1. Cassel Hospital Specialist Personality Disorder Service
From high dependency to self-responsibility The changing treatment model provided at the Cassel Hospital specialist inpatient and outreach service
Dr Wilhelm Skogstad, Consultant Psychiatrist in Psychotherapy
Amanda MacKenzie, Senior Nurse
Julia Blazdell, Expert by Experience
Lesley Day, Head of Service
Cassel Hospital Specialist Personality Disorder Service

2. Cassel Hospital Specialist Personality Disorder Service
Psychotherapeutic and psychosocial inpatient, day patient and outpatient treatment for people with severe personality disorders and complex needs

3. The Cassel - traditional and …

4. The Cassel - … modern

5. Traditional Model (1)
Inpatient
Treatment

6. Traditional Model (2)
Therapeutic
Community
Individual
Psychotherapy

7. Intermediate Model Inpatient Treatment Step-down Inpatient Treatment
6 months
Inpatient
Treatment
12 months
Outreach
Treatment
24 months

8. Cassel Research (M Chiesa et al)
One stage programme
12 months inpatient treatment at the Cassel
No follow-up treatment from the Cassel
Step-down programme
6 months inpatient treatment at the Cassel
2 years outreach treatment: 2/wk group psychotherapy + psychosocial outreach nursing + working with local services
Treatment as usual
General psychiatric care and management,with hospital admissions, community support, psychotropic medication etc.

9. Change in number of symptoms

10. Change in symptom severity
Chiesa et al. (2006). Six-year follow-up of three treatment programs to personality disorder Journal of Personality Disorders, 25,

11. Changes in global functioning

12. Change in social adaptation

13. Parasuicidal Behaviour

14. Hospitalisation

15. Work on patients’ transitions
Joint work with professionals and patient towards admission
Written information for patients
Pre-admission day visits to the Cassel
Pre-admission planning meetings
Buddy system for new patients
Special structures for new patients
Long anticipation of leaving
Transition phase with shorter weeks or as day patient
Working towards discharge with patient and local service
Consulting to local professionals
Setting up treatment and support for after discharge

16. Working with local services
Liaison with local professionals prior to referral
Working jointly with professionals and patient towards admission
Pre-admission planning meetings
Treatment reviews
CPA meetings
Frequent contact with local professionals to update and discuss
Joint work towards discharge back to local services
Pre-discharge planning meetings
Follow-up meetings with patient and/or professionals

17. Pathways through the Cassel
Intensive Community care - Revolving door
NHS or Private Sector Acute Unit
NHS or Private Sector Low/Medium
Secure Unit
Psychosocial Assessment at the Cassel
Residential treatment
at the Cassel
Joint work
by Cassel and local services
Transitional phase
e.g. shorter weeks, day patient - involving local services
Cassel Outreach
in cooperation with local services
Outpatient treatment through local services

18. Cassel Multidisciplinary Team

19. New Treatment Model Psychosocial Practice Psychotherapy
Community meetings
Work Groups
Physical and Social Activities
Special Interest Groups
Parents Group
Psychosocial Education
Community Management Meeting
Psychotherapy
Individual psychotherapy
Group Psychotherapy
Dance Movement Therapy
Couples/ Family sessions
MDT staff meetings.
Planning meetings
Reviews
CPA/ Professionals
Reflective practice
Supervision Groups

20. Why specialist residential treatment?
Significant risk (self-harm, suicide) - not manageable as outpatient
Long hospital admissions with failure to discharge/revolving door
Step-down from more secure setting
Local treatment resources exhausted
Change only possible through intensive treatment
No local specialist treatment available
Treatment only possible away from home

21. Current Model Psychosocial Practice Psychotherapy IN OUT CAMHS, CMHT/
Family/Carers/ Friends/ Psychiatric
Forensic Services (wards)
Shared living-learning Environment
‘Alongside’ rather than ‘for’ the patient
Psychosocial Practice
Community meetings
Work Groups
Physical and Social Activities
Special Interest Groups
Parents Group
Psychosocial Education
Community Management Meeting
Psychotherapy
Individual psychotherapy
Group Psychotherapy
Dance Movement Therapy
Couples/ Family sessions
MDT staff meetings.
Planning meetings
Reviews
CPA/ Professionals
Reflective practice
Supervision Groups
Family/carers/ friends,
Voluntary sector,
CMHT, Outreach
OUT

22. The process of change Relationships as central focus
Helping develop an internal container through an external container
Linking ‘understanding’ and ‘doing’
Fostering responsibility for themselves and others
Enabling supportive relationships between patients
Dealing with self-harm in a holistic way: challenging + understanding and support + emphasis on relationships (impact on others)
Taking measured risks: tolerating anxiety
Team work: bringing split-off aspects together in the staff team

23. References
Chiesa, M. (2000) Hospital adjustment in personality disorder patients admitted to a therapeutic community milieu. British Journal of Medical Psychology 73:
Chiesa, M., Fonagy, P., Holmes, J. & Drahorad, C. (2004) Residential versus community treatment of personality disorders; a comparative study of three treatment programs. American Journal of Psychiatry, 161(8), pp
Chiesa, M., Fonagy, P. & Holmes, J. (2006) Six-year follow-up of three treatment programs to personality disorder. Journal of Personality Disorders, 20(5), pp
Chiesa, M. & Healy, K. (2009) The struggle to establish a research culture in the psychotherapy hospital: Reflections from the Cassel Hospital experience. Bulletin of the Menninger Clinic 73, 3:
Day. L. & Flynn, D. (Eds) (2003) The internal and external worlds of children and adolescents; collaborative therapeutic care (Cassel Hospital Monograph Series No. 3 ) London: Karnac
Drahorad, C (1999) Reflections on being a patient in a therapeutic community. Therapeutic Communities, 20, 3:
Griffiths, P. & Pringle, P. (Eds) (1997) Psychosocial practice within a psychosocial setting (Cassel Hospital Monograph Series No. 1), Karnac Books, London
Hinshelwood, R. D. & Skogstad, W. (1998) The hospital in mind; the setting and the internal world. In: Pestalozzi, J. et al. (Eds) Psychoanalytic psychotherapy in institutional settings, London: Karnac pp
Skogstad, W. (2003) Internal and external reality in in-patient psychotherapy; working with severely disturbed patients at the Cassel Hospital. Psychoanalytic Psychotherapy, 17 (2), pp