Dr Wilhelm Skogstad, Consultant Psychiatrist in Psychotherapy Amanda MacKenzie, Senior Nurse

1. From high dependency to self-responsibilityThe 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 HospitalSpecialist 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, 493-509.

11. Changes in global functioning

12. Change in social adaptation

13. Parasuicidal Behaviour

14. Hospitalisation

15. 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 Work on patients’ transitions

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. NHS or Private SectorAcute Unit NHS or Private Sector Low/Medium Secure Unit Pathways through the Cassel Psychosocial Assessment at the Cassel Residential treatment at the Cassel Joint work by Cassel and local services Intensive Community care - Revolving door 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. 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 New Treatment Model

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. IN 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 Current Model 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: 259-267. • 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 1463-1470. • 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 493-509. • 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: 157-175. • 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: 195-215. • 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 59-73. • 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 97-118.