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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
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)