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Carers Strategy One Year On - More Help For Carers

It's disappointing to have so little response from carers affected by family schizophrenia .Carers hide ? their shame ? their fear of something worse if they get involved at all.
That somehow breathing the the word schizophrenia will get out and about and be applied to their family member, alter the family balance with friends and neighbours, and that it is an adverse designation, affecting them badly.
No carer wants to 'out' their family member as 'schizophrenic'. That does not mean that we carers cannot speak out, on behalf of schizophrenia in general. Maybe that is the trouble - it draws attention to the family, within whose care, is someone who does not - or, carers will agree - want their postion exposed - and, in any case, has not been told of the diagnostic labelling, and would reject it, and would be uncertain thereafter, if the carer accepts 'the diagnosis', that any material observed or disclosed by carer, will be passed on to 'them' , will be used against the sufferer ... who wants to hide the behaviour, or cannot remember it and denies it .... by them

But how to campaign without speaking from your experience. You do actually know more than the professionals do about living with schizophrenia, and, for example, by making a routine for them, indeed making them follow a routine, is supporting a personal lifefor them, knowing by experience what is best [ or at least learning what is worst for them, to be avoided.
The professionals do not know that a routine programme in aftercare weekly life, even an initially imposed one, is a treatment NEED
They do not put it in their Care Plan. So it is never recognised in finding requests as UNMET.
If it is UNMET, it is negligence.
This site will never put out names, addresses, or attribute here so that those requiring protective anonymity will get it

So, what is holding back comment and illustrative experience coming to this site.

There are about twenty 'hits' a week., but very few messages.

Understandable and accepted - the words schizophrenic and psychotic we want to avoid - perhaps that schizophrenia is part of the website title is offputting- It is deliberate, somebody has to try to tell the world, that what schizophrenia gets from the NHS is heedless bad publicity, and neglect - in aftercare.
The adverse public perception comes form poor service, not from the illness per se.

... for carers, particularly family carers .... [ ! come out of hiding, that will get you nowhere .... ] a web site to give voice to those who can't, and don't, voice for themselves
The site is edited by a retired consultant psychiatrist who has looked after a family member at home, affected by schizophrenia, for the last fifteen years.
For website beginners, clicking with the mouse on a highlit item e.g Care Programme Approach [ CPA } will take you to the appropriate page. You return to the Home Page by clicking on the back arrow button at the top of your internet page, or try pressing the back button on your keyboard, or there is usually a return highlight link at the bottom of the page

Items marked red are new or retain importance !!!

*** !!! Comparitive mental spend per person: English Primary Care Trusts
can we find 'the best buy area' to live in for after-care?

*** !!! e.g. carers week survey the website is well worth a visit.
carer week survey people pulled out mental health for me ... 11.5% = around 270 were adult mental illness carers 76% said they had been near beakdown.

Surveys of this kind combined with the Nice recommendations below give the way forward for campaigning on facts .... a survey for 'breaks within the week from caring' will come out of finding out what sufferers are doing during their day and week

*** !!! More confusion to the disadvantage of those affected by schizophrenia - the new Capacity tests [ Mental Capacity Act MCA] , and the new Deprivation of Liberty route [ summary DOLS Guidance ] , leads many with schizophrenia to be left in the lurch with their illness .... ' it's their choice ... they were not ill enough as I saw them ..'
Decisions allowing sufferers to go on with with fluctuating capacity, are being taken by people from inadequate qualification and experience, delaying patients getting to the people with authoritative clinical lead. Insist on their being seen by doctors.

E-mail reaction is always welcome ... mica2@tiscali.co.uk

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*** !!!NEW !!! . ]

National Institute of Clinical Excellence on schizophrenia .... [ NICE ] .... says nothing of much volume on aftercare - but Nice is very valuable as providing standards of reference to be quoted, to apply pressure for aftercare service provision - and it is buried in the three hundred pages

But - and to be accepted by Primary Care Trust commissioners - NICE is authoritative - quote it for aftercare resource in your area.

National Institute of Clinical Excellence [ NICE ] on Schizophrenia; updated 2009 - in continuing care - the most important aspect of schizophrenia: - this is what it says ( out of 335 pages ! ).

4.6.8.1 All teams providing services for people with schizophrenia
should offer [ ? and if they decline ? ]social, group and physical activities to people with schizophrenia
(including in inpatient settings) and record arrangements in their care plan.

4.6.9 Employment, education and occupational activities

4.6.9.1 Mental health services should work in partnership with local stakeholders, including those representing BME groups,
to enable people with mental health problems, including schizophrenia, to access local employment and educational opportunities.
This should be sensitive to the person's needs and skill level and is likely
to involve working with agencies
such as Jobcentre Plus, disability employment advisers and non-statutory providers. [ oh, and their family carers maybe ??? ]

The following is important - and how often does it happen ?

4.6.9.2 Routinely record the daytime activities of people with schizophrenia in their care plans, including occupational outcomes

Why are academic people not studying this with family carers looking after ongoing sufferers at home - or with the cluster of ongoing sufferers that are registered with an ordinary GP group practice - maybe 20-30 - or so, already 'documented'.
NICE must mean that if there are no aftercare occupational activities, something is missing , is wrong, in aftercare.

If those continuing in some lasting effect of schizophrenia are not in a routine, a certain programme of involvement with a regular activity of some sort - education, interest, hobbies, sheltered occupation, that engages them on days in the week - say monday, wednesday, friday - they drift - there is no 'internal' anchoring back into a reality outside , thinking wanders into illness, medication is forgotten, and they relapse.

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look at an 'official' review of rehabilitation and a link to those who have a service - does your area have one - please let me know ?!!

Carers must use their intervention at the Needs assesment - the first stage of the Care Programme Approach - professional service must follow this system, but ask and get it clear that they are following this process, so that you can insist - to have put into the Care Plan, provision for aftercare engagement in an activity outside the care base, on a regular basis,that will give you 'breaks in the week', to yourself - the Carer.
If no such plan is delivered, have it registered as an UNMET need in the Care Plan, and raise the deficiency at every Review, and quoting NICE, to every pressure point you can access in your area: GP,MP, repeated letters to the Primary Care Trust in your area, especially where you can be a group representing all carers of schizophrenia, like yourself

the quandaries facing the professional services.

*** !!!NEW !!! ... How to to get a better service ? Or more usually, I am afraid, not

There is a new NHS inspectorate, part of the Care Quality Commission [ CQC ] replcing the old Mental Health Commission.

*** !!!NEW !!! ..

This is what the MHC used to ask providers to reply to ... MHC

Note the absence of any indication that provider Trusts should tell what they are delivering as service to aftercare - rehablitation, supported housing ,sheltered lodging etc .

What is the point of all the other high-sounding provider teams if they do not have the capability to continue contact and feed into sheltered work. interest activity, educational opportunity, to give those with residual illness, somthing to do, and regular relief during the week for landlords, carers to continue with some kind of life of their own, dissipating tension between carer and sufferer, all round !

The government is now sold on local provider NHS Trusts, in their decision making, obtaining, and following, the views and experience of those receiving in the front-line

So, tell the new body that you carers are not to be left out in any review of local service; go to the CQC tell them in the next 'inspection' in your area , you want your carer after-care experience to be sampled

*** !!!NEW !!! ...The worst has happened: what can you do , what you can do ?? !! { in progress 24-48 hours - done ? e-mail comments please }

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If you are internet and table literate with linking try this service mapping website to find for your geographical area ... compare them to other areas [ e.g. supported housing has wide variation: Dorset lots, Cornwall none.
Or for your local Mental Health Trust
{ go to LIT - provider Trust area , under service group, tick 'allservices' then, at bottom, click RUN REPORT
and ; or in particular service type ... try continuing care ...type ... Rehabilitation and Recovery services - the after-care service ]

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Items marked red are new or retain importance !!! *** !!!

Not so new ..... into the NHS mental health services ... click on ....The patient [ and carer ] journey through illness

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"We all like to have anchor points of certainty in our lives, and even in psychiatry, with its whirlpools and eddies of doubt, we are searching for reminders that some fundamentals remain unchanged. The trouble is that relatively few are left [.,,,, a lead word for the editor of the British Journal of Psychiatry ,,, ' shame that he does not connect this thought to helping the sufferers from schizophrenia, who flounder without any such future anchor points in the the chaotic lives in their days, and weeks, ahead, and never get a routine programme of such anchor points as NEEDS in their afterrcare Plans ... from psychiatrists !

Only by re-connecting to a routine, daily and weekly, of regular interest activities outside the self on a regular basis
does a sufferer rebuild the internal brain networks, holding them together so that they stay , to match and support, continuing involvement in outside activitiesWandering thoughts need these anchor points in the routine to fall back upon, and refocus.

*** !!!Only half Mental Health Trusts have a co-ordinated Rehabilitation Service

'Breaks ' from caring within the week are an essential part of aftercare: they can be measured .

Establish the lack of 'activity breaks' in the week, and you have a measure of missing aftercare needs for carers and sufferers.
A good service would give family carers three session, in the ten session week [ monday - friday: morning ; afternoon = sessions ] when family sufferer is out doing something that occupies them - education, training, interest activity, sheltered work: and being out on a regular basis, family carers can then do something in their own time in those three sessions
These breaks relieve emotional tension in the care situation, and that reduces both relapse and violence.
Get that registered as a care situation need - documented with the your local NHS mental Health Provider Trust, and the local NHS commissioner Primary Care Trust as UNMET NEEDS at the first Needs Assessment stage [ the first step they have to do, when the specialist service meets your family sufferer ] of the Care Programme Approach

One way to collect of facts for the NHS suppliers, will be to ASK for and then put into a Carer Assessment protocol these questions - if it is not in the Needs Assessment then you will not get it

1.

Would it be helpful to you in your care situation, if there were breaks within the week where the person you cared for was out doing something on a regular weekly timetable ? If they won't include that question then you invert it and give the information yourself ... what would be helpful, indeed necessary , to me and my family member, in our care situation is to have such breaks, within the week, regularly

2.

What breaks of this kind did you ( did I - if necessary ) have in the last week - if that was a typical week ? - over the last month ? .. would be one measurement.

3.
Another would be to put into the core assessment [ the Needs Assessment ] stage 1. of the Care Programme Approach for someone with schizophrenia
... what will be the after care activities that will be provided for them in the Care Plan so as to provide breaks within the week for carers and their family member?

third world better ?

The claimed for better 'recovery' in third world countries is unexplained and is not capable of being learned from

summary DOLS Guidance .... the Offical advice The NHS complaints system; official your right in a serious and untoward incident. [ SUI ] Try your local PALS first " to give advice and support to clients [ patients - PALS are not health staff, even though paid and employed in NHS; 'clients' gives a different relationship for Pals ] , families and carers " ... - in my experience they are the most sympathetic, practical, functional and responsive of the helpers - your mental Health Trust will have a contact number Mental Capacity: advice for Carers Red Information for carers - allowances, benefits, direct payments etc :- click for the government website New 1. Direct payments when capacity is lacking. Consultation on direct payments regulations, Department of Health, 19th August 2008 The Health and Social Care Act 2008 extends the availability of direct payments to those people who lack the capacity to consent to their receipt. In addition, the government is also reviewing the current exclusions to receiving direct payments for those people who are subject to various provisions of mental health legislation in light of the modernisation of mental health law brought about by the Mental Health Act 2007. The Government is now consulting on regulations relating to these two changes. New 2. deprivation of Liberty protection [ DOLS ] Care Programme Approach [ CPA ] you carers must know about this - the four stage rule for applying mental health services But now - after a year taking 'evidence' this is the guidance that all the Mental Health NHS Trusts will follow. There is now a New CPA ... the same four stages . This is the less patronising guidance to the NHS Trusts that follows second line is best But better still click on the link "refocussing the care programme approach" in the right-hand column Even more important that you, the family carer, intervene at the Needs Assessment stage ... that is at the first stage in the CPA after first contact. That's the time when you ask about after-care service - what's available, and in particular what arrangements there will be, to give you and family patient "regular " breaks during the week " so that you and patient can have a life of their own. If no arrangments are provided for you family future care situation - then get that registered at once as an UNMET need. and about your entitlement at the needs assessment stage of the CPA for you to have a Carer Assessment Carer Assessments are for you to say what you want from the service - especially you want a life for your family member outside the home - an interest of their own. surprise ... surprise -the first line link on the new CPA page ( see above ) gives this within it ... needs assessments that find some needs unmet ...will, occasionally !!! lead to service improvement ... occasionally ??? !!!! ? Who decides about who continues on new CPA - the local Mental Health Trust service deliverers - the Mental Health teams - the DOH new CPA guidance says p 12 para 5 .. " " Services should continue to use current local eligibility criteria to make initial decisions on an individual's need for secondary mental health services " and if they are the wrong decisions ?". And don't think the Local Authority Social Services can help with aftercare - they have their own cut off point click on FACS = Fair ?access to social care - below that - they decide that - you are off their books, as well. Professional care and treatment does go wrong. *** !!!the List of Inquiries after Homicides Comment *** !!!What are the lessons - that are not learnt *** !!! One piece of information from the Inquiries where the perpetrator suffered fom schizophrenia is that very few have been helped into a daily and weekly routine of engagement with a meaningful programme of activity that they will want to continue. It's a common finding for most of those suffering from schizophrenia, and it is negligent. That is a failure to deliver a Treatment programme in aftercare. I Have asked all the 60 mental health Trusts whether they have a Rehabilitation service which includes a consultant psychiatrist [ sometimes called 'Recovery' ] - that is, a team dealing with after-care separate from the community mental health team ( they get the first referrals ), a Home Treatment team ( often the old crisis team ) or the Assertive Outreach Teams. So far 40 have respnded and the replies are half and half, yes and no. I will list the No people here, so that you can check the service in your area. And Complain!!	*** !!!New ... violence in schizophrenia down to street drugs ? go to About Schizophrenia These didn't make it another family story Here, is one recent 'another family voice' ? all hope gone These did - sort of. a family voice .... < Two necessities for 'some kind of recovery' Without these, in place, or as a written down commitment from professional aftercare, in definite preparation, my advice is not to have a family sufferer at home of course when there is a Care plan, inside which is one to put in place meaningful breaks WITHIN the Week ... then Ok. Too early an acceptance and your levcrage has gone for good !!! You will have more influence - more clout to insist on what has to be put in place for you to continue caring - if this is going to be the outcome - by raising the question of breaks from caring during the week whilst your family member is in the hands of the professional team. They will then feel obliged - where otherwise they will not - to put their authority with some persuasive coercion, into telling sufferer with continuing illness - that there is an aftercare imperative which they must join in with, to stay better and to get better. A 'must' but one for which the team will deliver the resource and the personal support, to find for the sufferer . With that relief in the form of breaks within the week, comes the break for the family carers. If they discharge before any of this is raised you will find that the team will take thier priorities elsewhere. Why not - you will be carrying the can . This is not cynical, it is often the reality. out of sight IS out of mind 1. Acceptable medication, maintained. A few can manage without medication - with limited lives There is little success with acceptable medication if the people better [ not well ] after it, do not have some kind of future in life for themselves. That leads to disappointment, emotional upsets on the way, and relapses. 'I take medication and where does it get me' ?! 2. A life outside the person; supporting a personal interest, a personal hope, giving an anchoring safe structure onto which to reconnect from wandering in thought, , a steadying and dependable routine that can be reliably there, onto which to fall back ; there in place for a settled future engagement. A programme that rebuilds and prepares, the internal associations that will go to support the routine. When this is not in place, You have UNMET NEED This is what carers and charities that want services to be better, need to campaign about. Government Strategy recognises the need. It has committed itself ... see page 13 on [ The Journey to Recovery: [ quoted in Unmet Needs ] a gloss on the National Standards Framework ] Many will relapse without this structure to 'lean on' as most ordinary people flounder without a job, or a domestic work habit; and without contact with company. The acute stage and the care crisis, the first signs of florid illness, are quickly and are presently adequately addressed with what is needed straight away. What is an NHS service neglect, and left unanswered in a deliberate way, has been to postpone and deny funding and service development for the after-care the best source of facts about schizophrenia.. to manage properly you have to measure ...The best source of a full range of trials in schizophrenia management *** !!! Background material towards trying to think into schizophrenia - what is going on, or not going on - how does this help being with the sufferer ... Daydreaming look at Compulsory community Care ..... as experienced in New York over the past five years ... now confirmed as American Law, Kendra's Law - they call it " Assisted Outpatient Treatment " american comment on the Kendra's Law experience - for and against ... New York figures *** !!! new MH Act people definitions.... the Act comes into effect today Nov 3 ... Supervised Community Treatment Orders [ SCT's ] , with limited compulsion the most significant change - challenge legally unless in a rehabilitation programme. Letter in the Royal College of Psychiatrists Journal about Community Treatment Orders [ SCT's ] , aftercare for those under Mental Health Act Orders, [ Supervised Community Treatment SCT's ] and the situation of carers.the original 'debate'..... transcribed CLICK on ...UNMET NEEDS... what to do !!! ... this is a vital, crucial, urgently important topic ... for carers ... particularly for family carers. Describing and listing UNMET needs at *** !!! the STAGE 1. of the CPA is the tool for getting public accountability of funding and spending and for blaming and shaming by using the Review stage to reveal what becomes the continuing neglect. Otherwise the unmet need is ignored in the game - 'not us to do ... for you to do' - between LASS and NHS. Unmet needs in the CPA is a clinical deficiency for the clinicians to register, and then for the responsible managers to be named and called into account about it. An unmet need that goes un-addressed can be challenged. It is something- when registered - that can be counted. Counting is the basis of management and accountability of management. What can be counted is there as a figure, there to be made public, as a neglect, to be the responsibilty of management to adress. *** !!! ... One comment from the latest Inquiry after Homicide the sheltered and assisted rehabilitation of this continuing illness. The Primary Care Trusts - the funders - knowing the inability of these sufferers to reach for power, or to sustain any ability to challenge through legal redress for this neglect, avoid examination of the failure by blaming the other - in section 117 for NHS and LASS, They wait [ we thought it was up to them ] for the other lead to take the leadership in providing rehabilitation pathways. Cochrane reviews are two years into reviewing rehabiliation in schizophrenia The Royal College of Psychiatry has no Section devoted to Rehabilitation to a level of recovery . Consultant leads no longer put rehabilitation Needs as unmet in the Core Assessment stage of the Care Programme Approach. *** .. two present pleas from experience for specialist Rehabilitation teams as essential to support the lomg term ill who otherwise disappear *** The neglected Need Primary Care Trust funding feel no requirement, nor demand, for them to commission rehabilitation services. A local example ...Pentreath Industries Preparing for community care in the County catchment of Cornwall during 1995, the activities available to in-patients were moved out to a Charity - Pentreath Industries - nationally procalaimed as exemplary - under a manager of a senior Sister. She held it in order, innovated, but could not get funding to develop from the local NHS commissioning body - the one that was £30,000,000 pounds overspent on general healtth - turning instead to european money, linked to preparing people back to competitive work. The initial funding out of a total adult mental health budget in 1996 of £13,000,000 was £340,000 annually [ 3.5 % ]. After three years, the European funding lapsed. Ten years later, in 2006, out of the overall adult mental health Budget of £40,000,000+ the Budget for Pentreath Industry was £370,000 [1% ] . So much for the longterm ill - seemingly less a burden [ on the NHS ! ] and in need of longterm intervention, than the acutely ill ??!!! Many of the initial support programmes accessible to the longterm sufferers from schizophrenia have disappeared. The old leaders - the consultants have their heads down, unable to declare the authority that belongs to them from their qualification, their training, their experience, their intelligence, and by being the most likely to stay long enough in post, and acquire the knowledge of how to practice the service in the locality, and to assess the capability of the other staffing. They are often now uncertain as to how far they can call upon the response from, and support of, the other members, within the secondary mental health specialist teams, who each have their own line managers., whose interests are to their careers. Stigma ... grandiosity, lying, and double orientation ? How should one behave towards a person with schizophrenia or allied disorder? Keep to the point Is memory difficulty the disability ? Three studies might this help in the future another chance finding usually the most productive schizophrenia, genetics and inheritance Gene studies in schizophrenia DISC1 etc *** a Wild theory - extrovert versus introvert ? There is a link to Paternal age at time of conception .... paternal age at the Police Station Prosecution guidelines Admission figures 1998 -2007 - *** ... aftercare failing in Canada - lessons ? *** ? KPP ? the longterm ill; what to do ? *** a New Zealand manager gave it a direction What a whole life can do for schizophrenia Recovery or remission ?? Remission in an outpatient sample.... Management and treatment the best buy ? - ?. .... any body know more than me about this ?? a quicker way to isolating the 'faulty gene variant - look at these sufferers without a family history E-mail reaction is welcome ,,, click on mica2@tiscali.co.uk can I print some of the content ? Family emotion studies *** family treatment; a caution original article third world better third world better ? comments on original article Leff comments on third world better figures another comment gross domestic product and duration before treatment Risk assessment ..... violence in schizophrenia Two carer groups give their views ... (1) a training group for carers, commenta at the end ... (2) .... an experienced group tell how it is ! ... Cues - a Questionnaire for Carers P>

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There always was a pathway for achieving change ,.... It should have been for the Consultant psychiatrist to get involved at the Needs Assessment stage of the Care Programme Approach,
to register something that is missing that would be of benefit to patient that cannot now met in the Care Plan, but must be for future care.

The unmet Need is the provision of a daily routine, and a weekly programme of patient engagement with an outside activity away from the family home, regularly supported, so that sufferer can develop and hold together, an interest, and a future aim, engaging inner decision and expectation, onto a framework of conmmitment which leads the direction of intention away from the illness thoughts; and family carer is supplied with regular 'breaks in the week' from caring: for both carer and sufferer, space and time for exchanges of developing High Emotional Expression [High EE ] to dissipate.

An UNMET need, registered as a service deficiency by the delivery mental Health Trust; is an UNMET NEED ,
is to be commissioned by the local NHS Primary Care Trust funder, and remedied by the Mental Health Trust delivering the aftercare service.
; - to be reviewed, reported and renewed, at every obligatory Review stage of the CPA by the Team Care Co-ordinator ; and the deficiency notified as well to the General Practitioner.

We carers will have to be the champion, the outspoken people for those who cannot know what is necessary for them, and cannot campaign for themselves.

The mechanism is for the carer to be intrusive, and involved, at the level of the Needs Assessment stage, the first stage of the Care Programme Approach [ CPA ] before the Care Plan which follows, assumes as its basis; future Home Treatment.
If necessary [ and you are resolute and together enough ] decline to have the patient home until UNMET need is registered as something crucial, to be addressed and attended to in the Plan.
Discharge home or a decision to continue treatment on a home basis [ or a Home basis ] should not proceed until the community carers can see what is needed and if not providedm, presently is UNMET.

Unmet Needs

..... where there is a benefit available which is not being delivered - that is an Unmet Need - a failure of service, to be remedied.

We are not meeting this need, and we are failing to provide this service.

So, how to make progress ... ...it is of crucial significance, and carers - family and care home managers - must attend to it

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more new gene news - getting there ?

Police and prosecution

Coroner Inquests Family carer rights

Studies of care sharing between families and professional NHS delivery are rare and lack the rigour that NICE takes into account.

An example of the difficulty would be comparing what is set out in the Needs Assessment stage of the Care Programme Approach and what is in the resultant Care Plan to support those needs in continuing care, in the family. There are good studies about the influence of High Emotion in a care situation and relapse, and not quite such good studies of a beneficial effect of educating family carers in the ways to conduct caring so that High EE does not arise or return.

But nothing about the success of mitigating high EE by providing, as a need, separation - distancing time and space - between sufferer and carer on a regular schedule of times during the week, so that family caring gets a break and a life of their own, and family dependent patient gets a meaningful and a willing compliance in the outside activities, which provide for those separation times.

It is uncommon for such a need for a regimen for outside commitment to be stated as a health need in the Needs Assessment, and as a consequence little funding from Health goes to setting up such outside activities.
Where needs of this kind are stated to be a health need for continuing care, the provision is just not there in a manner which the front line care co-oordinators can manage.

Such 'UNMET need should be registered with the commssioning and planning bodies , but that this can be done is not known to clinicians at the needs assessmnt stage. Staff in Mental health Trusts can mark a deficiency of provision as a service deficiency failure in forms provided, but there is no study which measures UNMET registers or Service deficiency statements.
The further management of such proposals seems to be too much for health professional teams to accept, and little is done.

What often happens is an unresolved issue between who it is that sets up and pays for such continuing care needs - the Local Authority - which has an obligation [ when the aftercare follows a Treatment Order Mental Health Act ] or the Local Mental Health Trust.
The difficulties foreseen lead to low specifications of such a continuing care need.

The list of psycho-social interventions delivered which benefit schizophrenia is so large - from sessions of learning chess - to living in a therapeutic environment, to all sorts of appoinments with some therapist - that it makes one doubt the significance of them other than that they have in common tie the sufferer within some structuring framework outside themselvs onto which they must focus their attention and hold themselves primed to do it 'a next time'. In other words anything that provides an externalising framework which yields a future commitment to engaging on something outside themselves is beneficial.
The outcomes are tested over relatively short durations of outcome. Selection depends upon not dropping out. Contro comparisons are difficult to provide a comparison without other variables.
None of them indicate which area of disability they are addressing ?

The list makes one wonder what would be the result if they were set up in a race against each other - which would win in the therapeutic stakes.
Perhaps they all offer professional hope to the lay care situation' and temporarily reduce anxiety in the principal carer ?
It has to be addresssed at the needs assessment stage - the very first stage of the Care Programme Approach, and then at every review thereafter.

D o H changes the Care Programme Approach - go to New CPA - now to be only one CPA - for the seriously ill who need aftercare

click on FACS = Fair ?access to social care