Appendix 8 An Inegrated Approach to the

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Information about Appendix 8 An Inegrated Approach to the
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Published on December 15, 2008

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Service and Training Models for Personality Disorder. : Service and Training Models for Personality Disorder. MRC Psych Module How are we going to support the delivery of a comprehensive service for PD? : How are we going to support the delivery of a comprehensive service for PD? The general context The current situation The clinical service for PD DH guidelines for PD service and training Service proposals Ways forward… General context. : General context. The local situation. What is PD? What is BPD? How common are personality disorders? The burden of PD. Cost impact on services. What is the local situation? : What is the local situation? Psychological therapies services across the Trust/Region. The Department of Psychotherapy. Secondary MH services Primary care Social services. Voluntary sector and housing. Probation. ‘it has been said that each generation of mental health professionals has to discover for itself the importance of personality disorder. Although personality disorder often seems elusive and to be clinically indispensable’. : ‘it has been said that each generation of mental health professionals has to discover for itself the importance of personality disorder. Although personality disorder often seems elusive and to be clinically indispensable’. Livesley, 2001 Changes to the Mental Health Act… : Changes to the Mental Health Act… ‘legitimate business of mental health services’ “Personality Disorder: No Longer a Diagnosis of Exclusion” DoH, January 2003 : “Personality Disorder: No Longer a Diagnosis of Exclusion” DoH, January 2003 Guidance Document for Trusts on how to meet needs. Aims to facilitate the implementation of the NSF for MH. Covers three areas: General adult mental health services Forensic Services Staff selection, supervision, education and training What is Personality Disorder? : What is Personality Disorder? ‘a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’. ICD-10 ‘an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early childhood, is stable over time and leads to distress or impairment’. DSM IV Clusters of personality disorder…DSM-IV : Clusters of personality disorder…DSM-IV Cluster A: Paranoid, schizoid, schizotypal Cluster B: Histrionic, narcissistic, antisocial, borderline Cluster C: Obsessive-compulsive, avoidant, dependant How common are personality disorders? : How common are personality disorders? Community: -10-13% -2% Antisocial PD Primary Care: -10-30% -Type C commonest De Girolomo & Dotto, 2000; Moran, 1999 In Secondary Care? : In Secondary Care? Inpatients: 36% in UK inpatients Drug and Alcohol Service: -78% alcohol inpatients -97% polydrug users De Jong et al., 1993 Prison -60-70% Singleton et al., 1998 So Which Personality Disorder? : So Which Personality Disorder? Cluster B and specifically Borderline… -present in crisis -poor impulse control and addictive behaviour -self-harm -aggression -eating disorders -massive and chronic anxiety state -repeated relationship breakdown -chronic feeling of emptiness -severe mood swings The Burden of Personality Disorder. : The Burden of Personality Disorder. Health -high use of A&E. -suicide (lifetime risk 10%) -DSH (70%) Social Voluntary sector Housing Probation Cost Impact on Services : Cost Impact on Services High psychiatric out patient use High in patient use (av. in pt stay 70 days) 80% are readmitted annually (Skodol et al 1983) ‘Revolving door’ “Diagnosis used as an argument to withold psychiatric help” (Kendell, 2002) How does a borderline patient challenge psychiatry? : How does a borderline patient challenge psychiatry? Co-morbid diagnosis: 44% Threats of suicide. Difficult to engage. Demanding. Non-compliant. A dedicated PD Service. : A dedicated PD Service. The Regional Borderline Treatment Service: -outpatient -education and training -supervision -consultation and liaison audit and research Integrated.. The clinical work of the BTS : The clinical work of the BTS Over 200 referrals per year Shift in referral source: primary care up to 50% Collaborative links with primary care Collaborative links with psychiatry (forensic, general adult): consultancy Working relationship with voluntary and housing (Pele Tower Project) What type of patients are coming to the BTS? : What type of patients are coming to the BTS? Young, intelligent, chaotic lifestyle, relationship problems. High level of personal trauma and/or sexual abuse Highly dissocial, perverse functioning, often male. Mature borderline, chronic MH user. Dual diagnosis. Training Initiatives : Training Initiatives An information/consultative resource Supervision/consultation Training of SPRs and SSHOs Multi disciplinary workshops Viewed assessment Viewed groups Lectures, seminars, training days and publications A proposal for level A,B, C training and education (MA in “The Management of People with BPD”) The Borderline Treatment ServiceRegional Department of Psychotherapy Newcastle : The Borderline Treatment ServiceRegional Department of Psychotherapy Newcastle CSA GROUP SLOW OPEN BPD PATIENT AUDIT ASSESSMENT SPECIALIST IN-HOUSE TRAINING FOR SHO, REGISTRAR & SpR IN PSYCHIATRY/ PSYCHOTHERAPY DISSOCIAL GROUP THERAPY REFLECTIVE BORDERLINE GROUP THERAPY SLOW OPEN ANALYTIC BORDERLINE GROUP INDIVIDUAL PSYCHOTHERAPY ANALYTIC SUPPORTIVE OUTCOME AUDIT SUPERVISORY WORKSHOP 1 PELE TOWER HOUSING PROJECT DIPLOMA/MA IN THE MANAGEMENT OF BPD SUPERVISORY WORKSHOP 2 PRIMARY CARE LIAISON PROJECT General features of management : General features of management Assessment -symptom -interpersonal functioning -social functioning -inner experience Consistency Constancy (team size) Risk assessment The Treatment : The Treatment Well structured Effort to enhance compliance Clear focus Relatively long term Encourage powerful attachment Well integrated with other services Pragmatic and flexible Is Hospitalisation helpful? : Is Hospitalisation helpful? Crisis intervention Co-morbid psychiatric disorders Chaotic behaviour Stabilising medication Reviewing diagnosis/treatment plan Full risk assessment Psychopharmacology of BPD : Psychopharmacology of BPD Empirical support for low dose neuroleptics in acute management in all three symptom domains – Affective dysregulation Cognitive – perceptual symptoms Impulsive – behavioural dyscontrol and interpersonal psychopatholgy. Target symptoms : Target symptoms Schizotypal symptoms. Psychoticism Anger and hositlity. Maintenance Treatment. : Maintenance Treatment. Dependent on compliance. Some support for prophylaxis against the vulnerability to cognitive – perceptual distortions, anger and impulse aggression (link to suicidalality). Antidepressants. : Antidepressants. Prominence of depressed mood and affective lability in the core pathology. Support for MAOI – atypical symptoms, hostile depression and impulsiveity. Some opt for SSRI – empirical support for anger, depressed mood and impulse aggression. The biology of depression might be different. The apparent independence of antidepressant effect in co-morbid diagnosis. Anticonvusants. : Anticonvusants. Brief reactive episodes of rage, affective and behavioural dyscontrol, transient perceptual distortions, depersonalised and derealised states resembling temporal lobe epileptic states. CBZ – useful for behavioural dyscontrol (affective and impulsive presentations). Lithium : Lithium Mood lability. Impulsive –aggression Lacking empirical data. Anxiolytics : Anxiolytics Anxiety is common – often acute and reactive with clear interpersonal stressors. Rapid acting BDZ Lack of trials. Disinhibition a problem. DH Scoping Study : DH Scoping Study Questionnaire 2002 to Trusts. 17% Trusts have dedicated PD service 40% some level of service 28% no identified service ie. Not core business. Guidance points : Guidance points All Trusts delivering GMH services need to consider how to meet the needs of patients with a personality disorder who experience significant distress or difficulty Trusts will need to consider: -the development of a specialist multi-disciplinary personality disorder team -the development of specialist day services in areas of high concentrations of morbidity (DoH, 2003) Why Is the National Guidance So Important? : Why Is the National Guidance So Important? Recognises the need of marginalised group. Treatment of PD becomes legitimate part of business of MH services. People who experience significant distress or difficulty as a result of PD will be able to access care through MH services. Why Is the National Guidance So Important? (contd) : Why Is the National Guidance So Important? (contd) Offenders with PD will be the responsibility of the forensic services. First ever national statement of intent…built on positive practice. “Helpful” characteristics of services… Guiding Principles for Service Models : Guiding Principles for Service Models Multidisciplinary input Led by clinicians with appropriate training and expertise Service organisation and delivery sensitive to differences in morbidity and geography Triggers for referral to specialist services depend on severity of PD and capacity of less specialised service Current evidence discourages prescriptive statement about types of treatment for PD Service Models. : Service Models. Sole practitioner. -less severe cases -specific problems Divided function. -’clinical shotgun wedding’ -CPA Specialist Teams -trained skilled practitioner -skill share model The Specialist Team Model : The Specialist Team Model A trained clinician with expertise in the management of BPD Integrated service Coordinated Good peer support and supervision Composition of staff can be balanced with good generic skill mix Team holds responsibility and shares risk management including assessment (CPA) Use of coherent, flexible approach with grounding in psychoanalytic technique The potential for developing training and education across Trust/region Features of the ‘Specialist Team’ : Features of the ‘Specialist Team’ Assessment and treatment in line with the care programme approach. Develop links with local district MH services and forensic services. Provide consultation, support, supervision and training for generic staff. Develop a self-help network and engage with user/carer groups. Set up out of hours/crisis arrangements. Role, identity and function of BTS and SPDT : Role, identity and function of BTS and SPDT BTS: expertise working with complex cases and training of clinical leads (level C) The SPDT: generically trained..provide a multi-disciplinary approach SPDT: train levels A and B staff (hub and spoke) Close and reciprocal link between BTS and SPDT SPDT housed in a day service The Borderline Treatment ServiceRegional Department of Psychotherapy Newcastle : The Borderline Treatment ServiceRegional Department of Psychotherapy Newcastle CSA GROUP SLOW OPEN BPD PATIENT AUDIT ASSESSMENT SPECIALIST IN-HOUSE TRAINING FOR SHO, REGISTRAR & SpR IN PSYCHIATRY/ PSYCHOTHERAPY DISSOCIAL GROUP THERAPY REFLECTIVE BORDERLINE GROUP THERAPY SLOW OPEN ANALYTIC BORDERLINE GROUP INDIVIDUAL PSYCHOTHERAPY ANALYTIC SUPPORTIVE OUTCOME AUDIT SUPERVISORY WORKSHOP 1 PELE TOWER HOUSING PROJECT DIPLOMA/MA IN THE MANAGEMENT OF BPD SUPERVISORY WORKSHOP 2 PRIMARY CARE LIAISON PROJECT Specialist PD Team : Specialist PD Team Experienced multi-disciplinary professionals in the management of PD Coherent theoretical approach Integration of multi-models of care Pragmatic Assertive CPA Function of the SPDT : Function of the SPDT Service delivery to patients with high distress and complexity Day service Long term, intensive approach CPA Generic therapeutic approach Culture for users and carers Self-help networks Day Service: a building… : Day Service: a building… Therapeutic space Training resource Multi-agency staff attachments Base for out of hours management/crisis intervention Post-treatment outpatient follow-up Audit and Research Locality Networks : Locality Networks Multidisciplinary, multi-agency Existing local CMHT and primary care staff Continuation of existing work with mental health problems but not taking on direct clinical responsibility for assessment and management of PD cases. Clinical remit to field referrals into the SPDT Support training to level A and B. Integration v. Fragmentation? : Integration v. Fragmentation? What is our model? Well communicated. Coherent. Joined-up. Quality of care. Puts users/carers at the front of policy. Can be reviewed by the trust policy for clinical governance. Forms of Integration. : Forms of Integration. Technical eclecticism - selecting best interventions or combination to tx person. Need to consider integration of personality. Theoretical integration - synthesis of different approaches and theories underlying them. Difficult, but the concept of self and other (object relations) may be common. Common factor approach - different forms of therapy are equally effective. Search for change mechanisms common to all. Common factors… : Common factors… Relationships and supportive factors arising from the therapeutic relationship. Technical factors - opportunity to learn and test out new skills. Evidence-based treatments ought to seek to maximise the effects of common factors. Principles that have implications for treatments. : Principles that have implications for treatments. 1. PD involves multiple domains of psychopathology. 2. PD involves core features common to all cases and all forms of disorder and specific features observed in some cases. 3. PD is a biopsychological condition with complex biological and psychosocial etiology. 4. Psychosocial adversity influences the organisation of the persoanlity. Implications for treatment. : Implications for treatment. Core feature - chronic interpersonal problems and self-pathlogy. So difficulties - establishing a treatment alliance and a collaborative working relationship. Adhering to the frame. Maintaining a consistent therapeutic process. The biological contribution to treatment. : The biological contribution to treatment. Both biological and psychological interventions may have a role in ind cases. Biological and developmental factors may place a limit to how much change can be achieved. Major goal of treatment is to enhance adaptation. Role of trauma in interventions. : Role of trauma in interventions. Treatments should incorporate strategies to address the consequence of trauma. Cognitive approach that only look at the trauma is likely to be insufficient. Add, supportive and validating experience. A Framework for Understanding Change. : A Framework for Understanding Change. Psychoanalysis - emphasis on clarification, confrontation and interpretation of the free association and working through in the transference. Cognitive - collaborative empiricism and more didactic. Cognitive-analytical - engagement in a collaborative description = conversational elaboration. Process of Change. : Process of Change. What are the steps through which change occurs? Consider addictive behaviours - Prochaska and DiClemente 1. Preconception. 2. Contemplation. 3. Preparation. 4. Action. 5. Maintenance. 6. Termination. Framework for expected changes : Framework for expected changes Problem recognition. : Problem recognition. Use supportive confrontation that raises doubt in patients’ mind about their denial. If done too soon, danger that the therapist is seen as critical or not understanding. Emphasis on the observation and description of the behaviour. Exploration. : Exploration. Encourage self exploration and to be collaborative. Difficult as both might view the behaviour in a model that frames it as arising without cause, spontaneously or biologically. Therapist’s challenge is also to have an open mind. Key component - recognise patterns of their behaviour and experience. Thus a sense of stability and consistency. Reframing. : Reframing. A second key area - reframe the meaning and explanation attributed to experience. Recognise that behaviour patterns are repeated. Psychoanalysis links this themes that arise from their lives and archaic structures. Promote self observation. Identify maintenance factors. Interpreting defenses that are obstacles to exploration. A more confrontational style (brief work) = anxiety provoking = poor tolerance. With disorganised borderlines this can lead to increased chaotic behaviours. Alternative behaviours and how to maintain. : Alternative behaviours and how to maintain. Change has attitudinal and behvioural components. Attitudinal component = fear of change. Behavioural component = new responses and inhibit the old. Patterns are often maintained by repetitive interactions with others that consolidate. Time is therefore required to change. New behaviours ought to become habitual patterns of action. The organisation. : The organisation. Partnership working. Integration, cohesiveness and coherence can be mirrored.

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