Transcript Slide 1

National Scottish Personality
Disorder Network, 27 March 2014
“Meeting Needs” – Developing a
holistic response for women
Linda Irvine and Dr Patricia Graham
In this presentation
Share our thoughts on developing a matched
care model for women in Lothian





What are we building on
Shared Values Base
Core components
Which therapy?
Next steps
What are we building
upon?
Looking backwards
Lothian Psychological Interventions Network
 2006
Taking Away the Mystery
 2008
Relating and Relationships
 2009
Making a difference
 2010
Thinking about Trauma
 2011
Beyond diagnosis
Establishment of Service User led Research Project
 2011
Delivering DBT: Staff Seminar
 2013
DBT Training
Launch of Lothian Institute for Psychological Knowledge and Practice

2014
Thinking About Trauma Diagnostic Criteria : helping or
hindering the clinician

Matched Care Model for Women
Policy Context





Lothian’s Joint Strategy for Mental Health and
Wellbeing – “A Sense of Belonging”
National Mental Health Strategy
Women’s Offenders Commission and
Government response to this
Scotland’s Strategy to Address Violence
Against Women and Girls – recently
consulted upon
Increasing focus on the impact of trauma
Shared Values Base
Unhelpful features for personality disorder services
(Haigh, 2008)









Availability determined by
postcode
Office hours only
Lack of continuity of staff
Staff without appropriate training
Treatment decided only by
funding/ availability/ diagnosis
Inability to fulfil promises made
Critical of expressed needs (e.g.
crisis or respite)
Staff respond only to behaviour
Staff not interested in causes of
behaviour







Dismissive or pessimistic
attitudes
Rigid adherence to a therapeutic
model in cases where it
becomes unhelpful
Passing on information without
knowing the person
Long-term admissions
Use of physical restraint and
obstructive levels of observation
Inappropriate, automatic or
forcible use of medication
Withdrawal of conduct used as
sanction
What service users want










Early intervention before crisis point
Specialist services , not part of
general services
Choices form a range of treatment
options
Therapeutic optimism and high
expectation
Develop patients' skills
Fosters use of creativity
Respects strengths and
weaknesses
Good, clear communication
Accepting, reliable, consistent
Clear and negotiated treatment
contracts









Focus on education and personal
development
Good assuagement / treatment link
Conducive environment
Listens to feedback and strong
voice of service users
Supportive peer networks
Shared understanding of boundaries
Appropriate follow-up and
continuing care
Involves patients as experts
Atmosphere of “trust and truth”
Much More Than a Label






A service user-led project which aims to promote better
understanding and support for people who have lived
experience of personality disorder diagnosis
“The fact that there is a project means that someone
cares about what happens to us”
Personal experience and narratives
Art
Poetry
Film
Co-produced and co-delivered training
What is the Resource?
About Personality
Disorder BY people
with lived
experience of a
personality disorder
diagnosis
Core Values
(The Consortium of Therapeutic Communities)





Relationships
Understanding how you relate to others and how others relate to you
leads to better intimate, family, social and working relationships.
Participation
Ability to influence one's environment and relationships is necessary for
personal well-being. Being involved in decision-making is required for
shared participation, responsibility, and ownership.
Process
There is not always a right answer and it is often useful for individuals,
groups and larger organisations to reflect rather than act immediately.
Balance
Positive and negative experiences are necessary for healthy
development of individuals, groups and the community.
Responsibility
Each individual has responsibility to the group, and the group in turn
has collective responsibility to all individuals in it.





Attachment
Healthy attachment is a developmental requirement for all human
beings, and should be seen as a basic human right.
Containment
A safe and supportive environment is required for an individual to
develop, to grow, or to change.
Respect
People need to feel respected and valued by others to be
healthy. Everybody is unique and nobody should be defined or
described by their problems alone.
Communication
All behaviour has meaning and represents communication which
deserves understanding.
Interdependence
Personal well-being arises from one's ability to develop
relationships which recognise mutual need.
Core components
Definitions




Main way of conceptualising their difficulties
Whole person with all their presenting problems needs to be
formulated in a way in which intervention can begin at whatever
point is possible and considered likely to be useful to the
individual themselves and the profession not separate from
other mental health problems identified but influences and is
influenced by all of these experiences
Flexible enough to fit local circumstances – appropriate model
without being over prescriptive
Evidence is constantly growing boundaries and integration with
other services
Tier 5
Residential Unit and Day Programme
Tertiary Referral
Tier 5
Tier 4
Inpatient and Specialist
Services including
Willow
Education
and liaison
Tier 3
Mental Health Services and A & E departments
including CMHTs; MHAS, IHTTs
Tier 2
Primary Health Care; including unscheduled care and out of
hours provision.
Tier 1
Communities and Local Neighbourhoods
Open Access Community based support groups for women
Third Sector Services including Women Supporting Women, Another Way;
Tier 0
Raising Public Awareness
Raising the level of knowledge of personality disorders and what can help and hinder. Key Partner:
CAPS - More than a Label and Carers Council
Increasing
intensity
&
specialism
Education, Training, Skills and Supervision






Supporters / Carers Training
Professionals
“Much more than a label” delivered by LEARN
Emergency and Crisis Presentations – Crisis Centre;
Mental Health Assessment Service; A & E Department
Specific skills
Reflective practice and supervision
Service User Network



Peer support
Independent advocacy
Collective advocacy
Third Sector Provision




Another Way
Women Supporting Women
Rape Crisis
Follow Me
New Components

Day Programme
Co-located

Inpatient Unit
Multi-professional team







Clinical Psychology
Art Therapy
Nursing
Psychiatry
Occupational Therapy
Social Work
Links to employment; housing; Children and
Families services; welfare
Which Therapy?
IPT
MI
CBT
CCBT
DBT
IPSTR
EMDR
BFT
CBASP
MBT
STEPPS
IPT
CAT
Common features of effective
psychological interventions (Batemen and Tyrer)







Tend to be well structured
Devote effort to collaboration and engagement
Clear focus ay an aspect of interpersonal relationships or a
problem behaviour
Various elements of treatment fit together in a way that is
understood by the patient and therapist
Relatively long term
Encourage a powerful attachment relationship between the
therapist and patient enabling the therapist to adopt a relatively
active stance
Tend to be well integrated with other services available to the
patient
Individual and group Therapies – in different
settings by different teams







A&E
General Mental Health Teams
Substance Misuse Services
Rivers Centre
Psychodynamic Psychotherapy;
Cullen Centre
Dialectical Behaviour Therapy; mentalisation;
interpersonal therapy; psychodynamic
psychotherapy; schema focused CBT; interpersonal
therapy
Re:D Collaborative
If we were able to re-orientate the criminal justice
system to focus on reducing reoffending behaviour
by understanding the motivations for offending,
which often stem from a complex mix of personal
experience and circumstances, mental health
conditions, drug and alcohol abuse and peer
influence, would this begin to lessen the health
inequalities experienced by a significant part of
Scottish society?”
Work to date








Community of Practice event lead to Re:D Collaborative
Film and narrative book produced detailing people’s lived
experience.
Leith Peer Programme
Funding for establishment of Community Justice Centre Hub
and spoke model covering Lothian and Borders
Explore opportunities to pilot a problem solving summary
criminal court
Pilot the use of Interpersonal Psychotherapy with women
who are committing low tariff offences
Enhance the psychological mindedness of staff working
in prison settings
Improving the care, treatment and support of women who
may have attracted a diagnosis of personality disorders
in prison settings
Evidence base and rationale






Very limited evidence base regarding interventions
Johnson and colleagues at Brown University
completed 3 studies using IPT with depressed,
substance using female prisoners
She delivered 24 sessions of group IPT over 8
weeks
All of the studies demonstrated a significant
reduction in depressive symptoms
Women’s feedback on intervention was very positive
IPT is relational, focuses on roles, accessible
Re:D IPT at Willow





In collaboration with John Markowitz and Jennifer Johnson
developed “real world” trial protocol
12 sessions of IPT aimed at treating depression in women
in CJS with multiple co-morbidities
Targeting women at an early stage in the criminal justice
system
Pro-active engagement and safety planning added to the
original model
Broad range of measures including: depression; anxiety;
PD; offending; trauma; life events; attachment; substance
use; engagement with services and community
Working with women in prison
proposal




HMP Edinburgh and HMP Cornton Vale
3 strands:
 Staff training on mental health awareness, PD
with trauma/attachment slant, MBT skills
 MBT-i groups for women with BPD
 IPT-G for depressed women
Pilot aiming to start 1st April 2014 and run until 31
March 2016
Evaluating three strands mix of quantitative and
qualitative methodologies
Next steps
Learning
 Positive and Hopeful Attitudes go Long Way

Issues around Labels and Language

Reliable, Useful Information

Well-informed and supported staff
Relationships
 Personal relationships a critical aspect of a service not
something to be fearful of
 Relationship Centered Provision
 Developing our thinking
 Finding the right physical environment
 Governance agreement
 A timeline for delivery
We continue to shape our
personality all our life
Albert Camus