1. A WARM Approach to emerging PD Kellyrose Gale, David Kingsley, Louise McKenna Rebecca Murphy Woodlands Unit The Priory Hospital Cheadle Royal WARM Approach (2015)

2. Context Poor evidence base for effective treatment in severe emerging Emotionally Unstable Personality Disorder in young people Risks often escalate in Acute Inpatient Units and they may get ‘stuck’ for months or even years making little progress In community settings, risks may be difficult to manage leading to multiple placements and limited change Often risk behaviours lead to high levels of arousal in staff who may over-protect or reject them. It is difficult to create an ‘emotionally safe’ context in which to treat these young people Past trauma often impacts on symptoms and attachments and makes therapeutic engagement more difficult

3. Defining the problem Inexperienced, inconsistent, poorly trained staff teams Difficult to hold several models in mind for varying client groups Staff who “don’t want to work with PDs” High incident rates / staff injuries / staff anxiety and turnover Reactive high-intensity ‘fire fighting’ approach Inpatient care may add to traumatic experiences for young people rather than treating them Cautious management leads to long periods of enhanced observations and ‘stuckness’ Young people aren’t going to engage in difficult long-term therapy if they think they might be discharged next week...

4. Woodlands Attachment Regulation Model Medication Positive Boundaries Adapted DBT / Trauma Work Promoting Healthy Attachments Resilience Secure Base Unconditional positive regard Therapeutic Risk Taking Planned admissions Trust & engagement Nurture Staff training Re- parenting Safety Hope Consistency

5. Effectiveness of WARM Incidents of violence and self-harm reduced in severity and frequency Outcome measures (HoNOSCA/ CGAS) Qualitative feedback – Young people / staff / parents & carers Lengths of stay (average 10 months) Discharge to community placements / home in most cases Engagement in therapeutic programme / intensive therapy Positive & effective coping strategies –DBT in practice not just in theory Able to reflect on impact of behaviour on self and others

6. Future Model Developments Collate the evidence for efficacy More detailed psychological assessment at admission and discharge Which aspects of the model are most effective? Which PD domains change the most and the least? How might our model be adapted for use in more generic / less secure / community settings Publication and Dissemination

7. Case Study 17 year old female with a history of significant overdose, suicide attempts, disruptive behaviours, aggression, non- engagement on previous units, violence towards staff and fellow young people. Prescribed enhanced observations continuously for 12 months on another unit prior to admission. Admitted for 10 months using the WARM approach. Discharged to community setting, applied for college course, voluntary work, ability to reflect, use of positive distraction techniques, ability to seek support appropriately.