Carers of people with dementia often experience their own feelings loss and emotional pain (McCurry, 2008; Meisen 2006, Woods, Wills, Higginson, Hobbins, & Whitby, 2003) while providing full-time care to the person with dementia who has complex and changing needs, which can result in major depression and anxiety, increasing the possibility of referral to mental health services. Treating carers distress is vital not only for their mental health but to enable them to continue in their caring role, without which the current care system would collapse.
Our service is meeting this need by providing psychological therapy services to carers of people with dementia of all ages where needed within the Mental Health Care of Older People's service in Newham. We have found that Cognitive Analytic Therapy (CAT) is an effective and flexible therapy for this purpose.
*This example was originally submitted to demonstrate implementation of NICE guideline CG42. The example has been reviewed and remains consistent with the updated NICE guideline NG97. The updated NICE guidance should be referred to if replicating this initiative.
Aims and objectives
To address the psychological needs of carers of people with dementia. Caregivers often report feeling very alone and left to cope with a wide range feelings associated with grief and their changing role within the relationship (Mc Curry 2008). The contribution that family carers make to support people with dementia has been more acknowledged in recent years (Woods, 2008) as has the potential costs to carers in terms of increased risk of psychological distress (Brodaty and Green 2000; Donaldson, Tarrier & Burns, 1998; Williamson & Schultz, 1993), physical health problems, and increased mortality (Schultz & Williamson, 1991). The NICE guidance on supporting people with dementia recommend that carers be given information about relevant services (including support services and psychological therapies for carers) and how to access them.
The Alzheimer's Society supports this and the carers' strategy commits to invest in developing these therapies, emphasizing that they must be accessible and convenient to carers of people with dementia (Alzheimer's Society, 2007). However, models of good practice and specialist service delivery appear patchy. Our service is working to meet this need by providing psychotherapy to carers of all ages where needed (in addition to running carer's groups) within the mental health care of older people's service. Within the borough there are no admiral nurses, whose role is to focus on the needs of carers of people with dementia.
The PTOA (Psychotherapy for Older Adults) is a specialist psychotherapy service set up by clinical psychologists within the mental health care of older people's service in Newham. As a specialist service in therapy and dementia we are well placed to address carer's psychological needs and to facilitate their understanding of dementia. We have found that Cognitive Analytic Therapy (CAT) lends itself as a flexible therapeutic model for this work, having been developed within the NHS as a time-limited model of psychotherapy with an explicit focus on problems in relationships within the social context. Our experience and initial analysis offers preliminary support for the value of a CAT approach to working psychotherapeutically with carers of people with dementia.
Reasons for implementing your project
The psychological needs of carers of people with dementia are increasingly being recognised across agencies. Carers of people with dementia face an unpredictable and complex illness and services often lack cohesion and fail to recognise their mental health needs, increasing the possibility that they will develop mental health problems. The Newham PTOA is made up of clinical psychologists with expertise in both dementia and psychotherapy and so is well placed to meet this need by providing psychotherapeutic interventions to carers.
How did you implement the project
Central to providing a responsive therapeutic service for carers is the joint working of the PTOA clinical psychologists into and with the following teams
1) the Diagnostic Memory Clinic multidisciplinary team (DMC), and 2) the Dementia Care Team.
This helps to establish a relatively' seamless relationship with families and good joint working with the other professionals in the teams where carer's mental health can be assessed and provided for at various points along the dementia journey. Within the borough anyone with a formal diagnosis of dementia will generally have been seen by the memory clinic or old age psychiatrists and will therefore be known to the service. We are also fortunate to have a close relationship with the manager of the local branch of Alzheimer's society, ensuring good links between the PTOA and voluntary sector.
Whilst a range of therapeutic approaches are practised in the PTOA Cognitive Analytic Therapy (CAT) has been a particularly useful and adaptive psychotherapeutic model when working with carers. Outcome measures indicate the benefits of this intervention. The model helps to make sense of how the caring role can trigger unhelpful coping patterns in the carer, which can be linked to early experiences as well as the wider social and cultural environment, (Ryle and Kerr, 2002), while also keeping the person with dementia in mind. All interventions are measured with standardised tools including the HADS (Hospital Anxiety and Depression Scale, Zigmond & Snaith, 1983) and the GHQ-12 (General Health Questionnaire, Goldberg, 1988) and more recently the CORE (Clinical Outcomes in Routine Evaluation). This work has been written up and accepted for publication in the British Journal of Psychotherapy.
Key learning points
Our experience and initial analysis offers preliminary support for the value of a CAT approach to working psychotherapeutically with carers of people with dementia. Further research and thought about service delivery for meeting the mental health needs of carers is required.