1. Structuring Treatment and Services for People with Personality Disorder Dr Tim Agnew, Consultant Psychiatrist for NHS Highland Personality Disorder Service.

2. Overview Tiers of service provision Phases of treatment Stages of change

3. Phase-based Treatment of PD Phases of treatment Some examples from Highland Discussion

4. A phase-based approach

5. 1a. Safety: –Interventions to ensure the safety of the patient and others 1b. Containment: –Interventions based primarily on general therapeutic strategies to contain behavioural and affective instability. May be supplemented with medication if appropriate. 1c. Control and regulation: –Interventions to reduce symptoms and improve self- regulation of affects and impulses eg behavioural, cognitive and pharmacological.

6. A phase-based approach 2. Exploration and change: –Interventions to change the cognitive, affective and situational factors contributing to problem behaviours eg cognitive, behavioural, psychodynamic and interpersonal. 3. Integration and synthesis: –Interventions designed to address core pathology and forge a new sense of self along with more integrated and adaptive interpersonal systems.

7. Focus of interventions

8. Phase 1: Behavioural Stabilisation Changes to DBT service Introduction of STEPPS (Most mental health services!)

9. Tiers of service provision

10. STEPPS October 2011 - Introduction of STEPPS to CMHTs Systems Training for Emotional Predictability and Problem Solving Tier 2 service

11. Changes to DBT service Referral system changed to address some of the problems of the old system and allow appropriate focus of limited DBT resource

12. Changes to DBT service No longer traditional referral-waiting list set-up Each sector allocated places on program When the place is soon to become available (within 8-12 weeks), community services are informed Asked to identify and refer the patient most in need of DBT for the sector

13. Changes to DBT service CPA now a requirement before patient seen for pre-treatment –Ensures a clear, regularly reviewed, comprehensive treatment plan including more than DBT alone –Formalises patient’s role in their own care –Assists effective transition from DBT to future treatment phases

14. Changes to DBT service DBT therapists will attend CPA review Present to support the patient to interact in the most effective manner with their care team Not simply giving information which the patient is equally well, or better placed, to provide

15. Phase 2: Exploration and change Trauma reprocessing as a Phase 2 intervention Psychological Trauma Service Development (PTSD) Group Aims of PTSD Group

16. Promote awareness, identification and treatment of trauma-related conditions and the supporting of education of the workforce towards these aims Development towards a trauma-informed service Development of specialist trauma services Identification of existing services for all phases of trauma work Identification of pathways and links between these services and people

17. Day Service for people with Personality Disorder Phase 2: Exploration and change Phase 3: Integration and synthesis

18. Who is it for? Any person with personality disorder (not only borderline) of 18yrs plus Need to be sufficiently behaviourally stable

19. Who is it not for? People who do not have a personality disorder People with risk issues that would preclude safely working in community environment People with factors which would preclude working in a cognitive and behavioural way

20. How is it accessed? Referrals from Mental Health Services Referral to be completed with, and signed off by, the service user PDQ-4 to be completed by the service user

21. Summary Phase 1: Behavioural stabilisation –Safety –Containment –Regulation and Control Phase 2: Exploration and change Phase 3: Integration and synthesis

22. Summary Phase 1 (Behavioural Stabilisation) –Changes to DBT service (Tier 3) –STEPPS (Tier 2) Phase 2 (Exploration and change) –Trauma services development –Day Service (Tier 3) Phase 3 (Integration and synthesis) –Day Service (Tier 3)

23. What next? Tier 1 –Education and awareness Tier 2 –Education and awareness –Consultation/ liaison Tier 3 –Early intervention/ CAMHS transitions

24. Thank you Discussion and questions