RECENT DEVELOPMENTS IN THE NHS HIGHLAND PERSONALITY DISORDER SERVICE Dr Tim AgnewRita Johnson Consultant Psychiatrist Expert by Experience and Psychotherapist Michelle VroonDenise Eadie Expert 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 strategies 1. Collaboration 2. Consistency 3. Motivation 4. Validation 5. Self-management

Phases of treatment Phase 1 Safety & Stabilisation (Present) Phase 2 Exploration & Change (Past) Phase 3 Integration & 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 Development Goal- setting Volunteer Post DBT Skills Materials Leaflets Awareness Training Steering Group ICP Decision- making Assessment

Collaboration - It’s a learning process!

2. Consistency CONSISTENCY PD-ICP Single Point of Access Assessment PD-ICP Phase-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. Radical Present Back Read History Genuineness

5. Self-management  Underpins everything else

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 Service Who 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