From high dependency to selfresponsibility
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
Cassel Hospital
Specialist Personality Disorder Service
Psychotherapeutic and psychosocial
inpatient, day patient and outpatient
treatment for people with severe
personality disorders and complex needs
The Cassel - traditional and …
The Cassel - … modern
Traditional Model (1)
Inpatient
Treatment
Traditional Model (2)
Therapeutic
Community
Individual
Psychotherapy
Intermediate Model
Inpatient Treatment
Step-down
Inpatient
Treatment.
Inpatient
Treatment
6 months
12 months
Outreach
Treatment
24 months
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.
Change in number of symptoms
75
70
65
m
60
e
a
n 55
Inpatient
Step down
TAU
50
45
40
Intake
6 mo
12 mo
24 mo
72 mo
Change in symptom severity
2.2
2
1.8
m
1.6
e
a
n 1.4
Inpatient
Step down
TAU
1.2
1
0.8
Intake
6 mo
12 mo
24 mo
36 mo
72 mo
Chiesa et al. (2006). Six-year follow-up of three treatment programs to
personality disorder Journal of Personality Disorders, 25, 493-509.
Changes in global functioning
62
58
m
e
a
n
54
Inpatient
Step down
TAU
50
46
42
Intake
6 mo
12 mo
24 mo
36 mo
72 mo
Change in social adaptation
3
Inpatient
Step down
2.8
TAU
2.6
m
e
2.4
a
n
2.2
2
1.8
Intake
6 mo
12 mo
24 mo
36 mo
72 mo
Parasuicidal Behaviour
62
Inpatient
52
Step down
TAU
42
% 32
22
12
2
-1
o
2t
0
o
m
2
0 -1
o
m
-2 4
2
1
o
m
-3 6
4
2
o
m
-7 2
0
6
Hospitalisation
Inpatient
Step down
TAU
60
50
40
% 30
20
10
0
o0
t
-12
-2
12
o
m
4
-3
24
o
m
6
-7
60
o
m
2
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
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
Pathways through the Cassel
Intensive
Community care Revolving door
NHS or Private Sector
NHS or Private Sector
Low/Medium
Secure Unit
Acute 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
Cassel Multidisciplinary Team
Consultant
Psychiatrist, Psychoanalyst
Dance
Movement
Therapist
Psychosocial
Nurses
Multi
Disciplinary Team
Community
Doctor
Social
Worker
(SHO)
SpRs
Psychotherapy
Psychotherapists
Adult and Adolescent
New Treatment Model
Psychosocial Practice
Psychotherapy
MDT staff meetings.
Community meetings
Work Groups
Physical and Social Activities
Special Interest Groups
Parents Group
Psychosocial Education
Community Management Meeting
Planning meetings
Reviews
CPA/ Professionals
Reflective practice
Supervision Groups
Individual psychotherapy
Group Psychotherapy
Dance Movement Therapy
Couples/ Family sessions
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
Current Model
Shared living-learning
Environment
IN
CAMHS, CMHT/
Family/Carers/ Friends/ Psychiatric
Forensic Services (wards)
Psychosocial Practice
‘Alongside’ rather
than ‘for’ the patient
Psychotherapy
MDT staff meetings.
Community meetings
Work Groups
Physical and Social Activities
Special Interest Groups
Parents Group
Psychosocial Education
Community Management Meeting
Planning meetings
Reviews
CPA/ Professionals
Reflective practice
Supervision Groups
Family/carers/ friends,
Voluntary sector,
CMHT, Outreach
OUT
Individual psychotherapy
Group Psychotherapy
Dance Movement Therapy
Couples/ Family sessions
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
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.