CEP Workbook Module 7 Integrated Care

Fraser Todd & Michelle Fowler 2013

This workshop is provided through the Mental Health Education Resource Centre and supported by the Canterbury District Health Board. It is one of a series of workshops designed to help practitioners and services improve their capability to work with people experiencing complicated and complex mental heath problems. The material presented in this workshop is drawn from Te Ariari o te Oranga (Todd 2010), though is updated here in several areas. Copyright is asserted by Fraser Todd over the content. It may be freely used with permission. The name Te Ariari o te Oranga means the dynamics of well -being. The name was coined by that staff ad students of Te Ngaru Learning Systems, was given to a series of bicultural training events on co-exiting and mental health and substance use problems (CEP) over the past decade, and given to the document Te Ariari o te Oranga: The Assessment and Management of Co-existing Mental Health and Substance Use Problems (Todd 2010) by Paraire Huata. As a term, it captures the practice and teaching of CEP in New Zealand where bicultural approaches are honoured.

Welcome to this Workshop

This workshop on Management of CEP is final of six advanced workshops. The relevant section in Te Ariari o te Oranga is essential background reading and much of that content will not be repeated in the workshop.

The MHERC CEP Workshop Series

Workshop 1: 1a. Introduction to CEP for frontline staff 1b. Introduction to CEP for managers Workshop 2: Recovery and Wellbeing Workshop 3: Motivation and Engagement Workshop 4: Assessment Workshop 5: Management I Workshop 6: Management II Workshop 7: Integrated Care To attend workshops 2-7, it is expected that participants will have either attended module 1 OR completed a self-directed learning package based on Workshop 1. It is essential that they are conversant with the generic principles that will be the focus of Workshop 1.

Workshop Overview Learning Intentions

Participants will be provided with the opportunity to:

 Understand and be more skilled in delivering person-focused, wellbeing-oriented integrated care Understand the steps to integrated care Gain specific strategies for enhancing integrated care

Te Whare o Tiki Integrated Care

In addition, we will aim to cover some of the Integrated Care components of the CEP Skills Framework Te Whare o Tiki. Te Whare O Tiki has been produced by Matua Raki to provide guidance and direction for learning and practice development in CEP.
Integrated Care is the seventh domain of the skills set and includes the following skills at three levels of competence, foundation, capable and enhanced: 7.1 Person centred and wellbeing focused care as a basis for integration 7.2 Assessment strategies 7.3 Multi-disciplinary team (MDT) functioning 7.4 Collaboration and referral

Workshop Outline
Mihi and Introductions Housekeeping Workshop overview Review of last workshops action planning exercise Introductory Mindfulness Exercise Overview of Integrated Care Specific Transdiagnostic Factors Collaboration

Review of the Case of Rachel Integrated Care

Exercise 1: Mindfulness Introduction Instructions will be given in the workshop.

Integrated Care
Integrated Care
A major trend in health care over the past two decades A response to the increasing fragmentation of health care services Some models strongly patient-centred Many different approaches Vertical (primary and secondary) and horizontal (between services at the same level of care e.g. specialist) integration World Health Organization definition Integrated care is a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment care rehabilitation and health promotion in relation to access, quality, user satisfaction and efficiency

Key Concepts: Autonomy Co-ordination Integration Continuity of care Of information Across primary-secondary interface Provider continuity

Dual Diagnosis Treatment Integration

Dual diagnosis treatment has primarily focused on treatment integration at the level of programmes and services. While integration at the point of the client and family has been stressed in most theoretical models (e.g. Minkoff et al) it has seldom been put into practice effectively.

Minkoff's Principles of Dual Diagnosis Treatment

1. Dual diagnosis is the rule not the exception 2. Individuals with dual diagnosis differ four quadrant model 3. Empathic, hopeful, integrated treatment relationships 4. Case management balanced with empathic detachment, contracting, consequences and contingent learning 5. Mental health and alcohol and drug problems should both be considered primary 6. Philosophical framework of disease and recovery models with parallel phases of recovery 7. Interventions must be individualised according to: quadrant, diagnosis, level of functioning, external constraints, phases of recover/stages of change, level of care

8. Clinical outcomes must be individualised Most dual diagnosis approaches focus on the merging of standard substance use and mental health treatments within a single team or across teams that collaborate closely. With this approach fragmentation will remain particularly with teams that do not collaborate effectively, and with agencies outside addiction and mental health systems which, given the nature of CEP, inevitably need to be involved in most cases.

The Effectiveness of Treatment Integration

Chow, C. et al. Mission Impossible: Treating serious mental illness and substance use cooccurring disorder with integrated treatment: a meta-analysis Mental Health and Substance Abuse 6;2:150-168 A meta-analysis of treatment integration approaches to CEP considers drug use, alcohol use, psychiatric symptoms and functioning. 13 studies included (2824 subjects). Integrated treatment v treatment as usual Those with alcohol problems mild benefit (small effect size) Those with drug use no benefit from residential treatment, some from outpatient treatment

Previous reviews: see Te Ariari o te Oranga

Person-centred Integrated Care

The key to delivering integrated care is to: Start with person-centred care, organizing care from the needs of the individual/family/whanau Identify core values, strengths, personal definition of well-being Obtain multiple sources of information from multiple life domains to Identify barriers to well-being and pathways to well-being and Consider nomothetic (diagnostic) and idiographic (individualized) and etiological/transdiagnostic factors Integrate the above information with an aetiological (causal) formulation Negotiate management goals and plan based on the opinion, across phases of treatment Use values and vision of well-being to engage and motivate Integrate treatments using a multidisciplinary team Where the teams capacity is exceeded, integrate specialists from external services through effective collaboration

Points of Integration

Key points for integration are: 1. Taking a well-being approach 2. Opinion and aetiological formulation 3. Multi Disciplinary Team to integrate different models and treatment approaches 4. Collaboration - with external services and agencies

Key Transdiagnostic Factors

Rumination
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Definition
Rumination can be defined as passive repetitive thoughts that are relatively uncontrolled and are focused on negative content and ones symptoms of distress. Other types of repetitive thought include:

Worry a series or chain of thought that are negatively affect-laden, in an attempt to problem-solve an issue where the outcome is not certain but contains negative outcomes Self-reflection not necessarily maladaptive (adaptive) Problem-solving (adaptive) Effective processing of thoughts and cognitions (adaptive)

Causes of Rumination
Attentional control weakness leading to difficulty disengaging from negative information Triggered by discrepancy between actual state and desired/expected state e.g. unresolved goal, trauma, loss = discrepancy increases attention and access of information related to the goal = rumination stops if goal is attained or abandoned Reinforced by learning through failure to learn better coping strategies Abstract thinking about problems rather than concrete thinking o Abstract thinking focuses on the why something happened; prevents problem solving e.g. what does this mean about me? Why cant I cope with things better? Why did this happen to me? Imagining catastrophic consequences o Concrete thinking focuses on the how something happened; supports problems solving

Consequences of Rumination
Increased maladaptive negative thinking Less effective problem solving; fewer solutions generated and less ability to implement solutions More social friction and less social support Increased depressed and anxious moods Later development of depressive symptoms Number and duration of future depressive episodes Symptoms of generalized anxiety and social anxiety Rumination explains much of the comorbidity between depression and anxiety. This effect is stronger in adolescents, but still large in adults Adolescent depression and anxiety load onto a single underlying dimension o In adolescents, rumination predicts almost all the association between depression and anxiety o Depression increases subsequent rumination, and rumination then increased anxiety In adults the effect is bidirectional:

NB stress-related rumination and brooding related to depression but not reflective rumination

Rumination

Depression

Anxiety

Rumination

Rumination = increased risk of major depression, bulimia and substance dependence in a prospective study of teenage girls. Also, externalising behaviours predicts rumination but not vice versa ( Rumination also linked with perceived lack of self-control and perfectionism and perfectionism may be a mediating variable between rumination and bulimia Distraction a useful strategy to cope and reduce rumination, though many struggle to stay with the distracting activity and subsequently get drawn back into rumination Females more likely to ruminate than males (?due to upbringing where sadness and depressive symptoms in response to stress are reinforced cf males). Aggression under the influence of alcohol strongly medicated by rumination i.e. alcohol leads to aggression mainly when people ruminate e.g. on a slight or humiliation The role of perfectionism in leading to depression is mediated strongly by rumination

Treatment
Telling people to stop worrying and ruminating does not work Discriminate between helpful and unhelpful repetitive thoughts Normalise we all do it Thought stopping and distraction works briefly Letting go of the goals and desires may reduce rumination Focus on changing the process of thinking rather than the content Improve attentional control (Cognitive Bias Modification), mindfulness Concreteness training o Focus on the details in the moment o notice specific and distinctive details of the context of the event o note how events unfolded e.g. imagine it as a movie o Problem solving skills Mindfulness

NB the key to rumination is the focus on abstract processes and therefore the failure to solve the problem (discrepancy between actual and desired state) driving the rumination.

Rumination Scale

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(Susan Nolen-Hoeksema)

People think and do many different things when they feel depressed. Please read each of the items below and indicate whether you almost never, sometimes, often, or almost always think or do each one when you feel down, sad, or depressed. Please indicate what you generally do, not what you think you should do.

1 almost never

2 sometimes

3 often

4 almost always

1. think about how alone you feel 2. think I wont be able to do my job if I dont snap out of this 3. think about your feelings of fatigue and achiness 4. think about how hard it is to concentrate 5. think What am I doing to deserve this? 6. think about how passive and unmotivated you feel. 7. analyze recent events to try to understand why you are depressed 8. think about how you dont seem to feel anything anymore 9. think Why cant I get going? 10. think Why do I always react this way? 11. go away by yourself and think about why you feel this way 12. write down what you are thinking about and analyze it

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13. think about a recent situation, wishing it had gone better 14. think I wont be able to concentrate if I keep feeling this way. 15. think Why do I have problems other people dont have? 16. think Why cant I handle things better? 17. think about how sad you feel. 18. think about all your shortcomings, failings, faults, mistakes 19. think about how you dont feel up to doing anything 20. analyze your personality to try to understand why you are depressed 21.go someplace alone to think about your feelings 22. think about how angry you are with yourself
NOTE:

Please find enclosed a copy of the Ruminative Responses Scale we have been using in much of our research on response styles for depression. For full information on the psychometric qualities of this scale, please see Treynor, Gonzalez, and Nolen-Hoeksema (2003), Cognitive Therapy and Research, 27, 247-259. To obtain scores on this scale, simply sum the scores on the 22 items. I am often asked about cut-offs for determining whether an individual is a ruminator or not. We have not established any cut-offs; instead, I believe the appropriate use of this questionnaire is as a continuous measure. If you wish to select groups of high or low ruminators, I recommend using percentile cut-offs from your own sample (e.g., selecting people who score in the top 33% of your sample as high ruminators and people who score in the bottom 33% as low ruminators). The original Response Styles Questionnaire also included Distraction and Problem- Solving subscales. Neither of these subscales has proven reliable or good predictors of depression change over time, so I am no longer distributing them. Please send me copies of reports of all studies in which you use any of these scales. Good luck in your research. 12

Sincerely, Susan Nolen-Hoeksema, Ph.D. Yale University

Cognitive and Attentional Bias

Attentional Bias
Attentional bias is the tendency for certain types of stimuli to capture attention. For example, a person may not examine all possible outcomes when making a decision, but focus on one or two that they are primed towards. Attentional biases also influence what information people focus on Anxiety disorders focus on threat and anger Depression focus on negative stimuli Substances use disorders cues and triggers for substance use; e.g. smokers look longer at smoking cures than non-smokers Chronic pain focus on painful facial expressions Social anxiety focus on social interactions

Attention Training
Aims to improve disorders by training to overcome attentional biases Primarily computer or web-based

Cognitive Bias
There are many types of cognitive bias. Some are closely related to attentional bias, They influence the inferences people make about stimuli such as social situations, and lead to errors of judgment Common cognitive biases include: o Fundamental Attribution Error the tendency to over-emphasize personality and under-emphasize the context when judging. o Confirmation bias the tendency to interpret information in a way that confirms a persons preconceived ideas. o Self-serving bias tendency to claim more responsibility for successes than failures o Belief bias the judgment about the logic of an argument being influenced by the belief in the outcome o Framing judging a situation by taking a narrow view of it o Hindsight bias -

coc

Perfectionism
(Shafran, Egan, Wade. Overcoming Perfectionism. Robinson, London 2010)

Definition
Perfectionism can be thought of as continual striving to achieve demanding standards that are self-imposed and relentlessly pursued. Perfectionism may be adaptive (helpful) or maladaptive (harmful). Maladaptive perfectionism arises when a person; o Experiences self-criticism for not meeting standards o Bases their self-worth on meeting high standards o Continues to strive towards the standards despite negative effects

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Perfectionism is a multidimensional construct o Frosts Multidimensional Perfectionism Scale Subsequently broken down to four subscales 1. Concern over Mistakes (CM) + Doubts about actions (D) 2. Parental Expectations (PE) & Parental Criticism (PC) 3. Personal Standards (PS) 4. Organization (O)

Causes of Perfectionism
Perfectionism has multiple causes, many of which are unclear Note that factors causing a problem and factors maintaining a problem may differ. Maintaining factors are probably more important for treatment

Maintaining factors include: Perfectionism is often rewarded: o Socially condoned e.g. praise from others for hard work and high standards o Gives structure e.g. each day is focused o Gives a sense of control e.g. each day is predictable o Leads to achievements e.g. recognition for hard work o Avoidance of feared situations and people e.g. working hard allows avoidance of socialising o Avoidance of discovering feared aspects of self e.g. believing they only do well because they work hard

Consequences of Perfectionism
Perfectionism is elevated in and contributes to the aetiology and maintenance of multiple psychiatric conditions especially: o Depression perfectionism scores elevated, especially self-oriented perfectionism

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o o o o o

Panic, = increased CM, PS and socially prescribed perfectionism Social anxiety = increased CM and socially prescribed perfectionism OCD = increased DA scores DA used as a measure of OCD severity by may Eating disorders Strongly associated with suicidal ideation and behaviour (socially prescribed perfectionism especially

Perfectionism also leads to a range of unhelpful behaviours: o Avoidance o Procrastination o Performance checking o Counterproductive behaviours e.g. list making or filing paper in order to enhance to ensure high performance may become excess and time consuming, actually impeding performance.

If perfectionism is present and not addressed, outcomes for these disorders are poorer

Perfectionism Screen
(Shafran, Egan and Wade) 1. Do you continually try your hardest to achieve high standards? 2. Do you focus on what you have not achieved rather than what you have achieved? 3. Do other people tell you that your standards are too high? 4. Are you very afraid of failing to meet your standards? 5. If you achieve your goal, do you tend to set the standard higher next time (e.g. run the race in a faster time)? 6. Do you base your self-esteem on striving and achievement? 7. Do you repeatedly check how well your are doing at meeting your goals? 8. Do you keep trying to meet your standards, even if this means that you amiss out on things or if it is causing other problems? 9. Do you tend to avoid tasks or put off doing them in case you fail or because of the time it would take? If the answer is YES to question six and the majority of the other questions, maladaptive perfectionism is likely. Shafran,R. Egan, S. Wade, T. Overcoming Perfectionism. Robinson, London, 2010

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Exercise 2: Rumination and Perfectionism Scales Complete the either the Rumination Scale or the Multidimensional Personality Scale on your own In small groups, discuss your result. What do you think it means for you? Do you have clients who you think are likely to have problems with rumination or perfectionism?

Multidimensional Perfectionism Scale

(Frost, R.)

Please select the option that best reflects your opinion, using the rating system below 1 2 3 4 5

Strongly Disagree

Disagree

Neither Agree or Disagree

Agree

Strongly Agree

1. My parents set very high standards for me. 2. Organization is very important to me. 3. As a child, I was punished for doing things less than perfectly. 4. If I do not set the highest standards or myself, I am likely to end up a second-rate person. 5. My parents never tried to understand my mistakes. 6. It is important to me that I be thoroughly competent in everything I do. 7. I am a neat person 8. I try to be an organized person. 9. If I fail at work/school, I am a failure as a person. 10. I should be upset if I make a mistake. 11. My parents wanted me to be the best at everything 12. I set higher goals for myself than most people. 13. If someone does a task at work/school better than me, I feel like I failed the whole task. 14. If I fail partly, it is as bad as being a complete failure. 15. Only outstanding performance is good enough in my family. 16. I am very good at focusing my efforts on attaining a goal. 17. Even when I do something very carefully, I often feel that it is not quite done right. 18. I hate being less than the best at things. 19. I have extremely high goals.

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

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20. My parents have expected excellence from me. 21. People will probably think less of me if I make a mistake. 22. I never felt like I could meet my parents expectations. 23. If I do not do as well as other people, it means I am an inferior human being. 24. Other people seem to accept lower standards from themselves than I do. 25. If I do not do well all the time, people will not respect me. 26. My parents have always had higher expectations for my future than I have. 27. I try to be a neat person. 28. I usually have doubts about the simple everyday things I do. 29. Neatness is very important to me. 30. I expect higher performance in my daily tasks than most people. 31. I am an organized person. 32. I tend to get behind in my work because I repeat things over and over. 33. It takes me a long time to do something right. 34. The fewer mistakes I make, the more people will like me. 35. I never felt like I could meet my parents standards.

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Treatment:
Self-monitor perfectionistic thoughts and behaviours (thought diary) o Eating o Body shape and weight o Social performance o Checking appliances and locks o Ordering objects o Organization o Cleanliness house etc o Appearance o Hygiene o Performance school, work, academic, sport, musical o Relationships o Parenting o Health o Entertaining Psychoeducation Behavioural experiments question beliefs about personal standards Look for and challenge all or nothing/black and white thinking Look for indecision and procrastination

Anger and Hostility

High levels of hostility is a major barrier to the development of the therapeutic relationship and treatment engagement

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Address Mental Health Conditions Associated with Anger & Hostility

PTSD Oppositional defiant disorder Antisocial personality disorder Borderline personality disorder Paranoid personality disorder Generalised anxiety disorder Panic disorder Major depressive disorder Intermittent explosive disorder Bipolar disorder Psychoses

Other Problems Associated with Anger

Failure to recognize physiological signs of anger Negative urgency Poor executive control Cognitive misattributions - mistrust Low self-esteem, protection from humiliation Rumination Avoidance of triggers Poor coping skills

Thoughts and Emotions Commonly Associated with Anger

Threat

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Invalidation Injustice Criticism Humiliation Important rules violated

Maladaptive Thoughts Commonly Associated with Anger

All or nothing thinking Jumping to conclusions Should statements Blaming Labeling Over-generalisation Cognitive bias seeing the bad things in a situation Magnification Emotional reasoning I feel angry, you must have wronged me

Treatment
Identify key triggers and contexts Plan strategies to cope with anger in these situations implementation intentions Recognise physiological symptoms of anger Catch the impulse to act mindfulness De-fusion mindfulness CBT identify and challenge maladaptive thoughts (anger diary, cognitive restructuring) Coping skills Teach skills to deal with rumination and poor problems solving Address avoidant coping (mindfulness)

Anger CBT Resources http://www.psychologytools.org/anger.html

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Collaboration
Six Principles of Effective Collaboration
1. 2. 3. 4. 5. 6. Recognise and accept the need for partnership Develop clarity and realism of purpose Ensure commitment and ownership Develop and maintain trust Create clear and robust partnership arrangements Monitor measure and learn

Personal Collaboration Skills

1. 2. 3. 4. 5. Listening Releasing your agenda, attending to the speaker, reflecting and amplifying speakers ideas Asserting Clarifying your intentions, expressing yourself, persistence Problems solving Seeing possibilities, changing position, determining underlying causes, identifying broader implications Facilitating Asking probing questions, building confidence in others, finding common solutions Handling conflict

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Causing - not revealing feelings, saying yes when you mean no, pretending not to be upset Resolving identifying hidden issues, resolving differences

Emotionally Intelligent Teams

Comprised of emotionally intelligent team members Key attributes Self-awareness Self-management Social awareness Relationship management Covert norms made overt o Subtle, often unstated beliefs, habits and behaviours of a team that subtly but powerfully influence its behaviour

Barriers to Collaboration
Stakeholders unwilling to work together Competitive culture or spirit Parochial attitudes Differing values and cultures Personal resistance to change Lack of shared agenda

Resistance
Placing personal needs ahead of those of tangata whaiora Fear of loss of power and influence Heavy investment in current goals and projects Identity bound in current position Journey too hard Destination worse than current position Power in resisting change Mistrust in those asking for change Pejorative attitudes between teams and service

Sources of Conflict Within Collaborations

Sources of Conflict Power struggles Holding things back to exert control Personal customs & preferences not being met The wrong people Wrong people chosen in the first place Low trust Meeting facilitator lacks necessary skills Vague vision and focus Vision and focus called into question Get off track Incomplete desired results and strategies Resolution Address power needs Address fear of loss of control Take time to review people preferences Choose new people Review the criteria for inclusion and ask people to nominate replacements hard but essential Enhance trust Share responsibility for leadership or change convener Establish/strengths vision and focus Review shared values and desired outcome Revise desired results and strategy

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Desired results ad outcome frequently debated even though they may be in writing Lack of clear authority Dominant organization presses for quick results Inconsistent attendance/changes in representation Insufficient time given for collaborative work

Ensure desired results are specific and strategies do-able Clarify authority Stress benefits of planning Ask those in authority to commit to consistent representation Formalise agreements regarding time & attendance

Collaborative Online Interactive Networks (COINS)

Online communication e.g. via email group Involves all key people involved in care of tangata whaiora Nominated facilitator Regular communications and updates Requires initial face-to-face (synchronous) interactive communication to develop trust

Key Factors in the Development of COINS

Identify sponsors, stakeholders and champions Establish the purpose, goals and ground-rules of the COIN Infrastructure email, instant messaging, chat, Skype, secure blog Clarity of purpose Personalise encourage personal contact and make it enjoyable Make the team visible Managerial and system support important

Strategies to Enhance Collaboration

Make shared goals and values explicit person-centredness! Allow time for the development of personal relationships Explicit support from key people in each service or agency Coins

Exercise 3: Collaboration Think about another service with which you collaborate in your clinical work, preferably around CEP

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On your own quickly complete the Partnership Assessment Tool on the next page, related to this collaboration. Score your answers and consider the results. In small groups, appoint someone to feedback then discuss your results What do you think you need to do to improve the partnership?

Partnership Assessment Tool

(UK

Strategic Partnering Taskforce 2003)

Please select the option that best reflects your opinion, using the rating system below 1 2 3 4

Strongly Disagree

Disagree

Agree

Strongly Agree

Principle 1: Recognise and accept the need for partnership To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment? 1 2 3 4 There have been substantial past achievements within the partnership 1 2 3 4 The factors associated with successful working are known and understood 1 2 3 4 The principal barriers to successful partnership working are known and understood 1 2 3 4 The extent to which partners engage in partnership working voluntarily or under pressure is recognised and understood 1 2 3 4 There is a clear understanding of partners interdependence in achieving some of their goals 1 2 3 4 There is mutual understanding of those areas of activity where partners can achieve goals by working independently of each other Score

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Principle 2: Develop clarity and realism of purpose To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment? 1 2 3 4 Our partnership has a clear vision, shared values and agreed service principles 1 2 3 4 We have clearly defined joint aims and objectives 1 2 3 4 These joint aims and objectives are realistic 1 2 3 4 The partnership has defined clear service outcomes 1 2 3 4 The reason why each partner is engaged in the partnership is understood and accepted 1 2 3 4 We have identified where early partnership success is most likely Score Principle 3: Ensure commitment and ownership To what extent do you agree with each of the following six statements in respect to the partnership which is the subject of this assessment exercise as a whole? 1 2 3 4 There is clear commitment to partnership working from the most senior levels of each partnership organisation There is widespread ownership of the partnership across and within all 1 2 3 4 parties Commitment to partnership working is sufficiently robust to withstand 1 2 3 4 most threats to its working 1 2 3 4 The partnership recognises and encourages networking skills The partnership is not dependent for its success solely upon individuals with these skills Not working ins partnership is discouraged and dealt with Score Principle 4: Develop and maintain trust To what extent do you agree with each of the following six statements in respect to the partnership which is the subject of this assessment exercise as a whole? 1 2 3 4 The way the partnership is structured recognises and values each partners contribution 1 2 3 4 The way the partnerships work is conducted appropriately recognises each partners contribution 1 2 3 4 Benefits derived from the partnership are fairy distributed among all parties 1 2 3 4 There is sufficient trust within the partnership to survive and mistrust that arises elsewhere 1 2 3 4 Levels of trust within the partnership are high enough to encourage significant risk-taking 1 2 3 4 The partnership has succeeded in having the right people in the right place at the right time to promote the partnership working 1 1 2 2 3 3 4 4

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Score Principle 5: Create clear and robust partnership arrangements To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? 1 2 3 4 It is clear what financial resources each partner brings to the partnership 1 2 3 4 The resources, other than finance, each partner brings to the partnership are understood and appreciated 1 2 3 4 Each partners areas of responsibility are clear and understood There are clear lines of accountability for the performance of the partnership as a whole Operational partnership arrangements are simple, time-limited and task-orientated The partnerships principal focus is on process, outcomes and innovation Score Principle 6: Monitor, measure and learn To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? The partnership has clear success criteria in terms of both service goals 1 2 3 4 and the partnership itself 1 2 3 4 The partnership has clear arrangements to effectively monitor & review how successfully its service aims & objectives are being met 1 2 3 4 There are clear arrangements to effectively monitor and review how the partnership itself is working 1 2 3 4 There are clear arrangements to ensure that monitoring & review findings will be widely shared and disseminated amongst partners 1 2 3 4 Partnership successes are well communicated outside the partnership 1 2 3 4 There are clear arrangements to ensure that partnership aims objectives and working arrangements are reconsidered and revise in the light of monitoring and review findings Score 1 1 1 2 2 2 3 3 3 4 4 4

Results
Principle 1: recognise and accept the need for partnership 19-24: Very high recognition and acceptance of the need for partnership 13-18: The need for partnership is recognised and accepted 7-12: Recognition and acceptance of the need for partnership is limited 6: Recognition and acceptance of the need for partnership is minimal. Principle 2: develop clarity and realism of purpose 19-24: The purpose of the partnership is very clear and realistic 13-18: There is some degree of purpose and realism to the partnership 7-12: Only limited clarity and realism of purpose exists 6: The partnership lacks any clarity or sense of purpose.

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Principle 3: ensure commitment and ownership 19-24 The partnership is characterized by strong commitment and wide ownership 13-18: There is some degree of commitment to, and ownership of, the partnership 7-12: Only limited partnership commitment and ownership can be identified 6: There is little or no commitment to, or ownership of, the partnership. Principle 4: develop and maintain trust 19-24: There is well-developed trust among partners 13-18: There is some degree of trust amongst partners 7-12: Trust amongst partners is poorly developed 6: There is little or no trust among partners. Principle 5: create clear and robust partnership working arrangements 19-24: Partnership working arrangements are very clear and robust 13-18: Partnership working arrangements are reasonably clear and robust 7-12: Partnership working arrangements are insufficiently clear and robust 6: Partnership working arrangements are poor. Principle 6: monitor, measure and learn 19-24: The partnership monitors, measures and learns from its performance very well 13-18: The partnership monitors, measures and learns from its performance reasonably well 7-12: The partnership monitors, measures and learns from its performance poorly in some respects 6: The partnership monitors, measures and learns from its performance poorly in most respects or not at all. Aggregate scores 109144 The partnership is working well enough in all or most respects to make the need for further detailed work unnecessary. 73108 The partnership is working well enough overall but some aspects may need further exploration and attention. 3772 The partnership may be working well in some respects but these are outweighed by areas of concern sufficient to require remedial action. 36 The partnership is working badly enough in all respects for further detailed remedial work to be essential.

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Review: Rachel - Integrated Care

Case Scenario - Rachel Rachel is a 30-year-old European mother of a 5 year-old daughter who was referred to your service via the local Emergency Department after having taken an overdose of 15 Paracetamol tablets the previous night. Rachel stated that the overdose had been an impulsive action after drinking a bottle of wine and having an argument with her partner about finances. She stated that she was not trying to kill herself or that she was at risk of future overdose as she was very embarrassed at the outcome. She is reluctant to attend the appointment with your service, but does so under pressure from her partner who threatens to leave her unless she does something about her drinking and her moodiness. History of Presenting Problems Rachel describes depressed mood meeting criteria for moderate Major Depressive Episode since her late teens. Her mood is worse for a few weeks, once every three months on average. At these times she finds life a struggle and has thoughts that she would be better off dead but has never actually developed the intent to kill herself.

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She experienced a sexual assault (rape) at a party while severely intoxicated at the age of 18 years. Since then she has experienced frequent intrusive memories and ruminations related to the rape which has impacted on her intimate relationships, and experiences hyperarousal much of the time though it is worse when socializing in larger groups. She denies any other significant mental health problems. Alcohol and Drug History Rachel did not drink regularly or to intoxication until after the sexual assault at age18 years. She started drinking to intoxication most weekend nights when socialising, and by the age of 20 years was drinking half to three quarters of a bottle of wine most evenings as well. Her alcohol use decreased when, at age 22 years she entered a relationship with the father of her daughter, and over the next few years she would only drink occasionally. Her partner left her when she became pregnant and decided to keep the child. She stopped drinking when she became pregnant at aged 25 years and did not consume alcohol again until her daughter was a year old and she entered a new relationship with her current partner who also drinks heavily. She has used cannabis on a daily basis since her mid teens and experiences craving, irritability and significant generalized anxiety when she goes without it for more than a few days, but find it helps her mood. She currently smokes 50gms of tobacco a week and would like to stop, as it is very expensive. Other Relevant History Youngest of three siblings with an older sister and the eldest a brother. Her father died in a motor vehicle accident when Rachel was 22 years old. Father alcohol dependence. Paternal Grandfather alcohol dependence 28

Brother convictions for assault, cannabis possession, heavy cannabis user Mother social phobia, less problematic the last few years Personal History: She attended six different primary schools due to her fathers frequent change in employment. At primary school she struggled academically with mathematics and reading but was otherwise intelligent. She often got into trouble for disobedience and being easily distracted. She was noted to have a short temper and be intolerant of discipline, talking back to teachers. She was sexually abused on one occasion at the age of 5 by a friend of her fathers. She was frequently truant from secondary school and noted to be irritable and argumentative when she did attend. Upon leaving school she worked in a range of waitressing, bar and sales jobs until becoming pregnant. Over the past two years she has taken several tertiary papers in social work and hopes to get a job in the future in community support. Her current relationship tends to involve frequent arguments though not violence. She has one or two friends whom she has know for ten years.

Phases of Treatment Early Treatment

Working with Rachel needs to be considered in terms of the key goals and tasks for each phase of treatment. After presenting at the Emergency Department, Rachel has been referred to your service and seen the next day. Initial safety was assessed at the Emergency Department, and she was deemed safe to go home and come and see your team soon after.

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The first session with you will involve starting or planning to start dealing with the key issues listed in the Early Phase below.

In Rachels case: Initiate a person-centred, well-being orientated integrated care Enhance engagement and motivation Re-assess safety the ED probably only assessed that she was safe to go home until your team saw her. Further assessment of risk over the short to medium term needs to be undertaken. Complete a comprehensive assessment and management plan Engage whanau support Link with other services and supports Detox Initial coping strategies and amplifiers

Early involve key supports e.g. whnau/family if appropriate assess and manage safety issues comprehensive and integrated assessment and management plan including integrated formulation to integrate care appoint case manager stabilise acute crises, substance use, physical, social problems detox if appropriate culturally

Middle monitoring and adjustment of medication active treatment of mental health and substance use problems including specific psychotherapies and social interventions specific whnau/family interventions maintain engagement and motivation increasing focus on steps to enhance well-being peer support groups continue to manage

Late

Autonomous Wellbeing Ensure community supports in place Clarify future access to services Fully transfer responsibility to tangata whaiora and family/whanau Transtiionto primary care

ongoing monitoring of treatment adherence ongoing work on relapse prevention further enance well-bieng & recovery enhancement of occupational and social skills increasing selfmanagement of mental health and substance use problems strategies to enhance well-being

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appropriate engagement processes and assessment address spiritual needs link with and involve other services as indicated engage whanau support enhance engagement & motivation initiate or adjust medication initial coping strategies to help manage crises

linkages with others involved relapse prevention re-culturation and increased ability to access cultural resources

Fully engage community supports

Tools and Strategies

Person-centred care establish values, define wellbeing and organize care to enhance wellbeing Overall goals related to enhancing quality of life established including: 1. Enhancing positive pathways 2. Treating barriers to well-being Comprehensive Assessment o Personal values card sort (paper based) o Best possible selves exercise to identify personal definition of well-being o Character strengths inventory o WHOQOL-Bref NZ o Timeline o Including risk assessment

Rachel identified her three most important values as:

1. Family

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2. Self-acceptance 3. Purpose

Rachel identified her Top 3 character strengths as:

1.Fairness 2. Kindness 3. Curiosity

Her WHOQOL results were:

Domain 1: Domain 2: Domain 3: Domain 4: Physical Health Psychological Social Relationships Environment = 31 = 44 = 50 = 56

Scores are out of 100 Norms are around 70, standard deviation around 12-15

Best Possible Self (5 Years)

Close relationship with her daughter, available as a supportive mother Have a happy, supprotive and loving family Feeling relaxed and happy within myself Mood stable, good sleep, healthy lifestyle Working in a job that was satisfying and had purpose Smokefree, cannabis free, drinking less alcohol and in control of this Financially stable Stable relationship with a loving, supportive and communicative partner Comfortable in social situations Enjoying hobbies that I enjoy Supportive friends Below are the results for Rachel. She meets one of the first two criteria (low positive affect) and five of the B criteria. Therefore she does not meet the criteria for Languishing though she is only one criterion off this.

Criterion A1 A2 Positive affect Life satisfaction

high, low or 0 (neutral) low 0

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B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11

Self-acceptance Social acceptance Personal growth Social actualization Purpose and meaning in life Social contribution Environmental mastery Social coherence Autonomy Positive relations with others Social integration

low low low 0 0 0 0 0 0 low 0

The Opinion: Rachels Diagnoses, Problems/Strengths and 4x4 grid

Axis1
Major Depressive Disorder Post-traumatic stress disorder Alcohol dependence with physiological dependence Cannabis dependence with physiological dependence Nicotine dependence with physiological dependence

Problems and Strengths

Negative ruminations Hyper-arousal and intrusive memories from rape Impulsivity Avoidant coping style Stressful relationship with partner

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Stress of caring for young child Lack of assertiveness in relationships (dependent traits)

Rachels 4x4 Grid

Below is the 4x4 grid for the aetiological formulation for Rachel we developed during the previous workshop.

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Vulnerability (Predisposing)

Triggers (Precipitating)

Maintaining (Perpetuating)

Strengths (Protecting)

Genetic predisposition (SUDS, social anxiety)

Intoxication

Biological

Hyper-arousal Depressogenic effects of alcohol Anxiolytic effects of alcohol Sleep Executive functioning Craving Avoidant coping style Rumination Intrusive memories Shame Automatic thoughts self-worth, control Flashbacks Dependent traits (re relationships Social withdrawal Limited social support networks Arguments with partner Choice of relationships Lack of love from family/partner/friends Lack of belonging (interpersonal niche Social niche?

Alcohol (PTSD symptoms, anxiety) Physical health Past abstinence

Psychological

Attentional control Impulsivity negative urgency Hyper-vigilance Low self-efficacy Some dependent traits? Inability to accept love?

Daughters age triggering memories of abuse Rape Intrusive memories trigger mood & substance use Lowered mood Withdrawal?

Intelligent Has developed some self-efficacy re social work, daughter

Attachment anxious Mistrust of others

Arguments Finance Large groups

Social

Good social skills Daughter Striving Ability to love

Identity Disconnection from the world?

Hostility / inconsiderate actions = further disconnection

Spiritual

Family values Hope actively future- orientated Has some meaning and purpose in life around social connection Identity mother, nurture Developing spirituality (love identity, niche, role, connection)

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Steps for Developing a Treatment Plan from the Opinion

The process of developing a comprehensive treatment plan based on the history and mental state examination involves the following steps: 1.The Opinion Diagnoses Problems and strengths 4x4 grid 2. The Formulation Statement The 4x4 grid with factors entered into the grid is developed into four paragraphs that are then fed back to the tangata whaiora as a narrative. This serves several purposes including allowing negotiation and shared understanding of how the problems are seen and how they relate to a persons life experiences, raising key issues that will be a focus for treatment, and it is also a mechanism of healing and treatment in its own right. 3.Goal Identification and Setting From the opinion, the key diagnoses, problems, strengths, and factors from the 4x4 grid (especially the maintaining factors and strengths are identified as key goals for treatment. 4. Goal Planning Key goals are prioritised and staged or ordered using the early, middle, late and autonomy phases. 5. Treatment planning Treatments are matched to the key goals and organised using the phases of treatment.

Step 1: Opinion (above) Step 2: Goal Identification and Setting

The key diagnoses, problems and strengths, and formulation factors will become the targets of treatment.

Step 3: Goal Planning Prioritising Goals

Give preference to: Urgent goals (involving safety, stabilisation) Serious problems Pivotal problems and trans-diagnostic factors from the formulation Easily Achieved Goals

Also consider: Favouring goals that are more internally motivated Goal conflict; - treatment v life goals - tangata whaiora v clinician goals

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Approach rather than avoidant goals Short term v distant goals - distant goals important for shaping treatment but short term more motivating

Most easily achieved goals for those with severe impairment: reduction in panic attacks other fears and anxieties increased assertiveness self-confidence

Least easily achieved goals for those with severe impairment: sleep problems pain reflecting on self and the future depressive symptoms

Rachel Goal Setting for early and moving to middle treatment phases

Wellbeing Risk and safety self, others, child, AOD related harms Improve mood Manage withdrawal alcohol, cannabis, nicotine Coping skills anger, emotional regulation Psycho-education regarding illnesses Education Encourage and support social work studies Support networks PTSD address rumination, intrusive memories, hyper-arousal Spiritual identity

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Early involve key supports e.g. whnau/family if appropriate assess and manage safety issues comprehensive and integrated assessment and management plan including integrated formulation to integrate care appoint case manager stabilise acute crises, substance use, physical, social problems detox if appropriate culturally appropriate engagement processes and assessment address spiritual needs link with and involve other services as indicated engage whanau support enhance engagement & motivation initiate or adjust medication initial coping strategies to help manage crises

Middle monitoring and adjustment of medication active treatment of mental health and substance use problems including specific psychotherapies and social interventions specific whnau/family interventions maintain engagement and motivation increasing focus on steps to enhance well-being peer support groups continue to manage linkages with others involved relapse prevention re-culturation and increased ability to access cultural resources

Late

Autonomous Wellbeing Ensure community supports in place Clarify future access to services Fully transfer responsibility to tangata whaiora and family/whanau Transtiionto primary care

ongoing monitoring of treatment adherence ongoing work on relapse prevention further enance well-bieng & recovery enhancement of occupational and social skills increasing selfmanagement of mental health and substance use problems strategies to enhance well-being Fully engage community supports

Step 4: Treatment Planning

Treating planning involves planning the general context of treatment and applying specific interventions to the selected goals. A useful structure for thinking about each phase of treatment is the 10-point format outlined below. For each phase of treatment consider the following (outlined further in Te Ariari) as well as specific 1. Setting

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2. 3. 4. 5.

Further information Treatment of medical condition Psychopharmacology Psychological interventions Psycho-education Motivation Deficits (disorders, problems) Well-being, recovery and strengths

The format of psychological interventions can be: Individual Group Self-directed (e.g. online treatment resources, books) The template below can be useful for organizing psychological interventions

Individual

Group

Self-directed

Psycho-education

Motivation

Diagnoses & Problems

Well-being, Recovery & Strengths

Whnau/family and social interventions Spiritual Interventions Education of tangata whaiora and whanau Social Needs Education/work/occupation Accommodation Finance 10. Self-help groups. 6. 7. 8. 9. On the next page is a template for helping organise interventions by phase of treatment

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Early

Middle

Late

Autonomous Well-being

1. Setting

2. Further information

3. Treatment of medical conditions

4. Psychopharmacology

5. Psychological

6. Family/whanau

7. Spiritual 8. Education of client/whanau

9. Social Needs

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10. Self-help

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Structuring 1:1 Treatment

1. Enhance motivate and set agenda (5 minutes) 2. Review (10-15 minutes) o Goals o Review past week o Review symptoms and goals o Review homework tasks and treatment adherence 3a. Specific Interventions: (10-20 minutes) 3b. Specific Interventions: (10-20 minutes) Specific interventions include: Amplifiers; skills that amplify specific interventions e.g. mindfulness, MI, Distress tolerance, Sensory modulation Interventions for specific problems: CBT, withdrawal management, relapse prevention, Positive Interventions 4. Review session and reinforce Commitment Talk & Wellbeing talk (Values, Wellbeing vision, (10 minutes)

3a

3b

Reflective listening and other motivational change enhancement techniques when change talk arises, and when well-being talk is identified.

1. Session 1

2.

3a.

3b.

4.

Review

Session 2 Review

Session 3 Review

Session 4

Enhance Motivation

Set homework Review Review Session

Session 5

Set session agenda

Review Enhance Commitm ent and Wellbeing Talk

Session 6 Review

Session 7 Review

Session 8 Review

Review

Appendices

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1. Rumination Scale 2. Perfectionism Screen 3. Multidimensional Perfectionism Scale 4. Partnership Assessment Tool

Rumination Scale
(Susan Nolen-Hoeksema) Please read each of the items below and indicate whether you almost never, sometimes, often, or almost always think or do each one when you feel down, sad, or depressed. Please indicate what you generally do, not what you think you should do. 1 almost never 1. think about how alone you feel 2. think I wont be able to do my job if I dont snap out of this 3. think about your feelings of fatigue and achiness 4. think about how hard it is to concentrate 5. think What am I doing to deserve this? 6. think about how passive and unmotivated you feel. 7. analyze recent events to try to understand why you are depressed 8. think about how you dont seem to feel anything anymore 9. think Why cant I get going? 10. think Why do I always react this way? 11. go away by yourself and think about why you feel this way 12. write down what you are thinking about and analyze it 13. think about a recent situation, wishing it had gone better 14. think I wont be able to concentrate if I keep feeling this way. 15. think Why do I have problems other people dont have? 16. think Why cant I handle things better? 17. think about how sad you feel. 18. think about all your shortcomings, failings, faults, mistakes 19. think about how you dont feel up to doing anything 20. analyze your personality to try to understand why you are depressed 21.go someplace alone to think about your feelings 22. think about how angry you are with yourself NOTE: 2 sometimes 3 often 4 almost always

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Please find enclosed a copy of the Ruminative Responses Scale we have been using in much of our research on response styles for depression. For full information on the psychometric qualities of this scale, please see Treynor, Gonzalez, and Nolen-Hoeksema (2003), Cognitive Therapy and Research, 27, 247-259. To obtain scores on this scale, simply sum the scores on the 22 items. I am often asked about cut-offs for determining whether an individual is a ruminator or not. We have not established any cut-offs; instead, I believe the appropriate use of this questionnaire is as a continuous measure. If you wish to select groups of high or low ruminators, I recommend using percentile cut -offs from your own sample (e.g., selecting people who score in the top 33% of your sample as high ruminators and people who score in the bottom 33% as low ruminators). Sincerely, Susan Nolen-Hoeksema, Ph.D. Yale University

Perfectionism Screen
(Shafran, Egan and Wade) 1. Do you continually try your hardest to achieve high standards? 2. Do you focus on what you have not achieved rather than what you have achieved? 3. Do other people tell you that your standards are too high? 4. Are you very afraid of failing to meet your standards? 5. If you achieve your goal, do you tend to set the standard higher next time (e.g. run the race in a faster time)? 6. Do you base your self-esteem on striving and achievement? 7. Do you repeatedly check how well your are doing at meeting your goals? 8. Do you keep trying to meet your standards, even if this means that you amiss out on things or if it is causing other problems? 9. Do you tend to avoid tasks or put off doing them in case you fail or because of the time it would take? If the answer is YES to question six and the majority of the other questions, maladaptive perfectionism is likely. Shafran,R. Egan, S. Wade, T. Overcoming Perfectionism. Robinson, London, 2010

Multidimensional Perfectionism Scale

(Frost, R.)

Please select the option that best reflects your opinion, using the rating system below

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Strongly Disagree

Disagree

Neither Agree or Disagree

Agree

Strongly Agree

1. My parents set very high standards for me. 2. Organization is very important to me. 3. As a child, I was punished for doing things less than perfectly. 4. If I do not set the highest standards or myself, I am likely to end up a second-rate person. 5. My parents never tried to understand my mistakes. 6. It is important to me that I be thoroughly competent in everything I do. 7. I am a neat person 8. I try to be an organized person. 9. If I fail at work/school, I am a failure as a person. 10. I should be upset if I make a mistake. 11. My parents wanted me to be the best at everything 12. I set higher goals for myself than most people. 13. If someone does a task at work/school better than me, I feel like I failed the whole task. 14. If I fail partly, it is as bad as being a complete failure. 15. Only outstanding performance is good enough in my family. 16. I am very good at focusing my efforts on attaining a goal. 17. Even when I do something very carefully, I often feel that it is not quite done right. 18. I hate being less than the best at things. 19. I have extremely high goals. 20. My parents have expected excellence from me. 21. People will probably think less of me if I make a mistake. 22. I never felt like I could meet my parents expectations. 23. If I do not do as well as other people, it means I am an inferior human being. 24. Other people seem to accept lower standards from themselves than I do. 25. If I do not do well all the time, people will not respect me. 26. My parents have always had higher expectations for my future than I have. 27. I try to be a neat person. 28. I usually have doubts about the simple everyday things I do. 29. Neatness is very important to me. 30. I expect higher performance in my daily tasks than most people. 31. I am an organized person. 32. I tend to get behind in my work because I repeat things over and over. 33. It takes me a long time to do something right. 34. The fewer mistakes I make, the more people will like me. 35. I never felt like I could meet my parents standards.

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Partnership Assessment Tool

(UK

Strategic Partnering Taskforce 2003)

Please select the option that best reflects your opinion, using the rating system below 1 2 3 4

Strongly Disagree

Disagree

Agree

Strongly Agree

Principle 1: Recognise and accept the need for partnership To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment? 1 2 3 4 There have been substantial past achievements within the partnership 1 2 3 4 The factors associated with successful working are known and understood 1 2 3 4 The principal barriers to successful partnership working are known and understood 1 2 3 4 The extent to which partners engage in partnership working voluntarily or under pressure is recognised and understood 1 2 3 4 There is a clear understanding of partners interdependence in achieving some of their goals 1 2 3 4 There is mutual understanding of those areas of activity where partners can achieve goals by working independently of each other Score Principle 2: Develop clarity and realism of purpose To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment? 1 2 3 4 Our partnership has a clear vision, shared values and agreed service principles 1 2 3 4 We have clearly defined joint aims and objectives 1 2 3 4 These joint aims and objectives are realistic 1 2 3 4 The partnership has defined clear service outcomes 1 2 3 4 The reason why each partner is engaged in the partnership is understood and accepted 1 2 3 4 We have identified where early partnership success is most likely Score Principle 3: Ensure commitment and ownership To what extent do you agree with each of the following six statements in respect to the partnership which is the subject of this assessment exercise as a whole? 1 2 3 4 There is clear commitment to partnership working from the most senior levels of each partnership organisation There is widespread ownership of the partnership across and within all 1 2 3 4 parties Commitment to partnership working is sufficiently robust to withstand 1 2 3 4 most threats to its working 1 2 3 4 The partnership recognises and encourages networking skills

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The partnership is not dependent for its success solely upon individuals with these skills Not working ins partnership is discouraged and dealt with Score

1 1

2 2

3 3

4 4

Principle 4: Develop and maintain trust To what extent do you agree with each of the following six statements in respect to the partnership which is the subject of this assessment exercise as a whole? 1 2 3 4 The way the partnership is structured recognises and values each partners contribution 1 2 3 4 The way the partnerships work is conducted appropriately recognises each partners contribution 1 2 3 4 Benefits derived from the partnership are fairy distributed among all parties 1 2 3 4 There is sufficient trust within the partnership to survive and mistrust that arises elsewhere 1 2 3 4 Levels of trust within the partnership are high enough to encourage significant risk-taking 1 2 3 4 The partnership has succeeded in having the right people in the right place at the right time to promote the partnership working Score Principle 5: Create clear and robust partnership arrangements To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? 1 2 3 4 It is clear what financial resources each partner brings to the partnership 1 2 3 4 The resources, other than finance, each partner brings to the partnership are understood and appreciated 1 2 3 4 Each partners areas of responsibility are clear and understood There are clear lines of accountability for the performance of the partnership as a whole Operational partnership arrangements are simple, time-limited and task-orientated The partnerships principal focus is on process, outcomes and innovation Score Principle 6: Monitor, measure and learn To what extent do you agree with each of the following six statements in respect of the partnership which is the subject of this assessment exercise as a whole? The partnership has clear success criteria in terms of both service goals 1 2 3 4 and the partnership itself 1 2 3 4 The partnership has clear arrangements to effectively monitor & review how successfully its service aims & objectives are being met 1 2 3 4 There are clear arrangements to effectively monitor and review how the partnership itself is working 1 1 1 2 2 2 3 3 3 4 4 4

There are clear arrangements to ensure that monitoring & review findings will be widely shared and disseminated amongst partners Partnership successes are well communicated outside the partnership There are clear arrangements to ensure that partnership aims objectives and working arrangements are reconsidered and revise in the light of monitoring and review findings Score

1 1 1

2 2 2

3 3 3

4 4 4

Results
Principle 1: recognise and accept the need for partnership 19-24: Very high recognition and acceptance of the need for partnership 13-18: The need for partnership is recognised and accepted 7-12: Recognition and acceptance of the need for partnership is limited 6: Recognition and acceptance of the need for partnership is minimal. Principle 2: develop clarity and realism of purpose 19-24: The purpose of the partnership is very clear and realistic 13-18: There is some degree of purpose and realism to the partnership 7-12: Only limited clarity and realism of purpose exists 6: The partnership lacks any clarity or sense of purpose. Principle 3: ensure commitment and ownership 19-24 The partnership is characterized by strong commitment and wide ownership 13-18: There is some degree of commitment to, and ownership of, the partnership 7-12: Only limited partnership commitment and ownership can be identified 6: There is little or no commitment to, or ownership of, the partnership. Principle 4: develop and maintain trust 19-24: There is well-developed trust among partners 13-18: There is some degree of trust amongst partners 7-12: Trust amongst partners is poorly developed 6: There is little or no trust among partners. Principle 5: create clear and robust partnership working arrangements 19-24: Partnership working arrangements are very clear and robust 13-18: Partnership working arrangements are reasonably clear and robust 7-12: Partnership working arrangements are insufficiently clear and robust 6: Partnership working arrangements are poor. Principle 6: monitor, measure and learn 19-24: The partnership monitors, measures and learns from its performance very well 13-18: The partnership monitors, measures and learns from its performance reasonably well 7-12: The partnership monitors, measures and learns from its performance poorly in some respects 6: The partnership monitors, measures and learns from its performance poorly in most respects or not at all. Aggregate scores 109144 The partnership is working well enough in all or most respects to make the need for further detailed work unnecessary. 73108 The partnership is working well enough overall but some aspects may need further exploration and attention. 3772 The partnership may be working well in some respects but these are outweighed by areas of concern sufficient to require remedial action.

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The partnership is working badly enough in all respects for further detailed remedial work to be essential.