From Containment to Care …. and to Treatment: High Secure Services For

Patients with Personality Disorder

Dr Gopi Krishnan, Clinical Director&

Dr Sue Evershed, Lead Psychologist

Gopi.krishnan@nottshc.nhs.uk Sue.evershed@nottshc.nhs.uk

HISTORICAL CONTEXTPOLITICAL/INSTITUTIONAL DYNAMICS

HUMBLE BEGINNINGS

1994

1 WARD SHSA

EXPANSION

1996

3 WARDS DEMAND

2000 6 WARDS

+ ASHWORTH

CATCHMENT AREA

PD/LD/MI

INTEGRATION

2002

ONWARDS

7 WARDS TRANSFER OF

ASHWORTH PATIENTS

CURRENT STRUCTURE

MDT working• Ward based teams• Clinical training• Programme delivery• Supervision

Psychological treatmentpathway

Integrated programmedelivery & development

Sophisticated stafftraining pathway

Assessment8

TreatmentMain Building

14

TreatmentMain Building

12

TreatmentMain Building

14

TreatmentVilla16

TreatmentVilla16

Treatment Villa16

Referring Organisations Per Year.

0

5

10

15

20

25

30

35

40

45

1996 1997 1998 1999 2000 2001 2002 2003

Year of Referral

Nu

mb

er

of

Pati

en

ts

Prison

Court

Mental HealthInstitution

Number of Treated and Un-treated Discharges Between 1998 and 2002.

0

2

4

6

8

10

12

1996 1997 1998 1999 2000 2001 2002 2003

Year of Discharge

Nu

mb

er o

f P

atie

nts

Treated

Un-Treated

Died

CHALLENGES

• Development of DSPD

• Continuity and flexibility- absence of care pathways

* prison* msu

• 50% admissions unplanned

• Changes in patient characteristics

Based on Personality Disorder Traits.

• Taken from previous reports and files, during preadmission assessments.

• Any mention of traits such as:

• Impulsivity

• Egocentricity

• Unempathic for Others

• Were collated as Personality Disorder traits and added up to give a figure.

0

0.5

1

1.5

2

2.5

3

3.5

1996 1997 1998 1999 2000 2001 2002 2003

Year of Admission

Num

ber

of P

D T

raits

Based on Co-Morbidity.

0

1

2

3

4

5

6

7

8

9

1996 1997 1998 1999 2000 2001 2002 2003

Year of Admission

Aver

age

Num

ber o

f Axi

s 1

Diso

rder

s

• The number of mental health type problems were collated.

• Taken from previous reports and files, during preadmission assessments.

• Any mention of problems such as:

• Depression• Schizophrenia• Anxiety

• Were collated as mental health type problems and added up to give a figure.

Based on PCL-R Scores

0

5

10

15

20

25

30

35

1996 1997 1998 1999 2000 2001 2002 2003

Year of Admission

Aver

age

Ove

rall

Scor

e on

the

PCLR

• The PCL-R has a total score of 0 – 40.

• These scores are taken from a small sample size of patients from each year, and then averaged using the median.

Based on an Increased Risk of Sexual / Violent Offending.

• Assessment of risk of sexual recidivism.

• Assessment outcome codes as:

• 1 = Low• 2 = Medium• 3 = High

• The HCR-20 shows the risk of violent re-offending.

• The HCR-20 results show that the admissions have always been quite high – in the late 20’s early 30’s. However the range of scores are bigger in 1996 than in 2002.

• 1996: lowest score = 9 and highest score = 29.

• 2002 lowest score = 16 and highest = 30.

0

1

2

3

1996 1997 1998 1999 2000 2001 2002

Year of Admission

Mea

n SV

R Ri

sk

Based on Behavioural Presentations.

0123456789

10

1996 1997 1998 1999 2000 2001 2002 2003

Year of Admission

Num

ber o

f Beh

avio

urs

Taken from previous reports and files, duringpreadmission assessments.

Includes behaviours such as:

– Self Harm / Suicide Attempts

– Hostage Taking / Threats– Acts of Sexual / Physical

Violence

Were collated asProblematic behaviours andadded up to give a figure ofproblematic behaviouralpresentations.

Changes in Patient Profile

In Complexity• Based on diagnostic criteria.• Co-morbidity.• Behavioural presentations.

In Risk• An increase in median PCL-R score.• An increase in risk of sexual offending.• An increase in risk of violent offending.

Implications for the Directorate

• Need to address clinical complexityNeed to address clinical complexity

• Need to address riskNeed to address risk

• Emphasis on team work, supervision & trainingEmphasis on team work, supervision & training

• Continued development of an integrated treatment pathwayContinued development of an integrated treatment pathway

High Risk Patients

• Start early

• Criminal versatility

• Continuing offending patterns

• Antisocial & anti-authority

• Impulsive

• Poor social interaction

• Rewards for bad behaviour

Personality Disorder

• Poor developmental histories

• Disturbed relationships and lack of support

• Long-term problematic traits

• Across all areas of life

• Affects thinking styles, emotions, & social behaviour

• Patients average 3 or more PD “types”

• Different sets of traits different constellations of impairment

Need to Adapt Standard Treatments

Treatment “resistant”

Disrupt treatment

Drop out

Don’t apply learning

Therapy can make them worse – myths and realities

Failure can make them worse

Effects on staff

Treatment Adaptations

Motivational focus

Parallel individual sessions

Developing drop prevention plans and integrated coping skills

Sensitive and risky topics, e.g., SOTP

Long, frequent and paced programmes

Integrating into ward life

Linking personality issues to risk

Building positive lifestyle

Treatment Pathway

AIMS

• Motivate

• Reduce risk

• Build effective

living skills

Motivation & Engagement

Therapy interfering behaviours, thoughts and emotions

Beliefs in the rewards for maladaptive behaviours

No or limited skills to explore or understand own behaviours

Reduced faith in therapy

Stigmatisation & failure

Exclusion & betrayal

Replays & reinforces history of interpersonal experience

Treatments for PD

Assessment and address specific therapy interference

Expectation and planning for lapses

Motivational work

Dosage & pace

Therapeutic alliance

Ruptures as opportunities

Consistency in environment

PD traits as maladaptive coping strategies

(Bateman, 2003; Davison, 2003; Linehan,1993; Livesley,2001; Young,1999)

Reoffending / Risk

TARGET CRIMINOGENIC NEEDS

Antisocial attitudes

Problem solving, self control & prosocial skills

Peer associations & family issues

Substance misuse

Prosocial rewards for adaptive behaviour

Offence cycles and relapse prevention plans

Post discharge planning

Future Aspirations

• In reach and out reach development work with prisons and RSU’s

• Improved integration of therapy into the milieu

• Named nurse development programmes

• Multidisciplinary Clinical Supervision developments

• Developing therapeutic programme accreditation processes

• Sharing practice and research agendas through NIMHE regional development centres

• Practice based research initiatives

• Therapeutic adherence training in a range of interventions• Developing/implementing Good Lives Model (Ward et al,

2002)