RECENT DEVELOPMENTS IN THE NHS HIGHLAND

PERSONALITY DISORDER SERVICE

Dr Tim Agnew Rita JohnsonConsultant Psychiatrist Expert by Experience

and Psychotherapist

Michelle Vroon Denise EadieExpert by Experience Occupational Therapy

Lead in Mental Health

Introduction

NHSH Personality Disorder Service NHSH Services for people with

personality disorder People with personality disorder in

services NHSH Personality Disorder Integrated

Care Pathway (PD-ICP)

Personality Disorder ICP

Introduction General Principles Assessment, Diagnosis and Formulation Self-management Crisis Management Psychosocial Interventions Medication Education and Awareness Consultation Community Personality Disorder Service In-patient Settings

General Principles

Recovery Stages of change Phase-based

approach Matched care

General strategies1. Collaboration2. Consistency3. Motivation4. Validation5. Self-

management

Phases of treatment

Phase 1Safety &

Stabilisation

(Present)

Phase 2Exploration & Change

(Past)

Phase 3Integration

& Synthesis(Future)

• safety, containment and promotion of self-regulation and control.

• Interventions with this focus include STEPPS and DBT.

• to identify and make changes to the factors which underlie the unhelpful behaviours. i.e. dealing with the effects of trauma and dissociation; treating self and interpersonal problems; and treating maladaptive traits.

• Interventions include trauma-focused CBT, EMDR and DBT-PE.• to promote a more integrated sense of self and a

healthier interpersonal environment –new leisure activities, occupational/educational activities, new roles and relationships.

• Interventions include Vocational Rehabilitation and the CAS Day Service.

1. Collaboration

Within Treatment

Service Developmen

t

Goal-setting

Volunteer Post

DBT Skills

Materials

Leaflets

AwarenessTraining

Steering Group

ICP

Decision-making

Assessment

Collaboration - It’s a learning process!

Confidence

Motivati

on

Change

Talk New Skills

Collaboration - It’s a learning process!

Anxiety

Doubt Buy-

In

2. Consistency

CONSISTENCY

CONSISTENCY

CONSISTENCY

PD-ICP

PD-ICP

PD-ICP

PD-ICP

Single Point of Access

Assessment

PD-ICPPhase-based

Approach

3. Motivation

Staff Training Understanding Co-production DBT consult

group Formulation

Clients Stages of change Skills deficit or

motivational deficit?

Empowerment Formulation Peer support

4. Validation

Assessment Formulation Treatment Plan Steering Group Validation training

6 Levels of validation NHSH Mental Health Conference Inverness Women’s Aid Train trainers in future?

1. Be 2. Reflect 3. Mind 4. Link 5. Normalise 6. RadicalPresent Back Read History Genuineness

5. Self-management

Underpins everything else

DIALECTICAL BEHAVIOURAL

THERAPY

COPING & SUCCEEDIN

G DAY SERVICE

PERSONAL RESPONSIBILIT

Y

LOCAL COMMUNIT

Y SUPPORTS

ABILITY TO INFLUENCE

IMPROVED UNDERSTANDING &

INFORMED CHOICES

CRISIS PLAN

ICP RESOURC

E LIST

Assessment, Diagnosis, Formulation

New single referral process for: Specialist assessment and treatment

recommendations Assessment for DBT Assessment for CAS Other

Evaluation of self-referral into CAS

Assessment, Diagnosis, Formulation

Standardised assessment Diagnosis and formulation Treatment recommendations

Phase-based, short-medium-long term plan

Standardised assessment training offered: PDS Braeside (Intensive Treatment Servicestaff Trainee psychiatrists

Assessment letter easily accessible in current casenotes

Facilitates future consultation

Crisis Management

Crisis self-management plan Crisis admission worksheet STORM training for junior doctors

Psychosocial Intervention Training

Introduction to trauma Safety and stabilisation Prolonged exposure STEPPS DBT-PE DBT Mentalizing based treatment skills

Psychosocial Interventions

Phase-based framework useful in structuring and sequencing psychosocial interventions

Challenge in “joining up” interventions as single treatment package

Medication

Prescribing agreement

Prazosin

Education and awareness

Community midwives GP Practices CMHTs Teaching sessions after quarterly PDS

meetings NHSH Mental Health Conference Creating Imaginative Learning

Education and awareness

Appropriate adult service Inverness Women’s Aid GP Protected Learning Time Police eModule Argyll and Bute wards and CMHTs Open to requests

Consultation

Interest in case discussion/consultation meetings

Community

Phase-based treatment recommendations: All interventions focused and time-limited Consistency and cohesion with everyone

working to same phase-based plan Ongoing opportunity for discussion

between PDS and CMHTs

Community

PDS keen to maintain and improve links with: STEPPS trainers CMHTs CAMHS

Keen to be involved as early as possible in the transition from CAMHS of young people with possible emergent personality disorder

Trauma services

Trauma stakeholders event in May 2015 Working to phase-based model Much common ground Keen to maintain and strengthen links to

other service providers

Personality Disorder ICP

Introduction General Principles Assessment, Diagnosis and Formulation Self-management Crisis Management Psychosocial Interventions Medication Education and Awareness Consultation Community Personality Disorder Service In-patient Settings

NHSH Personality Disorder ServiceWho are we?

1 WTE Consultant Psychiatrist 0.6 WTE Specialist MH Practitioner

(nurse) 0.2 WTE Specialist MH Practitioner (OT) 0.2 WTE MH Practitioner Secondment 0.4 WTE ST5 Psychiatrist (for 1 year) Plus 5 x 0.1 WTE DBT therapists (nurses) 0.2 WTE CAS Day Service Volunteer

Personality Disorder Service – what do we offer?

Assessment and treatment recommendations

DBT DBT-PE CAS Day Service Education and

awareness Very limited capacity for

joint case management Consultation

General diagnostic service

Trauma work outwith DBT

Sole case management or RMO role

Our Experiences

Michelle

DBT

&

On Wards

Personality Disorder Service – what do we offer?

Assessment and treatment recommendations

DBT DBT-PE

CAS Day Service Education and awareness Very limited capacity for

joint case management Consultation

General diagnostic service

Trauma work outwith DBT

Sole case management or RMO role

Coping & Succeeding Day Service (CAS)

Core Activities (4 week Modules)

• Physical Health & Well-Being• Living Skills

• Self-Management• Vocational Activities

Individual Goal Setting Non-Core

Activities• Crafts• Interests• Hobbies• Trying New

Things• Sharing skills

Morning & Afternoon Meetings

Allocation of Roles

• Chair• Minutes• Observer• Housekeeper• Creating Agenda• Group Governance

Group Members

CAS Volunteer

NHS Staff

Stakeholders

Visitors

Our Experiences

Rita

CAS

&

On Wards

Personality Disorder Service – what do we offer?

Assessment and treatment recommendations

DBT DBT-PE CAS Day Service Education and

awareness Very limited capacity for

joint case management Consultation

General diagnostic service

Trauma work outwith DBT

Sole case management or RMO role

Personality Disorder ICP

Introduction General Principles Assessment, Diagnosis and Formulation Self-management Crisis Management Psychosocial Interventions Medication Education and Awareness Consultation Community Personality Disorder Service In-patient Settings

Inpatient settings

Crisis admission worksheet Ward staff training

Any comments?

Introduction General Principles Assessment, Diagnosis

and Formulation Self-management Crisis Management Psychosocial

Interventions Medication Education and Awareness Consultation Community Personality Disorder

Service In-patient Settings