Transcript Structuring Treatment and Services for People with

Structuring Treatment
and Services for People
with Personality
Disorder
Dr Tim Agnew, Consultant Psychiatrist
for NHS Highland Personality Disorder
Service.
Overview
• Tiers of service provision
• Phases of treatment
• Stages of change
Phase-based Treatment of
PD
• Phases of treatment
• Some examples from Highland
• Discussion
A phase-based approach
Phase 1
(Behavioural
stabilisation)
Phase 2
(Exploration
and change)
Phase 3
(Integration
and
synthesis)
Integrated
problemfocused
approach for
PD (Livesley,
2003)
Safety
Containment
Regulation
and control
Exploration
and change
Integration
and synthesis
Dialectical
behaviour
therapy for
BPD
(Linehan,1992)
Behavioural
dyscontrol to
behavioural
control
Quiet
desperation to
emotional
experiencing
Problems in
living to ordinary
happiness and
unhappiness
Incompleteness
to capacity for
joy
Stage-based
treatment of
traumatic
disorders
(Herman,
1992)
Behavioural
stabilisation
Treatment of
hysteria
(Janet, 1889)
Trauma
reprocessing
Exploration of
traumatic
memories
Integration
Personality
reintegration,
rehabilitation
Stabilisation,
symptom
oriented
treatment
A phase-based approach
• 1a. Safety:
– Interventions to ensure the safety of the patient and
others
• 1b. Containment:
– Interventions based primarily on general therapeutic
strategies to contain behavioural and affective
instability. May be supplemented with medication if
appropriate.
• 1c. Control and regulation:
– Interventions to reduce symptoms and improve selfregulation of affects and impulses eg behavioural,
cognitive and pharmacological.
A phase-based approach
• 2. Exploration and change:
– Interventions to change the cognitive,
affective and situational factors contributing to
problem behaviours eg cognitive, behavioural,
psychodynamic and interpersonal.
• 3. Integration and synthesis:
– Interventions designed to address core
pathology and forge a new sense of self along
with more integrated and adaptive
interpersonal systems.
Focus of interventions
DBT STEPPS Day
Crisis
Crisis
Service Admission Intervention
Safety
+++
+
+
+++
+++
Containment +++ ++
++
+++
+++
Regulation
+++ +++
++
-/+
+++
and control
Exploration +++ +++
+++
and change
Integration
+
++
+++
and synthesis
Structured
Admission
+
+++
+++
-
Phase 1: Behavioural
Stabilisation
• Changes to DBT service
• Introduction of STEPPS
• (Most mental health services!)
Tiers of service provision
STEPPS
• October 2011 - Introduction of STEPPS to
CMHTs
• Systems Training for Emotional
Predictability and Problem Solving
• Tier 2 service
Changes to DBT service
• Referral system changed to address some
of the problems of the old system and
allow appropriate focus of limited DBT
resource
Changes to DBT service
• No longer traditional referral-waiting
list set-up
• Each sector allocated places on
program
• When the place is soon to become
available (within 8-12 weeks),
community services are informed
• Asked to identify and refer the patient
most in need of DBT for the sector
Changes to DBT service
• CPA now a requirement before
patient seen for pre-treatment
– Ensures a clear, regularly reviewed,
comprehensive treatment plan including more
than DBT alone
– Formalises patient’s role in their own care
– Assists effective transition from DBT to future
treatment phases
Changes to DBT service
• DBT therapists will attend CPA review
• Present to support the patient to interact in
the most effective manner with their care
team
• Not simply giving information which the
patient is equally well, or better placed, to
provide
Phase 2: Exploration and
change
• Trauma reprocessing as a Phase
2 intervention
• Psychological Trauma Service
Development (PTSD) Group
• Aims of PTSD Group
Aims of PTSD Group
• Promote awareness, identification and treatment
of trauma-related conditions and the supporting
of education of the workforce towards these
aims
• Development towards a trauma-informed service
• Development of specialist trauma services
• Identification of existing services for all phases
of trauma work
• Identification of pathways and links between
these services and people
Day Service for people with
Personality Disorder
• Phase 2: Exploration and
change
• Phase 3: Integration and
synthesis
Who is it for?
• Any person with personality disorder
(not only borderline) of 18yrs plus
• Need to be sufficiently behaviourally
stable
Who is it not for?
• People who do not have a personality
disorder
• People with risk issues that would
preclude safely working in community
environment
• People with factors which would preclude
working in a cognitive and behavioural
way
How is it accessed?
• Referrals from Mental Health
Services
• Referral to be completed with, and
signed off by, the service user
• PDQ-4 to be completed by the
service user
Summary
• Phase 1: Behavioural stabilisation
– Safety
– Containment
– Regulation and Control
• Phase 2: Exploration and change
• Phase 3: Integration and synthesis
Summary
• Phase 1 (Behavioural Stabilisation)
– Changes to DBT service (Tier 3)
– STEPPS (Tier 2)
• Phase 2 (Exploration and change)
– Trauma services development
– Day Service (Tier 3)
• Phase 3 (Integration and synthesis)
– Day Service (Tier 3)
What next?
• Tier 1
– Education and awareness
• Tier 2
– Education and awareness
– Consultation/ liaison
• Tier 3
– Early intervention/ CAMHS transitions
Thank you
• Discussion and questions