may never close as long as Morriset Hospital is open. The CJP told me at the first meeting that Kanagra was due to close end of this year, then they said it was due to close end of 2012/2013. The CJP have an agenda that involves securing their funding and filling vacanies and Sue is just a pawn in that agenda. Futhermore the CJP have lied about Kanangra's closure dates they would have the same paperwork I have about Kanangra, this just adds to my concerns about their true motives around moving Sue. They continue to lie to me about the placement for Sue, they are not a very trustworthy organisation.

I think the CJP are rushing things with Sue, they are still at beginners Phase, really, of dealing with clients like Sue. And in some ways she is a guinea pig for this housing model. The CJP motives are questionable. They think they can cope with Sue and do a better job than Kanangra, I know they can't.

Also has anyone considerd the fact that at the rate Sue is aging, she is aging quite fast due to her genetic disorders, that by the time Kanangra offically closes she may not need this high level of securtiy. She may just not be physically able to be a threat anymore. I think delaying CJP will solve the problem of housing Sue anyway.

Regards
Julie"

I haven't heard back from him.

Guardians reply

2011-02-18T07:18:00.002+11:00

"Hi Julie,
Yes, I have provided consent to Sue's move. I needed to make a decision either way with this. If I made the decision for her not to go, we would be back at square one, with no alternate accommodation options. My initial consent doesn't mean that you or myself cannot advocate on Sue's behalf regarding the move. It should not change your role as a family member advocating on her behalf and I encourage you in that role.

Please note that me providing consent to the move does not mean that I can't withdraw consent if appropriate

I understand that there are still issues with Montrose that you are not happy about. I share your concerns however I'm not prepared to forgo the Montrose residence at this stage. Not sure if you have heard anything about Kanangra closing - no-one has officially said anything, however, I am aware that there has recently been money allocated for the closure, so it will happen. A major concern of mine is that I don't really want Sue lumped in with the other residents when it does close. When that time comes, ADHC will be required to find accommodation for all the residents there and it's unlikely they will receive what Sue will have access to at Montrose. It's been my experience that when a large group of clients are moved at the same time, things get overlooked, or some are disadvantaged.

Peter"

18.01.2011

2011-02-18T07:17:00.001+11:00

in the same phone call i had with Kelly about the guardian signing off on Sue moving she also told me that Katrina had told her that she called me to let me know the RN was now going to be employed.

Lies
I didn't hear from Katrina to tell me the RN was back on board, i heard from her after i sen her an email saying i would support any staff member suing CJP because staff did not have access to IMI for Sue. Katrina rang less than 2 minutes after i sent that email saying the issues i raised about the not being RN employed would be looked at and they would try to find the money. But I haven't spoken to Katrina since then.

It was in this phone call that Kelly told me the Guardian had signed off on Sue's move. First i'd heard of it.

everybody get on board and let family know what's happening. We do fucking care what's happening to Sue. gezz.

I also spoke to Kelly about CJP staff talking to Sue about her daughter. Sue said "they said it was appalling that Sarah is in foster care" I told her that is a word Sue would not use, that in reality CJP should not to Sue at all about Sarah as it is nothing to do with them. And Sue may latch onto those conversations and rehash them, she's only just got calm about Sarah.

the reply form Kelly after our talk.

"It was good to touch base with you yesterday afternoon. please find the following documents

* Montrose milestones (as discussed this plan will need to be pushed back at least 6 weeks for the nursing recruitment to be completed)
* Montrose DBT model - this is a brief outline of key feature of the model including staff training (addition property modification have not been yet noted in this documents)
* Systemic DBT fact sheet - this is a brief overview of System DBT which Montrose will revolve around.
* Advertisements that Lifestyles have circulated thus far.

I have discussed the concerns you raised about CJP staff visiting Sue with the individuals involved, both people have assured me at no time did they say "it was inappropriate for Sue's daughter to be in foster placement". All conversations where at a table with 2 or 3 Kanangra staff present, at no time where they alone with Sue. Given the conflicting information, we will now have a very clear rule that states any person (CJP or not) are not to discuss Sue daughter with her.

Attached is a copy of the consent from OPG for Sue's move to Quakers Hill. This was forward to Katelynd while on leave hence the reason we only found out about yesterday.

Please be assured there has been no intentional "delaying tactics", I think it has been a combination of leave and enormous workloads that has delayed the forwarding of information.

To ensure communication in the future is regular and free flowing, as discussed yesterday, we will commence a weekly email process where all new information/progress will be relayed. You should expect these emails close of business each Friday at the latest (some may come through on Thursdays). We will send these emails regardless of new information being available or not to ensure we have a clear structure in place.

Please let me know if I have missed anything or if you have more questions

Thank you

Kelly"

Gaurdain signs off on Sue's move?

2011-02-18T07:08:00.002+11:00

Hi Peter
I had a call from Kelly Fishburn around 6.30pm last night who told me that you have signed off on Sue's move? Is this correct?
ta
Julie

2011-02-18T07:07:00.000+11:00

Email sent to the CJP because they kept on not letting me know what was happening with Sue move.

"Hi
I believe I have been more than patient with the CJP. I do not think it is unreasonable to ask for information that I was told the CJP would send me. I do not appreciate being told that it will take time to "get it together." I was told it was already together. I also do not think it's appropriate to pass the workload onto a staff member who is on leave.

Your firm has until the end of business Wednesday to provide: the ad for the staff at Montrose and also the draft plan for Sue's accommodation model, as well as the staff training breakdown.

If I do not receive these by Thursday, I will lodge a complaint. I do not like the delaying tactics the CJP use, it's counter productive, rude and excludes family from the knowledge of the events occurring in Sue's move. You offered to send them so now show some respect and do it.
ta
Julie"

2011-01-13T07:58:00.001+11:00

link to info about the closure of Kanangra

:Kanangra Centre to be closed with the target date being 30 June 2018 but a final decision will take account of any plans regarding Morisset Hospital. One government operated centre, Kanangra, does not have fully finalised funding arrangements. The final closure timeline for Kanangra will need to take account of any changes to Morisset Hospital with which it is co-located." (page 24)

taken from http://www.dadhc.nsw.gov.au/NR/rdonlyres/93E65784-353B-4E01-8858-303F4B247A76/5404/ADHC_StrongerTogether_20102016_phase2_web2.pdf

now this is vastly differant to what we were told at the first meeting, that it was due to close end of this year early next year. It is also differant to what Katrina said in the last email of it closing by 2013.

Now tell me Sue isn't being moved just cause she fills a spot, try to convince me now.Dare you. And did you think i wouldn't find the info, foolish. AND DO NOT LIE TO ME. Knew all along your motives were sus and that truth was not one of the strong points of the CJP in Sue's move.

LIARS.

Last email to ADHC

2011-01-13T07:48:00.000+11:00

copy of email sent to Katrina:

"Hi Katrina

Can you give me contact details for Matt and Stephanie from CJP, they
visited Sue around September. Also I would like a copy of the ad for the
staff at Montrose and also the draft plan for Sue's accommodation model.

As well as the staff training breakdown. You mentioned sending those to
me and I haven't received them yet.

Also I'm just checking my memory it is the end of the year that you said
Kanangra is due to close?

Can you email me back.

Ta Julie"

reply: "Will gather all the required info requested over the next few
days.Kanangra closing/transitioning over a 3 year period will clarrify
with them. Regards Katrina "

Katrina

2010-12-22T13:46:00.004+11:00

Just called me to assure me that Sue's needs are being met, that the fact there is no nurse is based on evidence of her needing less IMIs. She also said that it is an expensive thing to fund a nurse to sit there for 12hours if it is not needed. Granted it is, but what if it is needed? Oh well, can't move a mountain I guess. And by retracting funding it is evidence that it is a numbers game it's not about staff safety or clients needs.

She told me that the Senior Practitioner and the Practice Nursing Leader of ADHC(Karen) both agree that a nurse is not needed.

She told me that they are looking into sound proofing the house. That they took my point about her making lots of noise very seriously and that she agrees with me that it would be best if it is done prior to Sue moving in. Thank goodness. I could not work out how you could do it after.

Also they are going to plant some established trees out front for more privacy in case Sue does her nude dashes.

I have doubts very big doubts about this move.

She also agrees with me that Sue needs to be told who the staff are as soon as they start buddying up with her. So sensible. That honesty is the best policy. Yep it sure is.

But I cannot shake the feeling that Sue is being moved while her funding is still in jeopardy. And this kinds of proves it. "yes Julie her funding is all signed off on.” 6 days later “Oh we lost the funding for the nurse." Which is it CJP finalised and signed off on or still in negotiation stage.

I NEED COFFEE

ok mods

2010-12-22T13:39:00.000+11:00

the glass been removed, the fence isn't seen really as a problem. Not sure if the house is sound proofed. Curtains are still up. I suggested roller shutters.

Stupid CJP Stupid

2010-12-22T13:36:00.002+11:00

ok where to start

CJP just rang me. They have decided not to tell Sue who the staff are that are going to be going up and training with her. Katelynd told me that Janine and Ellie told her it would be best not to tell Sue who they are until 1-2 weeks before Sue moves.

I told Katelynd it is not good to lie to Sue. She said they aren't lying to her. I said Oh yes you are. And as these staff are going to work with Sue at the new house you are setting it up so she cannot trust them. You CANNOT LIE TO HER. Idiots, how many times does such a simple statement have to be said. Sue reacts very well to honesty, she never forgives anyone who lies to her.

Also they have lost funding for the Registered nurse. So I guess when they told me at the meeting on the 16th that all funding was signed off on that was also a lie. No nurse means Sue cannot have IMI when needed. Ok so she needs them less that say a year ago but the average is 2 a month in her stable home. Her move will escalate her violence especially because she has been lied to about the staff. The CJP is STUPIDTY in motion, go on try to convince me that Sue isn't being moved purely because she is a number, a body to fill the empty space.

Meeting

2010-12-22T13:36:00.000+11:00

The ad been placed for staff. All the funding has been signed off one. They have also taken funding from another house and redone it so it can come to Sue.

They still have no plan for if this move fails. Staff are going to go up and buddy up with Sue's staff and work directly with her as part od her staff training. I told them that Sue should be told about the move then because it will rather hard to hide it from her. And she doesn't react well to people lying to her.

They are thinking of doing the day programs in house at the start, the providor is Sunshine Homes.

We'll see how it goes.

2010-12-15T20:43:00.000+11:00

No email yet from Katelynd. And isn't it great that I'm doing their job by finding out where the mods are up to. Just fantastic commmitment to the job.

Good afternoon Jules,

Katelyn will send you a quick follow-up email shortly letting you know
the progress on the various listed issues.

Heihana is the building project officer he said to give him a call to
talk about the progress with the modifications his no is
*********.Katelynd also has an extensive up date to give you on the
building, the Staff recruitment with Lifestyles ect.

Are you right for transport tomorrow to come into Parramatta, let me
know if you require a lift.Looking forward to our meeting tomorrow as
lots of progress has been made on Sue's placement.

Cheers Katrina

here we go again

2010-12-14T09:03:00.000+11:00

ECT.

had a phone call with Sue Dr today. Dr Chenoworth has suggested that Sue have some more ECT.

No Sue is not depressed, she is eating, talking, doing her activities. So why did it get raised, because she is doing some facial twitches and hand movements.

She has been doing them for about 6 months now.

it is clear to me it's an anxiety reaction. Especially because she is very functional at the moment. She is not slipping into one of her depressions.

Now in May Sue space was converted to house a new client. Sue has spoken to me a lot about her concerns about this and how she'd cope. It was around this time that I noticed the hand movements. Since then they have increased to include the facial ones as well. Anxiety.
So I pointed this out to Eric and he said: "Hadn't thought of that. I think you're right." Great.

Ok so I spoke to Sue's psych at Kanangra about this being an anxiety reaction because of the new woman moving into Sue's unit and she also said: "Hadn't thought of that. Thought it was anxiety but wasn't sure what could have triggered it." I also suggested CBT (cognitive brain training) to help Sue cope and she said she was talking to someone else about that for Sue. So at least I'm on the right track

Now I need to ring Chenoworth.

I don't mean to sound critical, I understand that everyone is concerned about Sue and the movements because last time they were the herald of her slipping into her depression. But please look at all sides of the coin before you jump to ECT. Look at changes in her environment Sue doesn't cope well with change and she had a big change in her living arrangements.

it's a bit much to be thinking of giving someone ECT because they have a stress reaction.

2nd visit house part 2

2010-12-14T08:40:00.001+11:00

in some ways it was a pointless exercise. Nothing has been fixed/modified. The easy access into the property has not been secured. it needs to be as people can jump the fence to get into the property.

I think they forget it's not just about making sure the clients can't get out, it's also about he public not being able to get in. And they are as the property is being tagged, which doesn't bother me, but it does bother me that access is so easy onto the site. And even after having it pointed out to them it has not be fixed. It isn't hard it just needs some lattice work or something like that attached to the fence and then up under the eaves of the last unit.

Also ADHC/CJP still do not have a formal plan on what to do if this placement does not work out for Sue. Both the guardian and I are very concerned about this.

I also told Katelynd that I have real concerns about Sue accessing her day programs in the community. That she is being opened up to her being charged with assault. I get the real impression that they think they can change Sue's behaviour. That they can get her to not get angry. Good luck with that one. Because they say things like, if she hits someone, if that occurs. I'm telling you people it will occur.

And then when I get them to admit that they say stuff like "the only reason she doesn't get charged at Kanangra is because the staff choose not to." That's right. But Sue is access the community where those options are not in place. ADHC do not listen to what people say in the consultation process, and it will be Sue that will be punished for their arrogance. So I told Katelynd that if Sue ends up in front of a judge and goes to jail because she has been charged with assault then all hell will break lose.

Also ADHC still are trying to push that Sue does not have staff after 8pm. It's crap she has staff 24/7. Also they can see into Sue's space at all times. They cannot in the new house.

2010-12-14T08:22:00.002+11:00

ADHC bad communticators

2010-12-14T08:21:00.000+11:00

still waiting for the phone call from Katrina (email 29.11.2010)

"Good morning Julie just back from leave, I will ring you today to
organise a catch up this week. The service provider Life Styles has been
signed off (that is the contract). That great news for us and Sue.

Will talk today.

Cheers Katrina"

2nd visit house

2010-11-30T16:18:00.000+11:00

none of the modifcations have be done yet. It raining so it can't happen. Time for my cynicism. What about starting on the ones inside the house? Ok cynicism over now

They have started on the mods in staff area though.

More later. i'm tired

Still no more answers

2010-10-28T18:52:00.000+11:00

Heard form Katelynd today, she doesn't know if the house is sound proofed. I suggested she needs to find out. Really annoying to get a call without any answers and totally pointless.

CJP reply to my email to them on Monday

2010-10-20T17:19:00.002+11:00

Hi Julie,

I will read through the various points and get back with the most appropriate answers tomorrow. Many thanks for your vital input.

Cheers

Katrina

concerns sent to CJP

2010-10-19T07:54:00.000+11:00

Hi
After reading through both the CJP draft plan and the SNRG there are a few point I would like to make.

In the draft plan it says that one of the reasons why Sue has improved functionality and been free of further criminal prosecution is due to the fact that Kanangra provides her with: "the ability to socialise and have day activities without leaving the grounds." (CJP Draft plan)

As discussed at the meeting I have some real concerns about Sue not hitting other clients or staff at the community based day program you have established for her. What will be the consequences for Sue if this occurs? If Sue's behaviour means she can not attend day activities what options do you have in place for her?

As Sue's service provider Lifestyle Solutions is a NGO what plans do you have in place if Lifestyle Solutions decide that Sue can no longer be one of their clients ?

Current staffing at Kanangra is 2:1 for Sue at Kanangra, they have a clear line of site to Sue and are in her space. At 6pm that changes to a staff ratio of 1:1 but that staff member cannot approach Sue on their own they have to get another staff member if Sue needs assistance. After looking at the space and seeing how Sue's space is separated from the staff office how do you propose to monitor Sue? Also it sounded like from what Kelly said that after 8pm Sue will not have staff directly. How do you propose to monitor Sue?

I would like some additional information to be attached to the SNRG. I would like it noted that the changes I have seen in Sue's intellectual functionality has occurred since her ECT treatment at James Fletcher. It has nothing to do with her depression or admission to James Fletcher. Please add this amendment to the Physical Health section of Sues SNRG.

In regards to her physical health I would also like it noted that she does have some low muscle tone due most likely to her diagnosis of Phelen McDermid Syndrome. Also Sue carries the Fragile X gene and I believe she also has some of the aggression traits associated with this disorder.

Also noted in the SNRG as a strengths of Sue's should be her honesty about her behaviour. She always admits to it.

In the SNRG recommendation you state she should not live close to neighbours and her accommodation should be soundproofed. As you are going to move her to a residential setting the section of house where Sue will be living needs to be sound proofed as a priority. This need to be done before she moves in so that her noise does not become a factor after she moves into her new accommodation. You do not want neighbours up in arms about her noise and soundproofing is one of the SNRG;s recommendation and so far it has not been done.

Also all glass and the ties on curtains need to be removed from the property as discussed at the property walk through.

the meeting

2010-10-19T07:43:00.000+11:00

Our take on the meeting

Sue can't move with Kanangra. The decision has been made. It seems the funding for Sue has always come from CJP (and it's previous incarnations). She was at Kanangra because CJP didn't have suitable accommodation until now, and the space, I think and Sue's move has been pushed through because Kanangra is being closed.

At all the meeting about Kanangra's closure Sue was going to move with them but now that CJP has funding that cannot occur. CJP tried to say how they'd been there for Sue all along and they may view it that way seeing they are paying for her to be at Kanangra But as I said to them it was DADHC and therefore CJP that were refusing services to Sue when she was due for parole and at her release date saying that they would not meet her at the jail. That they were "wiping their hands of her." I don't understand why they would think that there past history with Sue should be forgotten or forgiven.

But after all of this the question that remains is whether Sue is capable at this point of participating in the scheme and whether the scheme will be suitable for Sue. But CJP assure us they will not let her fail. That all funding is specifically for Sue and therefore they will make sure that it works. That Sue is their responsibility for the rest of her life. We'll see.

Lifestyle Solutions will be the company running the centre and the name of the centre is Montrose. Lifestyle Solutions is run by Owen Campbell who was involved in closing the Watagan Centre. We were reassured he wasn't involved with running the centre.

We asked a lot of questions about the program and we are (mostly) reassured that Sue won't be forced through a program she would most likely fail at. They are expecting to keep her in secure accommodation for as long as necessary even if that is the rest of the life.

It is also extremely unlikely that the police will be called if Sue becomes violent as they are determined to prevent her from re-entering the criminal system.

Kanangra staff have made all the recommendations that will decide her program. It isn't CJP that has designed the framework. A lot of the things she has now such as the counselling and massage with continue. There is concern about her walks / exercise and their idea is that they will drive her to a park at a quiet time such as during school hours. They acknowledge they can't take her for walks in the streets of the suburb.

Sue will be driven up to Kanangra for special events but they can't give an idea about frequency at this stage. We suggested she make phone calls as well.

The staffing model is still a bit of a concern. 3 staff total at all times to about 5 clients, 2 staff all the time with Sue with 1 available for the others. 1 of Sue's staff will be RN. Lifestyle Solutions has a number of centres spread through the suburbs and so if any of her regular staff are off sick or on leave they will have a pool of other staff to call on. If the RN is off they will be replaced by another RN. At the meeting they didn't have enough comment on how it sometimes takes four staff to control Sue so they can give her a shot when she 'goes off'. They are starting recruitment now. They are looking at moving her into Montrose in December, date not yet set. We said she shouldn't be moved until after the Xmas party at Kanangra and they seem to think that's a good idea.

They are planning to drive Sue to day activities and they are talking about a couple of different places. Montrose staff will stay with her to minimise the possibility of trouble. They are also talking about bringing in activities to Montrose. I have some real concerns for how Sue will cope with day activities in the broader community and how the broader community will cope with Sue's behaviour. The SNRG recommendation say that the success of Sue at Kanangra is due to the fact that all activities can be on the grounds therefore minimising her contact with the police because of her behaviour. Sue better not end up in court again because the CJP decide to go against the recommendation and their own findings.

When we asked about possible objections from the neighbours to Sue making lots of noise they talked a lot of general ideas about consultation with the community. They gave examples of other spaces where there have been problems. They seemed a little worried about it. Consultation with the community doesn't happen until the staff move in.

Katelynd denied she'd been surprised to find out Sue has an official diagnosis or had had shock treatment. Julie says she expressed considerable surprise “Really?!?”. They said all her records have been studied.

We both seem to feel better about the move but we have worries, as we would expect even if we thought the move was perfect.

After reading the document referred to at the top of this email I think CJP has a lot going for it. This program would be excellent for someone just coming out of prison, because it would have to be an improvement. I just hope it's a good comparison to Kanangra.

We gave a few suggestions that we think will help with the move, foremost being that they have to start preparing Sue for the move very soon. They made a mistake by not consulting with us from the start but the only result of that was a few upset phone calls and the need for the rather intense meeting today. It went for about 2 ½ hours. The first thing we called them on was the lack of consultation and after a bit of to and froing (it was Kanangras responsibility, 'but it's in your own documentation that you consult with us', ok it's a joint responsibility and both of you could have) they apologised for not involving us. A few times. We pushed that button a few times.

We told them they need to be honest with Sue and she responds to that. Even if she reacts badly at first she will come back to the honesty. We suggested they tell her it's one step closer to living in the community (even if that doesn't happen) because she misses the independence. They should also say it's closer to us so we can visit more often.

CJP/DADHC meeting tomorrow

2010-10-10T11:11:00.000+11:00

The meeting is tomorrow. Some of the staff from Kanangra are coming to it as well. Not sure who.

I was told that we would go and view the accommadation with the Kanangra staff tomorrow but when Katelynd called on Friday she said that wasn't happening. Bad move i think the staff at Kanangra should see the property. They understand Sue's needs better than anyone. They also know what hazards, safety features need to be addressed. As they have a whole lot of safety and hazard reduction options in her unit.

So I'm off to get a whole bunch of paper work printed out for the meeting.

New thought

2010-10-06T08:11:00.000+11:00

a friend gave me another insight into this. She said: How much easier would Kanangra be to close if Sue wasn't there?

Well, seeing she would be the hardest to house and requires the most staff I'd imagine it would make it a whole lot easier.

Sue and her housing needs has been the big issue at the meetings I've been at concerning closing Kanangra. I know when i raised the issue that the DADHC staff just thought they could shove Sue into a ward/unit with other people. Thank god the head of Kanangra was there at the meeting and support me on what i was saying about Sue.

But hey if Sue is no longer there, then hey presto, problem solved.

BASTARDS.

If this is part of the plan then it is deplorable to manipulate and abuse someone that way.

SHAME on DADHC and the CJP.

DADHC worker Kelly

2010-10-06T08:04:00.000+11:00

Kelly it would be nice if you answered emails i sent you, rather than getting Katelynd to call me. It is disrepectful.

Even if you did want to defer to Katelynd you should have at least had the courtsey to email and tell me.

It does nothing at all for my opinion of you.

they want to change the meeting

2010-10-05T19:03:00.001+11:00

They want to bundle the two meetings into one. they want to change the meeting to the 11th. one and a bit days warning, great. Don't know if Julanna can get the day off changed at that short a notice.
Also they don't know if the guardian can come on the 11th. fabulous

Katelynd said the Kanangra staff have said they want to come to the meeting and they can come on the 11th which is why the shift. but we don't know who cause i forgot to ask.

But gezz makes sure everyone can come on the same day. Or are DADHC trying to separate those that oppose them.

DBT

2010-10-05T18:24:00.001+11:00

Even though Katelynd said this training is for staff, I'm betting that they think that Sue will be able to understand this as well. After all why train the staff if the client isn't utilising the same training.

yep I'm sure that someone with an IQ of 62 will get this. (sarcasim)
STUPID DADHC STUPID CJP?

This program is not desgined for people with an intellectual disability. For people with normal IQ and no damage to learning centres in the brain which has been worsened from ECT this may be a good program.

But not for Sue

Dialectical behavior therapy wiki info

2010-10-05T18:20:00.001+11:00

Dialectical behavior therapy
From Wikipedia, the free encyclopedia
Jump to: navigation, search
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Please help improve this article by adding reliable references. Unsourced material may be challenged and removed. (February 2008)

Dialectical behavior therapy (DBT) is a system of therapy originally developed to treat persons with borderline personality disorder (BPD) by Marsha M. Linehan, a psychology researcher at the University of Washington.[1][2] DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD.[3][4] Research indicates that DBT is also effective in treating patients who present varied symptoms and behaviors associated with spectrum mood disorders, including self-injury.[5] Recent work suggests its effectiveness with sexual abuse survivors [6] and chemical dependency.[7]
Contents
[hide]

* 1 Overview
* 2 The four modules
o 2.1 Mindfulness
+ 2.1.1 Skills within the Mindfulness module
# 2.1.1.1 The "What" Skills
# 2.1.1.2 The "How" Skills
o 2.2 Distress Tolerance
+ 2.2.1 Skills within the Distress tolerance module
o 2.3 Emotion Regulation
+ 2.3.1 Skills within the Emotion regulation module
o 2.4 Interpersonal Effectiveness
+ 2.4.1 Skills within the Interpersonal effectiveness module
* 3 Tools
o 3.1 Diary Cards
o 3.2 Chain Analysis
o 3.3 Milieu
* 4 See also
* 5 References
* 6 Further reading
* 7 External links

[edit] Overview

Linehan created DBT in response to her observation of therapist burnout after coping with non-motivated patients who repudiated cooperation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments and required a climate of unconditional acceptance (not Carl Rogers’ humanistically "positive" version, but Thich Nhat Hanh’s metaphysically neutral one[citation needed]) in which to develop a successful therapeutic alliance. Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction.

DBT strives to avoid having the client/patient see the therapist as an adversary rather than an ally in the treatment of psychological issues. Accordingly, in DBT the therapist aims to accept and validate the client’s feelings at any given time while nonetheless informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives.[2]

Linehan united commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress, in which thesis + antithesis → synthesis, and proceeded to assemble a modular array of skills for emotional self-regulation, drawn from Western (e.g., cognitive behavioral therapy and an interpersonal variant, “assertiveness training”) and Eastern (e.g., Buddhist mindfulness meditation) psychological traditions. Arguably her signal contribution was to elide the adversarial paradigm implicit in the hierarchical modernist therapeutic alliance, using the deconstructive spirit of Hegel and Buddhism to substitute a postmodern alliance based on intersubjective tough love.

All DBT involves two components:

1. An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards, and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
2. The group, which ordinarily meets once weekly for two to two-and-a-half hours, learns to use specific skills that are broken down into four modules: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.

Neither component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.
[edit] The four modules
[edit] Mindfulness

Mindfulness is one of the core concepts behind all elements of DBT. Mindfulness is the capacity to pay attention, non-judgmentally, to the present moment. Mindfulness is all about living in the moment, experiencing one's emotions and senses fully, yet with perspective. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts.
[edit] Skills within the Mindfulness module
[edit] The "What" Skills

Observe
This is used to non-judgmentally observe one’s environment within or outside oneself. It is helpful in understanding what is going on in any given situation.

Describe
This is used to express what one has observed with the observe skill. It is to be used without judgmental statements. This helps with letting others know what you have observed.

Participate
This is used to become fully involved in the activity that one is doing. To be able to fully focus on what one is doing.

[edit] The "How" Skills

Non-Judgmentally
This is the action of describing the facts, and not thinking about what’s “good” or “bad”, “fair”, or “unfair.” These are judgments because this is how you feel about the situation but isn’t a factual description. Being non-judgmental helps to get your point across in an effective manner without adding a judgment that someone else might disagree with.

One-Mindfully
This is used to focus on one thing. One-mindfully is helpful in keeping your mind from straying into emotion mind by a lack of focus.

Effectively
This is simply doing what works. It is a very broad-ranged skill and can be applied to any other skill to aid in being successful with said skill.[8]

[edit] Distress Tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.

Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although this is a nonjudgmental stance, this does not mean that it is one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.
[edit] Skills within the Distress tolerance module

[8]

Distract with ACCEPTS
This is a skill used to distract oneself temporarily from unpleasant emotions. The acronym breaks into:

Activities: Use positive activities that you enjoy.

Contribute: Help out others or your community.

Comparisons: Compare yourself either to people that are less fortunate or to how you used to be when you were in a worse state.

Emotions (other): cause yourself to feel something different by provoking your sense of humor or happiness with corresponding activities.

Push away: Put your situation on the back-burner for a while. Put something else temporarily first in your mind.

Thoughts (other): Force your mind to think about something else.

Sensations (other) – Do something that has an intense feeling other than what you are feeling, like a cold shower or a spicy candy.

Self Soothe
This is a skill in which one behaves in a comforting, nurturing, kind, and gentle way to oneself. You use it by doing something that is soothing to you. It is used in moments of distress or agitation.

IMPROVE the Moment
This skill is used in moments of distress to help one relax. The acronym stands for:

Imagery: Imagine relaxing scenes, things going well, or other things that please you.

Meaning: Find some purpose or meaning in what you are feeling.

Prayer: Either pray to whomever you worship or if not religious, chant a personal mantra.

Relaxation: Relax your muscles, breathe deeply; use with Self Soothing.

One thing in the moment: Focus your entire attention on what you are doing right now. Keep yourself in the present.

Vacation (brief): Take a break from it all for a short period of time.

Encouragement: Cheer-lead yourself. Tell yourself you can make it through this.

Pros and Cons
Think about the positive and negative things about not tolerating distress.

Radical Acceptance
Letting go of fighting reality. Accept your situation for what it is.

Turning the Mind
Turn your mind towards an acceptance stance. It should be used with Radical Acceptance.

Willingness vs. Willfulness
Being willing and open to do what is effective. Let go of a willful stance which goes against acceptance. Keep your eye on the goal in front of you.

[edit] Emotion Regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:[9][10]

* Identifying and labeling emotions
* Identifying obstacles to changing emotions
* Reducing vulnerability to emotion mind
* Increasing positive emotional events
* Increasing mindfulness to current emotions
* Taking opposite action
* Applying distress tolerance techniques

[edit] Skills within the Emotion regulation module

[8]

Story of Emotion
Used to understand what kind of emotion one is feeling. To use this, list the following:

1. Prompting event
2. Interpretation of the event
3. Body sensations
4. Body language
5. Action urge
6. Action
7. Emotion name, based on previous items on list.

PLEASE MASTER
Having ineffective health habits can make one more vulnerable to emotion mind. This skill is used to maintain a healthy body so one is more likely to have healthy emotions. It is an acronym that stands for the following:

PhysicaL Illness (treat): If you are sick or injured, get proper treatment for it.

Eating (balanced): Make sure you eat a proper healthy diet, and eat in moderation.

Avoid Mood-Altering Drugs: Do not take non-prescribed medication or illegal drugs. They are very harmful to your body, and can make your mood unpredictable.

Sleep (balanced): Do not sleep too much or too little. 8 hours of sleep is recommended per night for the average adult.

Exercise: Make sure you get an effective amount of exercise as this will both improve body image, and release endorphins (making you happier).

MASTERy (build): Try to do one thing a day to help build competence and control.

Opposite Action
This skill is used when you have an unjustified emotion, one that doesn’t belong in the situation at hand. You use it by doing the opposite of your urges in the moment. It is a tool to bring you out of an unwanted or unjustified emotion by replacing it with the emotion that is opposite.

Problem Solving
This is used to solve a problem when your emotion is justified. It is used in combination with other skills.

Letting Go of Emotional Suffering
Observe and experience your emotion, accept it, then let it go.

[edit] Interpersonal Effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.

Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing his or her own situation.

The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.
[edit] Skills within the Interpersonal effectiveness module

[8]

DEARMAN - to get something
Acronym for the skillset used to aid you in getting what you want when you ask:

Describe your situation.

Express why this is an issue and how you feel about it.

Assert yourself by asking clearly for what you want.

Reinforce your position by offering a positive consequence if you were to get what you want.

Mindful of the situation by focusing on what you want and ignore distractions.

Appear Confident even if you don’t feel confident.

Negotiate with a hesitant person and come to a comfortable compromise on your request.

GIVE - giving something
This is a skill that can aid you with maintaining your relationships, whether they are friendships, coworkers, family, romantic, etc. It is to be used in conversations. It is another acronym that stands for the following:

Gentle: Use appropriate language, no verbal or physical attacks, no put downs, avoid sarcasm unless you are sure the person is alright with it, and be courteous and non-judgmental.

Interested: When the person you are speaking to is talking about something, act interested in what they are saying. Maintain eye contact, ask questions, etc. Do not use your cell phone while having a conversation with another person!

Validate: Show that you understand a person’s situation and sympathize with them. Validation can be shown through words, body language and/or facial expressions.

Easy Manner: Be calm and comfortable during conversation, use humor, smile.

FAST - keeping self respect
This is a skill to aid you in maintaining your self-respect. It is to be used in combination with the other Interpersonal Effectiveness skills. It is another acronym, and it stands for the following:

Fair: Be fair to both yourself and the other person.

Apologies (few): Don’t apologize more than once for what you have done ineffectively, or apologize for something which was not ineffective.

Stick to Your Values: Stay true to what you believe in and stand by it. Don’t allow others to get you to do things against your values.

Truthful: Don’t lie. Lying can only pile up and damage relationships and your self-respect.

[edit] Tools
[edit] Diary Cards

Specially formatted cards for tracking Therapy interfering behaviors that distract or hinder a patient's progress.
[edit] Chain Analysis

Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining.[11] Growing body of research supports the use of behavior chain analysis with multiple populations.
[edit] Milieu

The milieu or the culture of the group involved plays a key role in the effectiveness of DBT.
[edit] See also

* Mindfulness (psychology)
* Cognitive behavioral therapy
* Rational emotive behavior therapy
* Nonviolent Communication
* Emotional dysregulation
* Social skill
* Behavioral psychotherapy

[edit] References

1. ^ Janowsky, David S. (1999). Psychotherapy indications and outcomes. Washington, DC: American Psychiatric Press. pp. 100. ISBN 0-88048-761-5.
2. ^ a b Linehan, M. M. & Dimeff, L. (2001). Dialectical Behavior Therapy in a nutshell, The California Psychologist, 34, 10-13.
3. ^ Linehan, M. M.; Armstrong, H. E.; Suarez, A.; Allmon, D.; Heard, H. L. (1991). "Cognitive-behavioral treatment of chronically parasuicidal borderline patients". Archives of General Psychiatry 48: 1060–64.
4. ^ Linehan, M. M.; Heard, H. L.; Armstrong, H. E. (1993). "Naturalistic follow-up of a behavioural treatment of chronically parasuicidal borderline patients". Archives of General Psychiatry 50: 971–974.
5. ^ Brody, J. E. (2008, May 6). The growing wave of teenage self-injury. New York Times. Retrieved July 1, 2008.
6. ^ Decker, S.E.; Naugle, A.E. (2008). "DBT for Sexual Abuse Survivors: Current Status and Future Directions". Journal of behavior Analysis of Offender and Victim: Treatment and Prevention 1 (4): 52–69. http://www.baojournal.com/JOBA-OVTP/JOBA-OVTP-VOL-1/JOBA-OVTP-1-4.pdf.
7. ^ [1]
8. ^ a b c d Lisa Dietz (2003). "DBT Skills List". http://www.dbtselfhelp.com/html/dbt_skills_list.html.
9. ^ Stone, M.H. (1987) In A. Tasman, R. E. Hales, & A. J. Frances (eds.), American Psychiatric Press review of psychiatry (Vol. 8, pp. 103-122). Washington DC: American Psychiatric Press.
10. ^ Holmes, P., Georgescu, S. & Liles, W. (2005). Further delineating the applicability of acceptance and change to private responses: The example of dialectical behavior therapy. The Behavior Analyst Today, 7(3), 301-311.[2]
11. ^ Sampl, S. Wakai, S., Trestman, R. and Keeney, E.M. (2008).Functional Analysis of Behavior in Corrections: Empowering Inmates in Skills Training Groups. Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention, 1(4), 42-51 BAO

* http://www.namimc.org/PDF/Ed%20Mtg/NAMI%20Ed%20Mtg%20-%20Wake%20Feb%202008%20Presentation.pdf
* Linehan,M.M., Armstrong,H.E., Suarez,A., Allmon,D., Heard,H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.
* Linehan,M.M., Heard,H.L. (1993) "Impact of treatment accessibility on clinical course of parasuicidal patients": Reply. Archives of General-Psychiatry, 50(2): 157-158.
* Linehan,M.M., Heard,H.L., Armstrong,H.E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971-974.
* Linehan,M.M., Tutek,D.A., Heard,H.L., Armstrong,H.E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151, 1771-1776.
* Linehan,M.M., Schmidt,H., Dimeff,L.A., Craft,J.C., Kanter,J., Comtois,K.A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addiction, 8(4), 279-292.
* Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13-26.
* Koons, C.R., Robins, C.J., Tweed, J.L., Lynch, T.R., Gonzalez, A.M., Morse, J.Q., Bishop, G.K., Butterfield, M.I., Bastian, L.A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371-390.
* van den Bosch, L.M.C., Verheul, R., Schippers, G.M., van den Brink, W. (2002). Dialectical Behavior Therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27(6), 911-923.
* Verheul, R., van den Bosch, L.M.C., Koeter, M.W.J., de Ridder, M.A.J., Stijnen, T., van den Brink, W. (2003). Dialectical behaviour therapy for women with borderline persoality disorder: 12-month, randomised clinical trial in the Netherlands. British Journal of Psychiatry, 182, 135-140.
* Linehan et al (2006) NIMH 3 Two-Year Randomized Control Trial and Follow up of DBT

[edit] Further reading

* The Miracle of Mindfulness by Thich Nhat Hanh. ISBN 0-8070-1239-4.
* Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan. 1993. ISBN 0-89862-034-1.
* Cognitive Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan. 1993. ISBN 0898621836.
* Fatal Flaws: Navigating Destructive Relationships with People with Disorders of Personality and Character by Stuart C. Yudovsky. ISBN 1585622141.
* The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation by Alan E. Fruzzetti. ISBN 157224450X.
* Dialectical Behavior Therapy with Suicidal Adolescents by Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan. Foreword by Charles R. Swenson. ISBN 978-1593853839.
* Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (New Harbinger Self-Help Workbook) by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley. ISBN 978-1572245136.
* Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control (New Harbinger Self-Help Workbook) by Scott E. Spradlin. ISBN 978-1572243095.
* Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression & Anxiety by Thomas Marra. ISBN 978-1572243637

Dialectical Behaviour Therapy

2010-10-05T18:17:00.003+11:00

An Overview of Dialectical Behaviour Therapy in the Treatment of Borderline Personality Disorder

by Barry Kiehn and Michaela Swales

Patients showing the features of Borderline Personality Disorder as defined in DSM-IV are notoriously difficult to treat (Linehan 1993a). They are difficult to keep in therapy, frequently fail to respond to our therapeutic efforts and make considerable demands on the emotional resources of the therapist, particular when suicidal and parasuicidal behaviours are prominent.

Dialectical Behaviour Therapy is an innovative method of treatment that has been developed specifically to treat this difficult group of patients in a way which is optimistic and which preserves the morale of the therapist.

The technique has been devised by Marsha Linehan at the University of Washington in Seattle and its effectiveness has been demonstrated in a controlled study, the results of which will be summarised later in this paper.
BORDERLINE PERSONALITY DISORDER

Dialectical Behaviour Therapy is based on a bio-social theory of borderline personality disorder. Linehan hypothesises that the disorder is a consequence of an emotionally vulnerable individual growing up within a particular set of environmental circumstances which she refers to as the 'Invalidating Environment'.

An 'emotionally vulnerable' person in this sense is someone whose autonomic nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to baseline once the stress is removed. It is proposed that this is the consequence of a biological diathesis.

The term 'Invalidating Environment' refers essentially to a situation in which the personal experiences and responses of the growing child are disqualified or "invalidated" by the significant others in her life. The child's personal communications are not accepted as an accurate indication of her true feelings and it is implied that, if they were accurate, then such feelings would not be a valid response to circumstances. Furthermore, an Invalidating Environment is characterised by a tendency to place a high value on self-control and self-reliance. Possible difficulties in these areas are not acknowledged and it is implied that problem solving should be easy given proper motivation. Any failure on the part of the child to perform to the expected standard is therefore ascribed to lack of motivation or some other negative characteristic of her character. (The feminine pronoun will be used throughout this paper when referring to the patient since the majority of BPD patients are female and Linehan's work has focused on this subgroup).

Linehan suggests that an emotionally vulnerable child can be expected to experience particular problems in such an environment. She will neither have the opportunity accurately to label and understand her feelings nor will she learn to trust her own responses to events. Neither is she helped to cope with situations that she may find difficult or stressful, since such problems are not acknowledged. It may be expected then that she will look to other people for indications of how she should be feeling and to solve her problems for her. However, it is in the nature of such an environment that the demands that she is allowed to make on others will tend to be severely restricted. The child's behaviour may then oscillate between opposite poles of emotional inhibition in an attempt to gain acceptance and extreme displays of emotion in order to have her feelings acknowledged. Erratic response to this pattern of behaviour by those in the environment may then create a situation of intermittent reinforcement resulting in the behaviour pattern becoming persistent.

Linehan suggests that a particular consequence of this state of affairs will be a failure to understand and control emotions; a failure to learn the skills required for 'emotion modulation'. Given the emotional vulnerability of these individuals this is postulated to result in a state of 'emotional dysregulation' which combines in a transactional manner with the Invalidating Environment to produce the typical symptoms of Borderline Personality Disorder.

Patients with BPD frequently describe a history of childhood sexual abuse and this is regarded within the model as representing a particularly extreme form of invalidation.

Linehan emphasises that this theory is not yet supported by empirical evidence but the value of the technique does not depend on the theory being correct since the clinical effectiveness of DBT does have empirical support.
PATIENTS' CHARACTERISTICS

Linehan groups the features of BPD in a particular way, describing the patients as showing dysregulation in the sphere of emotions, relationships, behaviour, cognition and the sense of self. She suggests that, as a consequence of the situation that has been described, they show six typical patterns of behaviour, the term 'behaviour' referring to emotional, cognitive and autonomic activity as well as external behaviour in the narrow sense.

Firstly, they show evidence of 'emotional vulnerability' as already described. They are aware of their difficulty coping with stress and may blame others for having unrealistic expectations and making unreasonable demands.

On the other hand they have internalised the characteristics of the Invalidating Environment and tend to show 'self-invalidation'. They invalidate their own responses and have unrealistic goals and expectations, feeling ashamed and angry with themselves when they experience difficulty or fail to achieve their goals.

These two features constitute the first pair of so-called 'dialectical dilemmas', the patient's position tending to swing between the opposing poles since each extreme is experienced as being distressing.

Next, they tend to experience frequent traumatic environmental events, in part related to their own dysfunctional lifestyle and exacerbated by their extreme emotional reactions with delayed return to baseline. This results in what Linehan refers to as a pattern of 'unrelenting crisis', one crisis following another before the previous one has been resolved. On the other hand, because of their difficulties with emotion modulation, they are unable to face, and therefore tend to inhibit, negative affect and particularly feelings associated with loss or grief. This 'inhibited grieving' and the 'unrelenting crisis' constitute the second 'dialectical dilemma'.

The opposite poles of the final dilemma are referred to as 'active passivity' and 'apparent competence'. Patients with BPD are active in finding other people who will solve their problems for them but are passive in relation to solving their own problems. On the other hand, they have learned to give the impression of being competent in response to the Invalidating Environment. In some situations they may indeed be competent but their skills do not generalise across different situations and are dependent on the mood state of the moment. This extreme mood dependency is seen as being a typical feature of patients with BPD.

A pattern of self-mutilation tends to develop as a means of coping with the intense and painful feelings experienced by these patients and suicide attempts may be seen as an expression of the fact that life is at times simply does not seem worth living. These behaviours in particular tend to result in frequent episodes of admission to psychiatric hospitals. Dialectical Behaviour Therapy, which will now be described, focuses specifically on this pattern of problem behaviours and in particular, the parasuicidal behaviour. DIALECTICAL BEHAVIOUR THERAPY The term 'dialectical' is derived from classical philosophy. It refers to a form of argument in which an assertion is first made about a particular issue (the 'thesis'), the opposing position is then formulated (the 'antithesis' ) and finally a 'synthesis' is sought between the two extremes, embodying the valuable features of each position and resolving any contradictions between the two. This synthesis then acts as the thesis for the next cycle. In this way truth is seen as a process which develops over time in transactions between people. From this perspective there can be no statement representing absolute truth. Truth is approached as the middle way between extremes. The dialectical approach to understanding and treatment of human problems is therefore non-dogmatic, open and has a systemic and transactional orientation. The dialectical viewpoint underlies the entire structure of therapy, the key dialectic being 'acceptance' on the one hand and 'change' on the other. Thus DBT includes specific techniques of acceptance and validation designed to counter the self-invalidation of the patient. These are balanced by techniques of problem solving to help her learn more adaptive ways of dealing with her difficulties and acquire the skills to do so. Dialectical strategies underlie all aspects of treatment to counter the extreme and rigid thinking encountered in these patients. The dialectical world view is apparent in the three pairs of 'dialectical dilemmas' already described, in the goals of therapy and in the attitudes and communication styles of the therapist which are to be described. The therapy is behavioural in that, without ignoring the past, it focuses on present behaviour and the current factors which are controlling that behaviour. THERAPIST CHARACTERISTICS IN DBT The success of treatment is dependant on the quality of the relationship between the patient and therapist. The emphasis is on this being a real human relationship in which both members matter and in which the needs of both have to be considered. Linehan is particularly alert to the risks of burnout to therapists treating these patients and therapist support and consultation is an integral and essential part of the treatment. In DBT support is not regarded as an optional extra. The basic idea is that the therapist gives DBT to the patient and receives DBT from his or her colleagues. The approach is a team approach. The therapist is asked to accept a number of working assumptions about the patient that will establish the required attitude for therapy: 1. The patient wants to change and, in spite of appearances, is trying her best at any particular time. 2. Her behaviour pattern is understandable given her background and present circumstances. Her life may currently not be worth living (however, the therapist will never agree that suicide is the appropriate solution but always stays on the side of life. The solution is rather to try and make life more worth living). 3. In spite of this she needs to try harder if things are ever to improve. She may not be entirely to blame for the way things are but it is her personal responsibility to make them different. 4. Patients can not fail in DBT. If things are not improving it is the treatment that is failing. In particular the therapist must avoid at all times viewing the patient, or talking about her, in pejorative terms since such an attitude will be antagonistic to successful therapeutic intervention and likely to feed into the problems that have led to the development of BPD in the first place. Linehan has a particular dislike for the word "manipulative" as commonly applied to these patients. She points out that this implies that they are skilled at managing other people when it is precisely the opposite that is true. Also the fact that the therapist may feel manipulated does not necessarily imply that this was the intention of the patient. It is more probable that the patient did not have the skills to deal with the situation more effectively. The therapist relates to the patient in two dialectically opposed styles. The primary style of relationship and communication is referred to as 'reciprocal communication', a style involving responsiveness, warmth and genuineness on the part of the therapist. Appropriate self-disclosure is encouraged but always with the interests of the patient in mind. The alternative style is referred to as 'irreverent communication'. This is a more confrontational and challenging style aimed at bringing the patient up with a jolt in order to deal with situations where therapy seems to be stuck or moving in an unhelpful direction. It will be observed that these two communication styles form the opposite ends of another dialectic and should be used in a balanced way as therapy proceeds. The therapist should try to interact with the patient in a way that is: 1. accepting of the patient as she is but which encourages change. 2. centred and firm yet flexible when the circumstances require it. 3. nurturing but benevolently demanding. The dialectical approach is here again apparent. There is a clear and open emphasis on the limits of behaviour acceptable to the therapist and these are dealt with in a very direct way. The therapist should be clear about his or her personal limits in relations to a particular patient and should as far as possible make these clear to her from the start. It is openly acknowledged that an unconditional relationship between therapist and patient is not humanly possible and it is always possible for the patient to cause the therapist to reject her if she tries hard enough. It is in the patient's interests therefore to learn to treat her therapist in a way that encourages the therapist to want to continue helping her. It is not in her interests to burn him or her out. This issue is confronted directly and openly in therapy. The therapist helps therapy to survive by consistently bringing it to the patient's attention when limits have been overstepped and then teaching her the skills to deal with the situation more effectively and acceptably. It is made quite clear that the issue is immediately concerned with the legitimate needs of the therapist and only indirectly with the needs of the patient who clearly stands to lose if she manages to burn out the therapist. The therapist is asked to adopt a non-defensive posture towards the patient, to accept that therapists are fallible and that mistakes will at times inevitably be made. Perfect therapy is simply not possible. It needs to be accepted as a working hypothesis that (to use Linehan's words) "all therapists are jerks". PATIENTS' AND THERAPISTS' AGREEMENTS This form of therapy must be entirely voluntary and depends for its success on having the co-operation of the patient. From the start, therefore, attention is given to orienting the patient to the nature of DBT and obtaining a commitment to undertake the work. A variety of specific strategies are described in the Linehan's book (Linehan 1993a) to facilitate this process. Before a patient will be taken on for DBT she will be required to give a number of undertakings: 1. To work in therapy for a specified period of time (Linehan initially contracts for one year). and, within reason, to attend all scheduled therapy sessions.

2. If suicidal or parasuicidal behaviours are present, she must agree to work on reducing these.

3. To work on any behaviours that interfere with the course of therapy ('therapy interfering behaviours').

4. To attend skills training.

The strength of these agreements may be variable and a "take what you can get approach" is advocated. Nevertheless a definite commitment at some level is required since reminding the patient about her commitment and re-establishing such commitment throughout the course of therapy are important strategies in DBT.

The therapist agrees to make every reasonable effort to help the patient and to treat her with respect, as well as to keep to the usual expectations of reliability and professional ethics. The therapist does not however give any undertaking to stop the patient from harming herself. On the contrary, it should be make quite clear that the therapist is simply not able to prevent her from doing so. The therapist will try rather to help her find ways of making her life more worth living. DBT is offered as a life-enhancement treatment and not as a suicide prevention treatment, although it is hoped that it may indeed achieve the latter.
MODES OF TREATMENT

There are four primary modes of treatment in DBT :

1. Individual therapy
2. Group skills training
3. Telephone contact
4. Therapist consultation

Whilst keeping within the overall model, group therapy and other modes of treatment may be added at the discretion of the therapist, providing the targets for that mode are clear and prioritised.

The individual therapist is the primary therapist. The main work of therapy is carried out in the INDIVIDUAL THERAPY sessions. The structure of individual therapy and some of the strategies used will be described shortly. The characteristics of the therapeutic alliance have already been described.

Between sessions the patient should be offered TELEPHONE CONTACT with the therapist, including out of hours telephone contact. This tends to be an aspect of DBT balked at by many prospective therapists. However, each therapist has the right to set clear limits on such contact and the purpose of telephone contact is also quite clearly defined. In particular, telephone contact is not for the purpose of psychotherapy. Rather it is to give the patient help and support in applying the skills that she is learning to her real life situation between sessions and to help her find ways of avoiding self-injury. Calls are also accepted for the purpose of relationship repair where the patient feels that she has damaged her relationship with her therapist and wants to put this right before the next session. Calls after the patient has injured herself are not acceptable and, after ensuring her immediate safety, no further calls are allowed for the next twenty four hours. This is to avoid reinforcing self-injury.

SKILLS TRAINING is usually carried out in a group context, ideally by someone other that the individual therapist. In the skills training groups patients are taught skills considered relevant to the particular problems experienced by people with borderline personality disorder. There are four modules focusing in turn on four groups of skills:

1. Core mindfulness skills.
2. Interpersonal effectiveness skills.
3. Emotion modulation skills.
4. Distress tolerance skills.

The 'core mindfulness skills' are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment.

The 'interpersonal effectiveness skills' which are taught focus on effective ways of achieving one's objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people.

'Emotion modulation skills' are ways of changing distressing emotional states and 'distress tolerance skills' include techniques for putting up with these emotional states if they can not be changed for the time being.

The skills are too many and varied to be described here in detail. They are fully described in a teaching format in the DBT skills training manual (Linehan, 1993b).

The therapists receive DBT from each other at the regular THERAPIST CONSULTATION GROUPS and, as already mentioned, this is regarded as an essential aspect of therapy. The members of the group are required to keep each other in the DBT mode and (among other things) are required to give a formal undertaking to remain dialectical in their interaction with each other, to avoid any pejorative descriptions of patient or therapist behaviour, to respect therapists' individual limits and generally are expected to treat each other at least as well as they treat their patients. Part of the session may be used for ongoing training purposes.
STAGES OF THERAPY AND TREATMENT TARGETS

Patients with BPD present multiple problems and this can pose problems for the therapist in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organised into a number of stages and structured in terms of hierarchies of targets at each stage.

The PRE-TREATMENT STAGE focuses on assessment, commitment and orientation to therapy.

STAGE 1 focuses on suicidal behaviours, therapy interfering behaviours and behaviours that interfere with the quality of life, together with developing the necessary skills to resolve these problems.

STAGE 2 deals with post-traumatic stress related problems (PTSD)

STAGE 3 focuses on self-esteem and individual treatment goals.

The targeted behaviours of each stage are brought under control before moving on to the next phase. In particular post-traumatic stress related problems such as those related to childhood sexual abuse are not dealt with directly until stage 1 has been successfully completed. To do so would risk an increase in serious self injury. Problems of this type (flashbacks for instance) emerging whilst the patient is still in stages 1 or 2 are dealt with using 'distress tolerance' techniques. The treatment of PTSD in stage 2 involves exposure to memories of the past trauma.

Therapy at each stage is focused on the specific targets for that stage which are arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy but it is essential for therapists working in each mode to be clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking.

The hierarchy of targets in individual therapy for example is as follows:

1. Decreasing suicidal behaviours.
2. Decreasing therapy interfering behaviours.
3. Decreasing behaviours that interfere with the quality of life.
4. Increasing behavioural skills.
5. Decreasing behaviours related to post-traumatic stress.
6. Improving self esteem.
7. Individual targets negotiated with the patient.

In any individual session these targets must be dealt with in that order. In particular, any incident of self harm that may have occurred since the last session must be dealt with first and the therapist must not allow him or herself to be distracted from this goal.

The importance given to 'therapy interfering behaviours' is a particular characteristic of DBT and reflects the difficulty of working with these patients. It is second only to suicidal behaviours in importance. These are any behaviours by the patient or therapist that interfere in any way with the proper conduct of therapy and risk preventing the patient from getting the help she needs. They include, for example, failure to attend sessions reliably, failure to keep to contracted agreements, or behaviours that overstep therapist limits.

Behaviours that interfere with the quality of life are such things as drug or alcohol abuse, sexual promiscuity, high risk behaviour and the like. What is or is not a quality of life interfering behaviour may be a matter for negotiation between patient and therapist.

The patient is required to record instances of targeted behaviours on the weekly diary cards. Failure to do so is regarded as therapy interfering behaviour.
TREATMENT STRATEGIES

Within this framework of stages, target hierarchies and modes of therapy a wide variety of therapeutic strategies and specific techniques is applied.

The core strategies in DBT are 'validation' and 'problem solving'. Attempts to facilitate change are surrounded by interventions that validate the patient's behaviour and responses as understandable in relation to her current life situation, and that show an understanding of her difficulties and suffering.

Problem solving focuses on the establishment of necessary skills. If the patient is not dealing with her problems effectively then it is to be anticipated either that she does not have the necessary skills to do so, or does have the skills but is prevented from using them. If she does not have the skills then she will need to learn them. This is the purpose of the skills training.

Having the skills, she may be prevented from using them in particular situations either because of environmental factors or because of emotional or cognitive problems getting in the way. To deal with these difficulties the following techniques may be applied in the course of therapy:

1. Contingency management
2. Cognitive therapy
3. Exposure based therapies
4. Pharmacotherapy

The principles of using these techniques are precisely those applying to their use in other contexts and will not be described in any detail. In DBT however they are used in a relatively informal way and interwoven into therapy. Linehan recommends that medication be prescribed by someone other than the primary therapist although this may not be practical.

Particular note should be made of the pervading application of contingency management throughout therapy, using the relationship with the therapist as the main reinforcer. In the session by session course of therapy care is taken to systematically reinforce targeted adaptive behaviours and to avoid reinforcing targeted maladaptive behaviours. This process is made quite overt to the patient, explaining that behaviour which reinforced can be expected to increase. A clear distinction is made between the observed effect of reinforcement and the motivation of the behaviour, pointing out that such a relationship between cause and effect does not imply that the behaviour is being carried out deliberately in order to obtain the reinforcement. Didactic teaching and insight strategies may also be used to help the patient achieve an understanding of the factors that may be controlling her behaviour.

The same contingency management approach is taken in dealing with behaviours that overstep the therapist's personal limits in which case they are referred to as 'observing limits procedures'.

Problem solving and change strategies are again balanced dialectically by the use of validation strategies. It is important at every stage to convey to the patient that her behaviour, including thoughts feelings and actions are understandable, even though they may be maladaptive or unhelpful.

Significant instances of targeted maladaptive behaviour occurring since the last session (which should have been recorded on the diary card) are initially dealt with by carrying out a detailed 'behavioural analysis'. In particular every single instance of suicidal or parasuicidal behaviour is dealt with in this way. Such behavioural analysis is an important aspect of DBT and may take up a large proportion of therapy time.

In the course of a typical behavioural analysis a particular instance of behaviour is first clearly defined in specific terms and then a 'chain analysis' is conducted, looking in detail at the sequence of events and attempting to link these events one to another. In the course of this process hypotheses are generated about the factors that may be controlling the behaviour. This is followed by, or interwoven with, a 'solution analysis' in which alternative ways of dealing with the situation at each stage are considered and evaluated. Finally one solution should be chosen for future implementation. Difficulties that may be experienced in carrying out this solution are considered and strategies of dealing with these can be worked out.

It is frequently the case that patients will attempt to avoid this behavioural analysis since they may experience the process of looking in such detail at their behaviour as aversive. However it is essential that the therapist should not be side tracked until the process is completed. In addition to achieving an understanding of the factors controlling behaviour, behavioural analysis can be seen as part of contingency management strategy, applying a somewhat aversive consequence to an episode of targeted maladaptive behaviour. The process can also be seen as an exposure technique helping to desensitise the patient to painful feelings and behaviours. Having completed the behavioural analysis the patient can then be rewarded with a 'heart to heart' conversation about the things she likes to discuss.

Behavioural analysis can be seen as a way of responding to maladaptive behaviour, and in particular to parasuicide, in a way that shows interest and concern but which avoids reinforcing the behaviour.

In DBT a particular approach is taken in dealing with the network of people with whom the patient is involved personally and professionally. These are referred to as 'case management strategies'. The basic idea is that the patient should be encouraged, with appropriate help and support, to deal with her own problems in the environment in which they occur. Therefore, as far as possible, the therapist does not do things for the patient but encourages the patient to do things for herself. This includes dealing with other professionals who may be involved with the patient. The therapist does not try to tell these other professionals how to deal with the patient but helps the patient learn how to deal with the other professionals. Inconsistencies between professionals are seen as inevitable and not necessarily something to be avoided. Such inconsistencies are rather seen as opportunities for the patient to practice her interpersonal effectiveness skills. If she grumbles about the help she is receiving from another professional she is helped to sort this out herself with the person involved. This is referred to as the 'consultation-to-the-patient strategy' which, among other things, serves to minimise the so-called "staff splitting" which tends to occur between professionals dealing with these patients.

Environmental intervention is acceptable but only in very specific situations where a particular outcome seems essential and the patient does not have the power or capability to produce this outcome. Such intervention should be the exception rather than the rule.
EMPIRICAL EVIDENCE

The effectiveness of DBT has been assessed in two major trials. The first (Linehan et al, 1991) compared the effectiveness of DBT relative to treatment as usual (TAU). The second (Linehan et al, in press) examined the effectiveness of DBT skills training when added to standard community psychotherapy.

In the first randomised controlled trial, there were three main goals:

Firstly, to reduce the frequency of parasuicidal behaviours. This is clearly of importance because of the distressing nature of the behaviour but also because of the increased risk of completed suicide in this group (Stone, 1987).

Secondly, to reduce behaviours that interfere with the progress of therapy ('therapy interfering behaviours'), as the attrition rate from therapy in borderline women with a history of parasuicidal behaviours is high.

Finally, to reduce behaviours that interfere with the patients' quality of life. In this study this latter goal was interpreted more specifically as a reduction in in-patient psychiatric days, which is hypothesised to interfere with the patient's quality of life.

Participants all met DSM-IIIR criteria for BPD, and were matched for number of lifetime parasuicide episodes, number of lifetime admissions to hospital, age and anticipated good or poor prognosis.

There were 22 patients in each group. The experimental group received standard DBT as outlined above. The experience of the patients in the treatment as usual group was variable; some received regular individual psychotherapy, others dropped out of individual therapy whilst continuing to have access to in-patient and day-patient services. All participants were assessed on number of parasuicidal episodes and a range of questionnaire measures of mood. Patients were blindly assessed at pre-treatment, 4, 8 and 12 months and followed up at 6 and 12 months post-treatment. Measures of treatment compliance and other treatment delivered (e.g. in patient psychiatric days) were also taken. At pre-treatment there were no significant differences on any of the measures between the control and experimental groups including demographic criteria.

With regard to the first aim of the trial (i.e. the reduction of suicidal behaviour), during the year of treatment patients in the control group engaged in more parasuicidal acts than DBT patients at all time points. The medical risk for parasuicidal acts was higher in the control group than in the DBT group.

Patients in the DBT group were more likely to start therapy and were more likely to remain in therapy than those in the control group. The one year attrition rate in the DBT group was 16.7% compared to 50% for those in the control group who commenced the year with a new therapist. The DBT patients reported more individual and group therapy treatment hours per week than the TAU group, which reflects the intensive nature of DBT treatment. However, the control patients reported more day treatment hours per week.

With regard to the third goal of the trial, patients in the control group had significantly more inpatient psychiatric days per person than those receiving DBT (38.6 days per year as compared to 8.46 days per year for the DBT group).

These results were considered to indicate the superiority of DBT over treatment as usual. However, one major criticism of the trial is that the variable and patchy therapeutic experience of the control group may be considered to favour DBT. This criticism can be challenged, however, since one of the treatment aims of DBT is to keep the patient in therapy. This it seems to have succeeded in doing. However, it is still pertinent to enquire how well DBT would compare to a consistent treatment alternative. An attempt was made to explore this by comparing the DBT patients with those in the TAU group who received regular individual therapy. It was found that the gains of the patients in the DBT group over the TAU group remained even using this more rigorous comparison.

Despite the more intensive nature of DBT it remained cheaper than TAU, largely because of the reduction in the number of in-patient and day-treatment days received by the DBT patients.

It is of interest that, although the DBT patients showed significant gains across the three areas of interest (number of parasuicides, treatment compliance and inpatient days), there were no between-group differences on any of the questionnaire measures of mood and suicidal ideation. During the follow-up year, patients in the DBT group had higher Global Assessment Scores and a better work performance than the patients in the TAU group. In the first 6 months, DBT patients had fewer suicidal acts, lower anger scores and better self-reported social adjustment than TAU patients. In the final 6 months, DBT patients had fewer in-patient days treatment and better interviewer rated social adjustment than TAU patients.

The second trial had two parts. Firstly, it compared standard community psychotherapy (SCP) plus the group skills component of DBT with SCP alone without added skills training. Secondly, it compared the SCP group from the first part of the present study with the experimental group in the previously described randomised control trial. In this latter comparison, assignment to conditions was not random. However, all subjects were screened in the same way, during the same time frame and were all subject to blind assessment.

The results of the first part of this study indicated that the addition of DBT skills training to SCP for this group of parasuicidal borderline women did not confer any additional therapeutic benefit. In this part of the study the skills training was truly ancillary in that there were no meetings between the individual therapists and the group therapists, nor were any attempts made to assist the patient to generalise the skills learnt in the group to her everyday life.

In the second part of the study there were some pre-treatment differences between the two groups. The DBT patients were less depressed than the control group and reported higher levels of unemployment. These differences were not considered to be particularly important for three reasons. Firstly, depression was not correlated with any of the outcome variables. Secondly, although the lower depression scores favoured the DBT group, the lower unemployment favoured the SCP group. Finally, the levels of depression did not differ between the two groups after the pre-treament point.

During the treatment year there were no significant differences between the groups with regard to staying in therapy. There were some slight differences in the distribution of therapeutic hours, with DBT patients reporting more group treatment hours than the SCP group. Most importantly, however, there were no significant relationships between number of treatment hours and any of the outcome variables. Over the treatment year, standard DBT patients compared to SCP patients had fewer parasuicidal episodes, fewer episodes leading to medical treatment and fewer psychiatric in-patient days. DBT patients also reported less anger than the SCP patients.

This research then provides some evidence for the therapeutic efficacy of DBT. This evidence is primarily derived from one randomised control trial in which DBT was found to be superior on a number of variables to treatment as usual. Clearly this finding requires replication. There is also some evidence to suggest that DBT is superior to other forms of psychotherapy with this group of patients. However, this result comes from a comparison made using only a sub-sample of patients in the randomised trial (Linehan et al, 1991) and from a further comparison between two groups from different studies (Linehan et al, in press). Consequently, the effectiveness of DBT compared to other alternative treatments awaits further exploration. This will remain a challenge, particularly given the high drop-out rates from treatment of this group of patients.
SUMMARY AND CONCLUSIONS

Dialectical Behaviour Therapy then is a novel method of therapy specifically designed to meet the needs of patients with Borderline Personality Disorder and their therapists. It directly addresses the problem of keeping these patients in therapy and the difficulty of maintaining therapist motivation and professional well-being. It is based on a clear and potentially testable theory of BPD and encourages a positive and validating attitude to these patients in the light of this theory. The approach incorporates what is valuable from other forms of therapy, and is based on a clear acknowledgement of the value of a strong relationship between therapist and patient. Therapy is clearly structured in stages and at each stage a clear hierarchy of targets is defined. The method offers a particularly helpful approach to the management of parasuicide with a clearly defined response to such behaviours. The techniques used in DBT are extensive and varied, addressing essentially every aspect of therapy and they are underpinned by a dialectical philosophy that recommends a balanced, flexible and systemic approach to the work of therapy. Techniques for achieving change are balanced by techniques of acceptance, problem solving is surrounded by validation, confrontation is balanced by understanding. The patient is helped to understand her problem behaviours and then deal with situations more effectively. She is taught the necessary skills to enable her to do so and helped to deal with any problems that she may have in applying them in her natural environment. Generalisation outside therapy is not assumed but encouraged directly. Advice and support available between sessions and the patient is encouraged and helped to take responsibility for dealing with life's challenges herself. The method is supported by empirical evidence which suggests that it is successful in reducing self-injury and time spent in psychiatric in-patient treatment.

REFERENCES

Linehan, M.M. (1993a) Cognitive Behavioural Treatment of Borderline Personality Disorder. The Guilford Press, New York and London.

Linehan, M.M. (1993b) Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press, New York and London.

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. & Heard, H.L. (1991) Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

Linehan, M.M., Heard, H.L. & Armstrong, H.E. (in press) Dialectical behaviour therapy, with and without behavioural skills training, for chronically parasuicidal borderline patients.

Stone, M.H. (1987) The course of borderline personality disorder. In Tasman, A., Hales, R.E. & Frances, A.J. (eds) American Psychiatric Press Review of Psychiatry. Washington DC; American Psychiatric Press inc. 8, 103-122.

Barry Kiehn, Consultant Child and Adolescent Psychiatrist, Gwynfa Adolescent Service, Pen-y-Bryn Road, Upper Colwyn Bay, Clwyd, North Wales, LL29 6AL.
e-mail: b.kiehn@bbcnc.org.uk

Michaela Swales, Chartered Clinical Psychologist, Gwynfa Adolescent Service and Lecturer in the Psychology of Adolescence, University College of North Wales, Bangor, Gwynedd, LL57 2DG.
e-mail: pss051@bangor.ac.uk

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DADHC are idiots

2010-10-05T18:11:00.000+11:00

was told today that in Sue's new housing model if she assaults staff police will be called.

HOW FUCKING STUPID IS DADHC AND THE CJP?

OF COURSE SUE WILL ASSAULTS STAFF. Sue is violent, extremely violent.

i told them that means they are actually opening Sue up to be once again sent to JAIL.
ANd then they go onto to talk about Behaviour modification. STUPID STUPID PEOPLE> THEY JUST DON"T GET IT.
Sue is super aggresive.
She is not trainable.

Where she is now police are not called if she hits staff. DADHC and the CJP are just willfully dis-regaurding Sue's dangerous behaviour. She's a fucking guinea pig for this project.

FUCKING IDIOTS?

oh and that this is part of the training that staff will have to do and enforce on Sue and some of the training they expect SUe to do
http://www.wesleymission.org.au/community_services/counselling/Behaviour_Therapy_Training.asp
http://priory.com/dbt.htm
http://en.wikipedia.org/wiki/Dialectical_behavior_therapy

All good and well, but Sue has an intellectual disability. Also she can no longer learn new skills since the ECT.

WHAT THE FUCK ARE THEY THINKING?

was told i can not have copy of the report. Sue's guardian can release it to me but DADHC can't.

once again DADHC don't know they're own policy. It's a stupid policy, family should have the same right as the guardian in regaurd to assessments findings.

DADHC staff

2010-10-05T15:57:00.001+11:00

I'm going to give Katelynd the benefit of doubt and assume she is not in the office as she always responds quickly to my emails.

I'm also do believe Katelynd when she says that she is just the front person.
So i emailed to Katelynd's boss about the DADHC assessment. Just in case it needs to run past her before they send it to me.

Let's see how long it takes her to respond and if she will scan the assessment for me.

still waiting on assesment

2010-10-05T15:53:00.000+11:00

ok now I'm a little pissed.

2nd request for this info

"Hi Kelly

We have a meeting with you on Thursday at 2pm. I am still waiting to receive the copy of the assesment that DADHC have done on Sue.

I'm assuming that Kateylnd is not in the office as she is very quick to respond to emails.

The document was meant to have been posted to me on the 24th Sept.

Can you scan it and send it to me? I need it prior to the meeting.

Thank you

Julie"

One could start to think they don't want me to see this report.

DADHC assesment

2010-10-01T07:58:00.002+10:00

I sent an email to Katelynd yesterday to let her know I haven't received the copy of DADHC assessment they did on Sue about her suitability to move. She told me she was sending it on the 24th Sept 2010.

Can't work out how they did an assessment on someone they have never meet. Very strange.

That's one very big question that remains unanswered. How'd you do that assessment?
What do you read a file?
How's that work?
I'm guessing the file that DADHC is using is old because Katelynd didn't know about Sue's diagnosis. So how valid is your assessment?
Not very is the answer.

Unbelievable. And very scary.

I wonder how these people would feel if a stranger walked into their lives, never took the time to meet them and then started making decisions about where they lived based on old and out of date information. Even worse is that they are doing it against all the advice of your carers, medical staff and family. So much for consultation with all involved.

How arrogant and stupid can one organisation be, I give you DADHC.

meeting set for the 7th

2010-09-28T14:23:00.002+10:00

Ok heard back meeting on the 7th with Me, Katelynd, Kelly and Katrina.

Wonder of they are getting RSS feeds.

meeting

2010-09-28T08:57:00.000+10:00

I rang Katelynd and told her I think we need a meeting before the 13th. I'd like to think that that will happen and that they will have some answers to my questions. But I'm cynical and I won't bank on all parties being available before the 13th or that they will have answers to the questions I have asked.

One big thing that I forgot to ask them was: "Has anyone considered the fact that Sue may not want to move from the area she is living in?" She had been in the Newcastle region since she was 19. She likes the region and has always said she never wants to live down in the city. This proposed move will move her to the city. I reckon they have not even considered that one.

Not many people have ever asked Sue where she wants to live. Also how do you think her behaviour will respond to a forced move against her will? I know how that one will go.

When she moved to Kanangra I spent a long time explaining it to her and continuing to explaining it to her for quite a while. And I also explained how Kanangra meet her parole conditions. One of the first things she asked me was it the place in Morisset and she said it was good it was in the region she likes. And then she was pleased to find people that she knew there. It made the move for her a bit easier.

Also in her new accommodation if she assaults staff will police be called? If so then isn't that just setting her up to more contact with the criminal justice system and jail?

For now where she is that does not occur, the police are not called.

Also how are you going to cope with her self harm stuff? Are you going to be as pro active as Kanangra. No knifes, no glass, no access to things to throw at staff?

I keep on coming up with new questions. Which is good but i reckon they have not considered them.

speak of the devil

2010-09-24T16:29:00.003+10:00

Here is the email reply from one member of the CJP DADHC

"Afternoon Julie,

I wanted to let you know that we have received your email.

Thankyou for passing on your concerns and questions regarding Sue moving into the community.
My managers have asked me to let you know that they have taken on board the seriousness of the issues you raised in your email and to reassure you that they will be responding in more detail shortly.

As you would know, we have organised a meeting for 13th October 2010 with the OPG at Quakers Hill. My managers have asked me to let you know that if you would like to meet prior to this date, we are more than happy to facilitate an earlier appointment with you at our Parramatta Office.

Kind Regards,

Katelynd"

no replies

2010-09-24T16:17:00.001+10:00

I find it disheartening that only the guardian has e-mailed me back. The others could have sent an email back saying they were working on answers to my questions.

It does nothing to stop my concerns about their motivation.

frustrated

2010-09-24T09:28:00.002+10:00

I do not understand why DADHC and the Criminal Justice program are still think of moving Susie. Everyone involved that work with her daily and have done for a number of years now say she is not ready.

I have looked at the outside of the place and due to the fact the Sue cannot have access to the community all she is going to do is sit in a unit with no outside contact, it's just really a differant style of jail.

STUPID STUPID PEOPLE.

So far simple questions like
What happens if you move her and it fails where will she be moved to?
Are you going to provide activites for her?
How many staff?
Level of training?

Have come back with "I can't answer that"

Gezz people get it together
i haven't even asked the really hard ones.

Like birth control? What happens if she gets out of the housing? What happens if the neighbours call the police?

HOPELESS JUTS HOPELESS.
they really haven't thought this thing through have they.

And to top it off Katelynd way to Kanangra and DIDN'T MEET SUE.

when i asked her why she said she was running late. I told her the least she should have done was to pop in and quickly introduce herself 5 minutes that all it would have taken. It's rude, inconsiderate and smacks of them treating Sue with disregard.

email sent to those involved in trying to move Sue

2010-09-24T09:21:00.000+10:00

this is what i sent to all the names i have that are invloved in trying to move Sue from Kanangra. I will post their replies if i get any.

Hi
I am Sue's sister and I have some questions about why your agency is considering moving her.

Why are you considering moving her when her staff and the psychiatrist at Kanangra have told you she is not ready to move?
What is the pool of staff that will work with Sue and how many staff will be on duty each day at the accommodation you are thinking of moving her to?
How many staff are going to be assigned to Sue?
What are the staffs qualifications and experience?
What day programs and activities are you going to provide for Sue and where are they going to be held?
I have been told that Sue will be able to maintain contact with her friends at Kanangra how will this be achieved?
Is there a plan to move Sue into the wider community?
If this move fails what is the plan for Sue's accommodation? Can she move back to Kanangra?
What are you going to do if neighbours complain about the behaviour and noise from your residents?
Are the other clients permanent residents? Do they have an intellectual disability?
Have you read Sue's file?
Do you know what her various diagnosis are?
Have you read her court records?
What makes you think this placement will work when others have not?
Have you read her parole conditions?
Do you think you can modify Sue's behaviour better than Kanangra?
What happens to the housing and Sue when funding for the project Stronger Together stops or is rescinded?
How are you going to deal with her mental health issues? Will she have ongoing psych support as she has at Kanangra?
Who suggested Sue was valid candidate for this move? And why? Have they meet Sue or talked with Sue or her staff?
Was Sue assessed for this placement? If so how? What was the criteria?
When was the last time anyone connected with this project meet Sue?
Who is The Office of the Senior Practitioner?
Is Sue being considered to be moved because of a need to fill vacancies?
Why not just leave Sue where she is and move her with the rest of the Kanangra clients?

Or is it on the table to move Sue purely because the Ombudsmen has criticised DADHC'sDADHC's role and that in "In 2004, in response to a complaint about the lack of progress of the SOG, we initiated an investigation of DADHC's conduct as lead agency of the SOG. Our investigation found significant problems with DADHC's leadership of the SOG, little progress on individual projects initiated under the auspice of the SOG, and little evidence of agencies working collaboratively and cooperatively to achieve better service delivery for people with an intellectual disability in contact with the criminal justice system."
(NSW Ombudsmen, Supporting people with an intellectual disability in the criminal justice system: Progress report A special report to Parliament under s31 and s26 of the Ombudsman Act 1974 August 2008)

Is the Community Justice Program Program Guidelines Version 1.0 still the guidelines your agency is working off? If so then Sue does not meet your own policy guideline: "to assist people moving from a correctional facility into the community, and to meet the accommodation and support options for those who are exiting a correctional facility." Sue is currently housed, she is not in jail. Neither is she :"Without support and stable housing in the post release period", or at risk "of homelessness often resulting in returning to gaol." Neither is Sue a valid candidate for: "moving through and out of the accommodation and support services" that DADHC provide. She cannot live in the broader community.

Your report also says that: many of the clients you will help "have little access to consistent financial, vocational, educational and social opportunities or support." That is not the case with Sue. She has excellent support at Kanangra.

You are considering moving someone who is currently housed safely and stably and has not had any contact with the police since she has been housed at Kanangra. Why are you thinking of intervening when she is already settled?

I would like to raise the fact that prior to Kanangra Sue had had 7 previous housing options provided by DADHC. All of these failed. Why do you think she is in Kanangra?

I have grave concerns when DADHC staff start talking about training Sue, that she can be taught to behave via behaviour modification. Why do you think she is in Kanangra? Kanangra does behaviour modification. Sue is not just acting out, or a "bad person" like previous DADHC staff have told me and she can not be "trained" to behave and DADHC staff need to realise that and get their head out of the sand and to stop expecting Sue to achieve things that she can not. You set her up to fail and then hold her responsible for your actions and your failings.

You need to listen to the Kanangra staff, they are the experts. They deal with Sue everyday. Why does the Criminal Justice Program and DADHC think they know better than Kanangra? One could come to the conclusion that you are saying that Kanangra do not know what they are doing. And if you think that then DADHC and the Criminal Justice Program are once again failing their clients and falling into a state of do-gooding, or maybe playing a numbers game, without thought or concern for their charges and really, in the end, that just amounts to stupidity.

To end I find it disturbing that Sue is still being consider to be moved against the advice of those working with her and I am wondering now whether it is because DADHC is currently under review by the ombudsmen via the Senior Officers Group?

Thank you
Julie

More News

2010-09-22T19:15:00.002+10:00

I spoke with the staff at Kanangra today they said they have told Katelynd that Sue is not ready to be moved. That Sue has an active life, a peer group and she has activities to do each, that she walks each day and is settled there. That it is not in her best interest to be moved. That a move would only disrupt her and trigger off her behaviour disorder. They said that Katelynd didn't seem to have answers to how Sue's activities needs would be meet, that she said she was just an underling and she didn't know or have answers to these concerns.

These are concerns I also voiced to Katelynd. Kanangra told me they also said to Katelynd that they were concerned what will happen to Sue if the move fails.

They told me that Katelynd could not answer the issue of housing Sue if they move her and it fails.

They told me to point out to Katelynd that two staff is not enough to deal with Sue that they need a pool of staff cause when she erupts it takes four staff to deal with her.

When Katelynd rang me today I told I did not understand why Sue was even being considered to be moved when the staff that deal with her everyday including her psychiatrist say it is not in Sue's best interest. I was told that it is part of the consultation process. I said that that did not answer the question. It's tokenism. That's all it really is. I told Katelynd that what is really happening is that Sue is a number, it's all a numbers game and for the house/funding to occur they have to have people and Sue was just a number. She said no she wasn't but she would not tell me why the move is still on the table when every person who is involved with Sue objects to the move.

So I have contact emails for not only Katelynd but for the higher up staff. I've got a long list of questions and they better have answers not just dismissive "I don't know."

tell me this isn't just a numbers game, tell me i'm wrong, tell me DADHC isn't going to set her up to fail again. My alarm bells are screaming and they are screaming because the concerns of family and staff in consultation phase are not being listened to.

New News

2010-09-15T07:55:00.001+10:00

Had a call on Monday from Kaitlyn from ADAHC - Criminal Justice Program. They are starting the process of moving the people out of Kanangra and back into the community. Now those words got my defences up because Sue cannot live in the community. Which is what I said very firmly to Kaitlin : "Why would you want to move someone back into the community when it was failed over and over again. It;s like lets set her up to fail again and really fuck her over."

Like I said I got defensive and a tad offensive. Oh well.

So in told Kaitlyn I was not happy about the situation and then I asked her to tell me about the place they have in mind for Sue.

They are using Sue's current accommodation as the model for where she will move into. So she will have a stand alone completely secured unit to her self that will have two permanent staff. The property will also have other units surround in it and that Sue can visit much like where she is now. The whole complex will be secure.

All the staff will have specific training to deal with Sue's many problems. I also told Maitland about Sue's diagnoses of her disability. Now I don't know if she didn't read Sue's file or if the information isn't in Sue's file but she knows now and I will make sure it is documented in her file so everyone who come into contact with Sue has the info available to them.

Maitland could not answer all my questions and told me she doesn't know everything as she way down the bottom of the hierarchy. Her bosses are David Coyne and and Kelly Fishbourne I think I need to talk to them but I reckon I've got buckly's and no chance there..

She did keep rabbiting on about Sue's behaviour being able to be modified, why can no one except Kanangra and me and my gal acknowledge the fact that that cannot happen. Sue is not"bad" she had a medically diagnosed disorder that creates behaviour disorders. Get a grip people. I'm not trying to excuse her behaviour but Sue is Sue. You can get her to aim for things based on good behaviour but when she blows there is no way to stop it and you need to get your head out of the sand and stop setting her up.

I said this to Kaitlyn, I don't think she got it. I really hope the new staff get it, the staff at Kanangra are wonderful and get Sue and her disability.

I will get to look at the property and I will be a kind of consultant as they want my feedback about it.

I want the best for Sue and that is the main aim.

Mental Health Hearing

2009-02-23T14:20:00.002+11:00

They approved ECT for Sue. 12 treatments to be completed by 17/4/2009 all of my concerns and I were basically dismissed. None of my concerns were deemed "relevant."

When i asked whether the main doctor (who had singed off on this order) Dr Chenoworth had physically examined Sue or had made his diagnose via case notes. I was told that it wasn't relevant whether he has physically looked at Sue. Pardon me but there is a big difference between physically looking at someone and making a judgements based on paperwork.

They said that her "condition was life threatening due to weight loss over the last 10 months of around 50 kilos." I did point out that she has only been sick for 5 months and that Dr Fraser (the staff doctor where she lives) had Sue on a very strict diet because at one point she had weighed 130 kilos. I was told that wasn't the relevant either. Excuse me it is relevant when part of her weight loss was done under the guidance of her practitioner as a health issue and had nothing to do with her current "depressive" state. She has lost weight in the last 5 months but not 50 kilos.

Actually she has put on weight in the last 6 weeks between my visits to her. What happened to truth, i don't want fabrication and misleading information used to pursue the ECT treatment plan. But hey it was.

They also said that Sue was catatonic. "appearing mentally stupefied, unresponsive, and motionless, or almost so; seemingly unaware of one's environment. http://define.com/catatonic" Sue was meant to attend the hearing and when Dr Kim Newnham was asked why Sue wasn't at the hearing she said: "that Sue had to be medicated because of her aggressive behaviour and that Sue was throwing chairs around the room since this morning:" Doesn't sound like she motionless and catatonic to me sounds like she's really angry to me but hey what would i know i'm only her sister.

The most annoying thing about this hearing is the total lack of concerns for what ECT did to Sue last time and how it affected her ability to function. My concerns around this were dismissed by someone asking in a very judgmenetal tone: "And just how long is it since you've seen your sister? How dare they assume that i don't visit. Cause that was the tone they used. I told them only a few days ago on the 23rd of January. That i was aware of her state and i was concerned but i don't believe in ECT being given to people with intellectually disabilities." I asked the rude lady "had she visited Sue? Or looked in on Sue?" She didn't answer. I was told there was no other option bare ECT. I said "why not try medication for angry people. I was told they had tried various medication. I said i was very well aware of what medication had been tried on Sue and all of them were solely for depression and mood disorders why not try an alternate medication for anger/psychosis i was told ECT was the only option. That they would not consider any other option.

Why not if only trail it for a week just to see. Nope I was dismissed, all my concerns about Sue were dismissed or I was told were not relevant. The bitch in me hopes one day these people will have to face a hearing like this and be told there irrelevlnt and that their concerns are not relevant and then be dismissed in the cold rude manner that i was.

Shock Treament battle (Again)

2009-02-03T08:05:00.002+11:00

Ok, just a brief post more info later. Sue hasn't been well lately. She isn't toileting, she isn't talking, she has very strange hand movement, and a gaiety walk and she seems to have some hallucination happening as well. As she appears to be seeing stuff that isn't there, she gets a fixed look on an empty room. This has been going on for about 5 months. I have seen here go through this twice before, the last time they gave her ECt (shock treatment) and it impaired her ability to function in the world and her ability to learn new skills.

Yesterday she was sent to James Fletcher by her Dr at Kanangra Dr. Fraser to be assessed for more shock treatment. In my conversations with Eric he has told me he's not overly concerned about what the shock treatment will do to her functionality he's more concerned about her well being now. He said she is at the maximum amount of anti depressants and mood stabiliser that she can tolerate. I said to him doesn't that kind of give weight to my opinion on what is wrong with Sue at the moment and that she is angry and has shut down, that she isn't depressed. He said that it is more of an indication of sever depression. We disagree on this. I think Sue got really mad and just shut down. You don't treat anger with ECT.

Anyway she's been assessed by a Dr Kim Newnham at James Fletcher and apparently the request for shock treatment goes in to hearing today. I've left two messages for Dr. Newnham to call me prior to her assessment of Sue but she has not returned my calls. She did ask a nurse Sujatha to call me and let me know that Sue was being assessed as needing shock treatment. Coward, also it could be viewed as excluding the one person who is opposed to the treatment plan, after all that's how they got to give her shock treatment before buy not letting me know about the hearings at the Mental Health Tribunal. It seems James Fletcher maintains a policy of excluding those opposed to their plans.

So this morning i have to ring the Mental Health Tribunal to find out what time the hearing is so i can put my views across. fingers crossed i can get the information i need.

Also just a side note i found it a little disturbing that on the answering machine at the Metal Health Tribunal that they have as part of their message info on what to do for "Emergency shock treatment orders" outside of business hours of the tribunal. I don't understand how ECT could be an emergency situation. Surely it can wait till the morning and the hearing process. It's scary. Just plain scary what is happening to people with mental health disorders.

Susie update

2006-09-13T09:59:00.000+10:00

Sue seems to be going pretty well. The staff are saying she is not having as many outbursts. They have set up a phone link for her so she can call me at an arranged time each week. It gives her some responsibility but she is also free to not call me if she doesn't want to. I think that's really important, she shouldn't have to talk to me if she doesn't want to. So far though she has called me every week.

Some calls she is more cheerful than others. last week she sounded very morose. Only managed to make her laugh once, usually I can get her giggling. She tells me that she is assigned the job of folding the washers for her ward. She sounds like she really enjoys that, it's good for her morale to be doing something constructive and with some amount of responsablity as well.

She is now in ward 3 so she has moved out of her own unit, into one with other patients. She says she sometimes gets scared of them and when I ask her why she says she’s scared of them hitting her or of her hitting them. I give her suggesting such as if they hit you don't hit them back go to the staff and tell them. Also if she fells like hitting other patients that she should go for a walk if she can or if she can't tell the staff she fells like hitting this person. The staff will talk to her and calm her down. I also remind her that the staff will thinks she great if she tells them she's angry enough to hit rather than just hitting someone.

She tells me she has used all of my suggesting and that when she told the staff she wanted to hit someone they told her they were really proud of her for not hitting the person and for coming and talking to them. She said it made her fell really good to be told she did the right thing. Praise for doing the right thing is really important to Sue.

I'm hoping my health will be well enough to go see her around her birthday. I know she is missing seeing me and I miss seeing her. it just isn't that easy to get up there with not being well. Time will tell about that one, I need to get someone to drive me up that way as I can't drive that far. You think it would be easy to organise that but it has proved rather elusive. I might have to make it a week round trip and take a slow drive myself, do it in stages.

I'm just relieved she is with people who know what they are doing.

She seems to be coping well with the knowledge of her daughter having the same condition she has. I tell her how much easier ti will be for her daughter as she has been diagnosed early unlike her who was 35 before she got diagnosed. And I tell her about all the options that her daughter will have, special education tools, support at school etc, all things that she never had. I tell her that her daughter is with a good family and that will only do what is right for her daughter. She has some very normal concerns for her daughter which some of her DADHC workers have been surprised by, not me or my partner, we expect Sue the react this way, the way any parent would to a child with needs. Some DADHC just don't get it, she is a human being with very human frailties, needs and concerns.

Filling in more gaps

2006-05-14T11:13:00.000+10:00

Within three weeks of talking to Ethel we got a call from Newcastle DADHC to let us know what the new plan was. Sue was being moved to Kanangra, into a properly renovated secure cottage, with full access to the proper programs. Newcastle tried to put out that is was something they had come up with. They were told that we were aware that Ethel had talked to them and that we were in contact with Ethel and that the Newcastle office was being held accountable for Sue.

Sue was released from Mulawa the following January and there have been slow but constant improvements since then.

The strain left Julie and I from that point. For a long time we just totally backed away from the whole subject except to ring Sue once in a while. We finally felt that Sue was in responsible and competent hands at Kanangra.

Eventually we became a little more involved, mainly talking to the Kanangra staff. We have very little contact with Newcastle DADHC. They still do strange things sometimes, lie, try to take responsibility for others work, say stupid unthinking things to Sue and upset her! The guardians that have been appointed have been a mixed bunch, one never talked to Sue, read her file or attended meetings. The next one was better but had to be educated about the advantages of Kanangra. He was a bit of a hothead at first and wanted Sue out in the community before she was ready. The advocate from People with Disabilities was the same way. He was told to stay away from Sue if he wasn't interested enough in her best interests to work out what she needed and what Kanangra could do for her.

Kanangra though! I'm so impressed by their knowledge, their capabilities, their downright common sense! Their ability simply to understand the difficulties Sue faces with her behaviour problems, her anger, and her inclination to hit out. To not get scared, to have techniques for managing all that, and programs to help her change her reactions. Big stuff and they know what they're doing. They actually don't take her outbursts personally!! I think every other worker she has been in contact with over ... well, most of her life really, has been scared and personally offended by Sues outbursts. They didn't know what they were doing, and they didn't try to get further training in that area.

Kanangra don't push Sue away or try to fob her off on someone else. They won't let her progress to a new stage of the programs until she passes the earlier stages. They actually assess her progress and document everything. She won't be pushed through the system to suit someone else’s political agenda.

There is a big political agenda surrounding these issues. The larger institutions are seen to be bad. And some of them have been horrible, we know because Sue has ended up in some really bad places over the years. Maybe having a system like Kanangra with proper programs but in smaller spaces closer to the community may be ideal, but those options don't exist yet, and too many people have been moved out of the larger institutions to suit that political agenda without being moved into the proper alternative. "Look how good we are, we are closing the large nasty institutions!!!"

Funny how that isn't a political point anymore. Everyone in Sydney has become aware of the particular type of homeless person we are likely to come across. In Hyde Park, around Eddy Avenue, in Martin Place, at the State Library, under every possible overpass and overhang and even the shallowest doorway, being populated by the people who were pushed out of the system before they were ready just so political points could be made about closing the institutions. They don't boast about it anymore because the horrible human cost has become blatantly obvious to everyone who works in the cbd. Sue nearly ended up one of them and if it hadn't been for the constant fighting by mostly Julie and also by myself, and Ethel arriving from Victoria in the nick of time, she would have been sleeping out in the cold, her anger and violence out of control, probably hurting other people, probably being hurt, and what would the end of that have been?

Ok, that takes us up to January 2005, and in a general way up to the end up 2005. More later.

Filling in some gaps

2006-05-14T09:57:00.000+10:00

I need to put an update here too, just to fill in some of the gaps. "Kanangra part 3" was written back in November 2004 and a lot happened very quickly, both with Sue and in our personal lives. I think we ran out of steam for writing here because we didn't think anyone was reading it. Even if only one person reads this with interest it is still worth it.

So. Also in November 2004 was the forum (see entry 'Guess where I'm going?', dated Oct 27 2004).

The forum was mainly about how the legal profession could lift it's game in order to divert people with intellectual disabilities from the prison system. The whole thing was quite good, I did learn stuff I didn't already know, but it's not the area that Julie and I have been concentrating on with her sister Sue - we're mainly interested in housing and the role of DADHC (Dept. of Ageing, Disability and Home Care). Turns out someone from DADHC, Ethel McAlpine, was there. She's new, just up from Victoria where they do have decent services.

Eventually they opened the forum to the floor. I talked for about 5 minutes and my main line was that the legal side of things could be cleaned up until it is nice and glossy but it won't make any difference until DADHC comes to the party. I only mentioned Sue a little, bringing her situation back to problems within DADHC. Only a little passionate and that was mainly because the adrenaline was pumping so hard. There were a few appreciative noises from the audience as I brought up different points.

The discussion moved on, people talked about other things and about 30 mins later it finished. Ethel got up, came straight over to me and said "You're supporting Sue Patterson" !! I wasn't really surprised that she knew the case, but I was surprised that she recognised it from the little I said and doubly pleased that she came over to talk to me. She listened to me for a good 10 minutes, and I can do a lot of detailed lobbying in that time! She told me that the Newcastle office had been told that they had to have a workable solution by the time Sue was released in January. I also managed to tell her more details about the problems with Newcastle DADHC that she hadn't been aware of.

I did resist the urge to push her about it not being just about Sue. Time enough for that.

Was I ever buzzing after that!!!! I think talking to Ethel made me feel some hope that someone was going to do the right thing by Sue. It was the first time in years that I'd felt any hope at all.

More gaps filled in soon.

Next Step

2006-04-03T16:47:00.000+10:00

Sue has moved up a step in her progress she has moved into a ward, she is happier for now as she is with other people other than staff. It had to be that way until her behaviour had settled enough to trust that she would not harm others. So far so good. She had stopped talking to me for about three months prior to her moving. When I spoke with her about it she said she had no memeory of it, which is unualsul. Usaully she say, “yeah I was mad at you for not fixing it.” She’s over what ever it was and is now teasing me and cracking jokes.

She has also been recently diagnosed with terminal 22q13 deletion syndrome, as has her daughter. Actually it was her daughter being diagnosed that resulted in me contacting her doctor to have Sue tested. I had never heard of this condition before. I am wondering if this deletion is why every so often Sue goes silent and her toileting skills stop.
http://www.22q13.org/home.html

For now though she is happy, more pieces to her puzzle are falling into to place wiht each new diagnoses, which means her treatment and needs will be meet better. For now wher she is is wonderful, they are great.

Another book

2004-12-05T09:21:00.000+11:00

Main Title: Offenders with developmental disabilities / edited by
William R. Lindsay, John L. Taylor, and Peter Sturmey.

Published/Created: Chichester, West Sussex, England ; Hoboken, NJ :
Wiley, c2004.

Description: xix, 363 p. ; 26 cm.

ISBN: 0470854103 (cloth : alk. paper)
0471486353 (pbk. : alk. paper)

Notes: Includes bibliographical references and index.

Subjects: Offenders with mental disabilities.
Offenders with mental disabilities--Rehabilitation.
Developmentally disabled--Rehabilitation.
People with mental disabilities and crime.
Criminal psychology.

Series: Wiley series in forensic clinical psychology

For over a century, developmental disabilities have been associated with crime in prejudicial and pejorative contexts. Offenders with Developmental Disabilities provides a balanced, comprehensive review of the prevalence, nature and development of offending by those with intellectual disabilities. Not only does this volume include coverage of evidence-based assessment and treatment ideas, strategies and plans, but also places the field in a historical, legal and ethical context. William Lindsay, John Taylor and Peter Sturmey have brought together a wealth of contributors from differing backgrounds to share new material and knowledge of assessments, treatment, and service issues in a single volume. Divided into five parts, Part I opens with theoretical issues; Part II deals with legal and services contexts including ethical concerns; Part III considers risk assessment, general assessment and approaches to evaluation; Part IV addresses specific issues of sexual offending, anger and aggression, fire raising, dual diagnosis, female offenders and personality disorder; Part V concludes with service development, professional and research issues. Forensic practitioners and students from psychology and psychiatry, lawyers and advocates, nurses and social workers will all find this comprehensive and practical book an inspiration in taking this field forward.

Essential reading.

2004-12-01T19:57:00.000+11:00

Anger treatment for people with developmental disabilities : a theory, evidence, and manual based approach / John L. Taylor, Raymond W. Novaco.

Chichester, West Sussex, England ; Hoboken, NJ : Wiley, c2005.

ISBN: 0470870044 0470870052

Contents:
* Anger and aggression : conceptual background and historical perspective
* Anger and its dysregulation : a guiding framework
* Anger treatment effectiveness
* Emotional problems, aggression, and psychotherapy for people with developmental disabilities
* Anger treatment for people with developmental disabilities
* Issues in anger assessment and treatment evaluation
* Development, delivery, and maintenance of a cognitive-behavioural anger treatment protocol for people with developmental disabilities
* Anger treatment protocol : preparatory phase (6 sessions)
* Anger treatment protocol : treatment phase (12 sessions)
* Therapist training, supervision and process considerations / Bruce T. Gillmer
* Anger treatment for women with developmental disabilities / Alison Robertson.

Subjects:
Developmentally disabled--Rehabilitation.
Anger--Treatment.
Aggressiveness--Treatment.
Cognitive therapy.

Kanangra Part 3

2004-11-09T16:19:00.000+11:00

The plot thickens with DADHC. They will not admit Sue to Kanangra where she can get access to all Kanangra's programs and counseling services because of DADHCs no admission policy into institutions. So here is their brainwave, house Sue and Sue’s staff in a condemned building on the Kanangra site. That way "she is in a secure facility but not actually admitted. Everybody’s happy Julie” her case worker said to me.

They do not intend to fix the upstairs of the building that has rotten floorboards which is why the building was condemned. No, instead, and in keeping with true DADHC form, they propose to just close off the staircase leading to the upstairs floor.

Might sound reasonable. But if the flooring is bad enough to be considered an O.H.S issue for staff which resulted in the building being closed how does DADHC think they are going to get round this? Also if the floorboards are rotten what sort of condition are the supports in? I can see the headlines now, ID client and staff killed when floorboards collapsed at DADHC run facility.

This really does highlight just how little DADHC think of Sue's safety to even consider housing her in a condemned building.

What is wrong with these people? I do wonder how they would feel if I was the worker and they were the family member and I suggested housing like this for their sister. It also show that DADHC do not care about workers safety either.

I know Sue needs housing and that it has to be a secure facility, but it also has to be safe and a condemned building does not sound safe to me.

Kanangra Part 2

2004-11-03T15:09:00.000+11:00

On the 29/10/2004 I received a phone call from the Office Manager of Newcastle DADHC. She told me they were now looking at placing Sue at Kanangra. That she knew that even if the funding money they were applying for was approved today there was no way that a house would be ready for Sue to occupy by her release date from Mulawa on the 27/01/2005. That they need a plan B and Kanangra was it. She said that Sue's case worker Jenny was at Kanangra with an architect to look at a space that was currently being used as a library in the main facility and to also look at another building on the grounds to see which would be easier and to convert to accommodate Sue.

All I can say is 'about time'. I think the only reason they are now looking at Kanangra is they don't have another option. They are under pressure from me, Sue's guardian, Mulawa and by now I'd imagine that People With Disabilities have spoken with them about Sue's housing crisis. Also they probably see getting Sue out of Mulawa as a way to get us all off their case. I have said all along she needs to be at Kanangra because they have programmes to meet Sue's needs, and will also keep Sue separate from the community as it's a locked/secure facility.

I haven't heard back from them yet to see what the outcome is but I hope for Sue's sake they place her there. The psychiatrist from Mulawa said to me "Sue cannot be rehabilitated in goal as don't have the programmes to meet her needs."

Senior Psychologist Mulawa.

2004-11-01T16:27:00.000+11:00

I spoke with the Senior Psychologist at Mulawa on the 25/10/2004 about how Sue was going and to also see if she knew of all the reports about Sue such as her E.C.T. "treatments" and her diagnosis of Intermittent Explosive Disorder.

I could hear Sue screaming in the background. She said it was because Sue wanted morning tea, but Sue knew that they didn't have morning tea at Mulawa. She didn't know why she was acting up. I asked her if she had been told that Sue had had E.C.T. She said she hadn't. I told her that since Sue had E.C.T. she could not retain information as well as she use to. She said that it explained a lot about Sue and the way she behaves. I told her it was a DADHC dirty little secret about Sue and that they tell no one about it.

She said she knew about her other diagnosis of Intermittent Explosive Disorder, Attachment Disorder and Borderline Personality Disorder.

She said that Sue is the most complex person that she has ever come across, that they cannot cope with her and that the only way they can deal with her is to put her into isolation. She believes this is not good for Sue, that it only makes her behaviour worse when she is finally let out to mingle with the other prisoners.

She said that Sue cannot control her behaviour, and that she has let Sue know that to get out of there she has to behave but it seems to be beyond her to do so.

So if she is out of control isn't that further evidence that her Intermittent Explosive Disorder, as well as the fact that she can't retain information, is part of why she is acting the way she is? Prison will not reform Sue, it will not be the catalyst for her to behave as she has a disorder and a disability, and when you think logically about it and join all the dots it is clear that her being a calm, nice, non-violent person is beyond her right now. What she needs a secure facility, one where she can't leave the grounds, that is specifically for people with an ID and behaviour disorders, a faculty that is trained to deal with dual diagnosis clients. A facility that can work out if medication will help her at this point and use special programmes to modify her behaviour. A facility that can cope with her, one that won't throw up it arms and go "we don't know what to do".

Prenancy, part 4

2004-10-31T09:30:00.000+11:00

Pregnancy, part 4, 12th May 2001

Susie eventually went into labor. She was sitting on the corner of the bed looking a bit confused and said she thought she'd wet herself. We bundled her into the car and drove her to Nepean Hospital. Sue really like being put in a wheelchair and wheeled around to the ward!

It was about 11.30pm by the time we got there and the hospital staff said she was in very early stages of labor. Julie and I decided I'd take first shift, Julie would go home, eat and try to get some sleep, and I'd ring her when I needed a break.

The staff at the hospital set us up in a pre-birthing ward. No one else was there. She explained to Sue and me that Sue would be staying in here for a while until the later stages of labor, that she was still really early stages so far. Sue started becoming agitated after Julie left so I asked the staff to leave and spent some time working out what was upsetting Sue. She wanted Keith and when I explained she couldn't have him, he wasn't allowed to come to the hospital because of his violence, and anyway he hadn't kept in contact with her and we didn't know where he was, she decided she needed Julie instead.

Julie had only left about half an hour before. She isn't well at the best of times. She has chronic fatigue that recurs, and she's hypoglycemic, needing to eat regularly to keep her blood sugar stable. Sue was getting so agitated that I had to agree to call Julie and ask her to come back. I used it as a bargaining point, told Sue she had to quieten down before I could leave the room to call Julie, that if she didn't quieten down the staff would have to give her needle to medicate her. She managed to bring it all down a couple of notches, I left the room, asked the staff which phone to ring on and asked Julie to come back. All up only about 45 minutes since she left. I don't think she'd grabbed more than a mouthful of food, but she grabbed food to bring with her.

Sue was moved to a birthing room and now that Julie turned up she was a lot calmer. She said she liked the room and I realised the environment had upset her. I asked her what she didn't like about the other room and she said it was a hospital. She looked confused at that because the whole place was a hospital. I looked around and realised, and Sue confirmed, the birthing room was like a bedroom (with a few hospital instruments) and had a reclining lounge chair, bathroom, blankets, dimmer lights, and the first room was just a hospital ward. Very hospital ward! She doesn't like hospitals, feels very out of control in them, they mean not being able to come and go as she wants, being medicated against her will, medical procedures, pain and upset.

Guess where I'm going?

2004-10-27T20:14:00.000+10:00

Gaol as Community Housing?

A Forum on Intellectual Disability and Criminal Justice

brought to you by

The Law Society of New South Wales
The Public Defenders Office, New South Wales
The Criminal Defence Lawyers Association of New South Wales
The Lawyers Reform Association
The Coalition on Intellectual Disability and Criminal Justice

5:30-7:30 pm
Tuesday, 9 November 2004
Level 2, The Law Society Building
170 Phillip Street, Sydney

2 CLE or CPD Points Attached

No Charge for Attendance

SPEAKERS

Dr Meredith Martin, Clinician and Member, Mental Health Review Tribunal

Andrew Haesler, Public Defender

Tania Evers, Barrister

Jim Simpson, Lawyer and Disability Advocate

Jane Sanders, The Shopfront Youth Legal Centre

James Condren, NSW Council for Intellectual Disability

Julie Hoysted, Parent

CHAIRED BY: Associate Professor Chris Cunneen, Institute of Criminology

For bookings and enquiries, please contact
Jennie Pakula, Law Society of NSW
at jap@lawsocnsw.asn.au or on (02) 9926 0390

People with intellectual disabilities are highly represented in prison and in juvenile detention - at least 400% overrepresented in juvenile detention says the latest Government study!

What are the barriers to diversionary and non-custodial options for offenders with intellectual disabilites?
How can practitioners and advocates for reform best equip themselves in working to overcome these barriers?

People with Disabilities

2004-10-26T14:44:00.000+10:00

Yesterday I contacted PWD again to see if they would advocate for Sue. PWD in the past have been Sue's advocate.

I initially contact PWD about Sues situation about 3 months ago and was told by the intake officer that they would not take Sue's case on as she had a case worker. Yesterday they decided that Sue was in fact in need of advocacy because they like me believe that DADHC are taking to long to finalise the application for funding to provide accommodation for Sue. DADHC have known they have to get funding for Sue since May and yesterday I was told it is sitting on someone's desk waiting for them and get sign off on before it goes to the Minister for consideration for funding. The last straw snapped.

So onto the phone to PWD and I am very pleased that they are involved in Sues case as in the past they have been great advocates for securing funding and services for Sue.

Intermittent Explosive Disorder

2004-10-14T13:08:00.000+10:00

http://www.keepmedia.com/pubs/PsychologyToday/2002/10/10/11472?extID=10038&data=intermittent_explosive_disorder
http://psychcentral.com/disorders/sx51.htm
http://www.psychnet-uk.com/dsm_iv/intermittent_explosive_disorder.htm
http://www.findarticles.com/p/articles/mi_g2602/is_0003/ai_2602000327http://www.mentalhelp.net/poc/view_doc.php?type=doc&amp;id=1226&cn=114&clnt%3Dclnt00001&

Parole Hearing

2004-10-14T13:03:00.000+10:00

Sues parole came due on the 7^th of this month. Her hearing was adjourned because she is facing another assault charge this time of a prisoner guard. Her hearing for that offence occurs on the 2^nd of November and I believe she will be sentenced for that crime. I think this is correct, she has committed a crime she has to face to consequences, but I do wonder how they decide whether she is psychotic or not. She has been classed that way numerous times before, various psychiatrists have said that she cannot control her behaviour. If she was psychotic then she’d come under the jurisdiction of Mental Health and maybe would be placed in a facility where she can get the kind of help she needs. <>Mulawa has no psychiatric ward as far as I know as Sue is being held in solitary confinement because that is the only way the prison system can cope with her. Her behaviour will continue to deteriorate as long as she is held there and not in facility that can assess her, put her on medication and get her into some behaviour modification programs.

She has constantly been diagnosed as a person with intermittent explosive disorder, border line personality disorder and attachment disorder. I have at least 3 reports that say she is incapable of controlling her anger and is psychotic. These reports where all done while she was in a locked down psychiatric ward. Now that she needs to be placed in a facility like that again they are saying she has no mental health conditions. Why? Politics. It all comes back to the no admission policy, and deinstitutionalising. Most deinstitutionalising is a good thing, but where do people like Sue go?

Yes, Sue has to be contained, and she has to serve her sentence for assault. But what happens after her sentence is completed? Will she, like other women in her situation, end up serving years in prison simply because there is no facility for them to go to? The parole officer at Mulawa told Sues case worker that “they have two women who have been there long term simply because there is nowhere that can deal with them.” It’s disgraceful that that happens. We need legislation changed so that those people that need institutionlised care aren’t kept in prison, or even worse, released onto the streets and become the faceless homeless.

Punishment

2004-10-11T20:16:00.000+10:00

I can’t work out how a person doesn’t have a mental health problem if they can’t control their temper. At the very least people with a normal intellect need counseling, anger management, behaviour intervention and / or modification. If someone has an intellectual disability and either has a low success rate with learning these techniques because they can’t learn new things well, or an inability to retain knowledge if it isn’t being reinforced and practiced every day, how can they be bad? Why is it that these people are punished by the authorities turning their backs on them and refusing to find them housing? Why are they punished by making them homeless? Forcing them to become street people? Why is it better for society to have these people on the streets instead of in a secure facility?