| The Sequoia offers a weekly day programme for those with long standing and disabling emotional difficulties, mainly with a diagnosis of Borderline Personality Disorder but not exclusively. Community members are expected to attend from 10 am to 3 pm (5 hours per day) for 3 days per week (Monday, Tuesday and Thursday). Maintaining attendance is an important part of the programme with Therapeutic Community (TC) members committing to 80% attendance and making sure they ring in if they are not able to come. This is because of the way in which the Community functions, it is important that individuals can rely on other Community members being there to aid consistency in group work. Remarkably, the attendance threshold was originally set at 60% attendance and this was voted on by members of the TC to be raised to 80%, showing just how committed the service users really are to this programme. Each service user is entitled to ‘holidays’ (13 days + Bank Holidays) to ensure equality/diversity. Members manage their own diaries and their own leave. What We DidThe Problem: In July 1996, major changes were proposed to the Mental Health Act (1983) following the Lin and Megan Russell case. Both were beaten to death during a robbery by Michael Stones who was subsequently diagnosed with a Personality Disorder (PD). The changes brought a new focus to Personality Disorders and how they should be treated, driven by the NICE guidelines and paper ‘Personality Disorder no longer a Diagnosis for Exclusion’. The Mental Health Act 2007 enacted changes to the way in which people were detained and treated under the Act. Locally, this was also when Dr Wojciech Gierynski (who has a special interest in PD) and Suzanne Brown (NAViGO Senior Operational Lead for Acute) who were wanting to work with this group of services users formulated a group of staff and trained in delivering Dialectical Behavioural Therapy (DBT). This team at the time was called the Personality Disorder Partnership. Over time delivering DBT alongside their already full time posts posed some inconsistency in the service that was offered. The overriding approach and therapy within the current TC programme is governed by consistency, trust and the development of relationships, a huge contrast and improvement in how we work with this complex disorder now in comparison historically. What became apparent was that individuals with a Personality Disorder diagnosis were getting stuck in the system with staff struggling to know how best they could be managed. To manage the risk we found that often there were extremely long inpatient stays and out of area expensive placements which actually conversely often has a detrimental effect on people with this type of illness. In fact, this key group of service users (6 people) were found to account for most repeat admissions within NAViGO with subsequent high bed day ratings (1045 days from April 16-April 17 equating to £418k). Suzanne and Wojciech visited a number of different settings around the country to understand what was currently available for people with PD. Following a visit to the Cawley Centre in London, the whole concept and principles of the therapeutic community way of working appeared to be an innovative way to work with such complexities. Curiosity and an eagerness to learn about the model, the whole ‘new team’ enrolled on the ‘Living Learning Experience’ to experience how it actually feels to fully participate in a TC and to truly try and understand how a TC functions in reality. Feeling energised and excited about a new way of working it was at this point that NAViGO signed up to The Community of Communities, a Royal College of Psychiatry scheme that provides core standards for TCs. The C of C operates in a similar way to the AIMS programme, in that it undertakes peer reviews of services to encourage best practice. The Sequoia Therapeutic Community opened at NAViGO’s Harrison House site in September 2015. The Solution: The Sequoia offers a weekly day programme for those with long standing and disabling emotional difficulties, mainly with a diagnosis of Borderline Personality Disorder but not exclusively. Community members are expected to attend from 10 am to 3 pm (5 hours per day) for 3 days per week (Monday, Tuesday, & Thursday). The model used for The Sequoia is based on the work undertaken by William Tuke (who founded The Retreat in York William Tuke). Tuke philosophised that people needed to be given meaningful support and valued roles / jobs in order to be released from the asylums of the time. The Sequoia offers an intensive 24 month psychotherapy programme where learning can come from understanding one another, and supporting each other in the process of change and mutual recovery. Therapy comes from whole-hearted participation in the whole programme. Sequoia also offers a 24 months “leaver’s programme” after the community members reach the end of the two year period in the main programme. A) The Team: A small but dedicated team of five staff oversee the Community, currently three Social Workers, one of whom is also the Senior Operational Lead for Acute Services, a Health Care Worker and a part time Consultant Psychiatrist. A volunteer who was a community member and successfully completed the two year programme now offers her much valued support as an ‘Expert by Experience’, role that simply cannot be undertaken by a staff member therefore extremely valued within our community. There is also funding for a part time Psychologist but at this time the TC members feel this is not needed and democracy is crucial for our programme to work and to be successful. B) Referral Process: We have made the referral process simple as we don’t want paper work and form filling to block entries into our programme. To make a referral, colleagues need to email both Suzanne Brown and Wojciech Gierynski with brief details about the individual, which must include their name and NHS number and why the referrer thinks the individual needs the TC. There are no forms to fill out as the team will then look into the case history and invite the service user in for a discussion, saving additional stress around form filling. Community members can be anyone who has a complex history, is emotionally unstable and is chaotic in presentation. It may be that other services are struggling to manage these individuals.
When the service user has undergone assessment and wants to engage in our programme, a staff member is allocated to act as Care Coordinator for them to offer a consistent approach – PD service users tend to be chaotic across all services so this model reduces strain on colleagues and improves the experience for service users. Despite having a named care co-ordinator we have a ‘whole systems approach’ to patient care. In essence this means that ALL staff know EVERY member so in the absence of CCO (leave / sickness) the member is always consistently supported. To minimise ‘drop out’, all potential new service users go through a starter process which includes 6 x 2 hour sessions, consisting of a Mentalisation Based Therapy introduction and meeting the community. Sessions include staff and 2 community members so that when a new service user commits fully there is a degree of familiarity. This is also an opportunity to explain rules and standards and give the new service user the opportunity to understand how the programme works. Over the four years of the programme running it has become apparent that this client group often have tremendous difficulties with endings which is often interpreted as rejection stemming from early life experiences. To avoid repeating cycles of chaos and crisis the members who chose to have ongoing support remain under CPA and ‘drop in’ after group times or access telephone support from staff who have a true understanding and formulation of their earlier lives and help them from repeating patterns of self-destructive behaviours. There is an exclusion criteria for substances misuse but people are directed into dual diagnosis services and then supported to revisit Sequoia once this is no longer an issue. How Does Sequoia Work? Service users (Members) spend a substantial amount of time together as a Community including cooking, eating together whilst supporting each other to face their own personal challenges. There are a range of therapies employed by the Community which include: · Mentalisation Based Therapy (MBT) · Dialectical Behaviour Therapy (DBT) · Laughter Yoga · Cognitive Analytical Therapy (CAT) – Suzannes CAT role is psychoanalytical which is helpful on the initial formulation and underpins the problematic procedures which continually play out during their time in the programme · Art group The Sequoia strives to work towards the Core Values identified by the Community of Communities (regulatory body at the Royal College of Psychiatrists) – the common shared values which underline all aspects of the work are:- · Promoting developing healthy attachment · Offering safe and supportive environment for containment of emotional distress · Respecting and valuing everyone’s individuality · Developing communication skills to learn to understand each other · Establishing supportive relationships with others · Encouraging full participation to influence one’s environment · Finding a balance in accepting that positive and negative experiences are necessary for healthy development of individuals · Taking responsibility for self and the Group The main goals of treatment for each Community member:- · To be able to regulate emotions through the discovery of alternative skilful behaviours · To be able to form and sustain meaningful relationships · To be able to manage dissociative symptoms, if present · To have gained confidence and to be able to find purpose in life determined by themselves · To have gained awareness of their own identity. · To be able to live more independently than prior to commencement of the Sequoia with less reliance on mental health services. Democracy is the concept that underpins everything at The Sequoia; the team strive to create a family atmosphere so that each individual who is part of the Community takes responsibility for their own actions, gets involved and helps to make decisions as a collective Group. It is about respecting each other and in turn giving each person a voice. This helps to build confidence based on the attachment theory. Everyone has a view, and is encouraged to make decisions on, for example, menus/cooking, cleaning, rules and even voting people in or out of programme. Healthy attachment is a developmental requirement for everyone and should be seen as a basic human right. The ability to form relationships with others is formed when we are children and unfortunately it is extremely common for people with a PD diagnosis to be victims of abuse when younger or to lack the relevant role models to learn how to develop relationships properly. Due to the complexity, it is prerequisite that individuals referred to Sequoia TC are on the Care Programme Approach (CPA). When a member is deemed to need an inpatient admission, it has to be noted however, that this is a rare occasion, the member is not allowed to come to group. This decision was made collectively to encourage the member to remain in group, discuss and work through their problems. However, during any inpatient admission, staff members visit them and attend the doctor’s reviews to encourage a speedy return to the programme and discharge off the inpatient unit. Family support meetings are available to all members on a weekly basis to help educate, enable and extend family networks around supporting TC members in the home environment and beyond the length of the programme. The Ethos: Therapeutic Communities are structured, psychologically informed environments. They are places where the social relationships, structure of the day and different activities are all deliberately designed to help people’s health and well-being. In TCs people with various longstanding emotional problems spend time and engage in therapy together in an organised and structured way, without drugs or self-damaging behaviour, so that a new life in outside society is made possible. Each member plays a crucial part in their own and others development and therapy. Members are often brutally open and honest in how they see and perceive how others are behaving. Each crisis and chaotic situation provides a valuable opportunity for self and others to learn new interpersonal skills rather than continue to use self-destructive behaviours such as anger, aggression, self-harming and avoidance. Each crisis situation allows staff to reinforce DBT skills and Mentalisation is always at the heart in all interpersonal transactions. The clue is in the title. TCs function as communities, with all members expected to commit to their values and standards. This is a key element of the programme in that people must accept responsibility for their own actions and behaviours in order to be allowed to join the Group. In a nutshell, it is designed to mimic a family environment where certain expectations are placed on Community members in order to build their social relationships and improve their overall health and well-being. The Sequoia operates very much along these lines with TC members ‘gelling’ and living with family values but expected to have transparency; being challenging i.e., ‘what do you do in a disagreement’; making positive relationships/attachments and beginning to learn how to control emotions to decrease self-harming/self-defeating behaviours. A Day in the Life of…The programmes/structure within the TC are decided upon by the Group in a totally democratic way, a typical weekly example of this would be:- Monday · ‘Check In’ · Community Meeting including Business part · Lunch with staff also cooking etc… · Dialectical Behaviour Therapy (DBT) Skills teaching · ‘Check Out’ Tuesday · Members Only Meeting (without staff) / Staff Supervision Meeting · Cooking Lunch · Small MBT Analytical Therapy Groups (community split into two smaller groups) · Lunch · Mentalisation Based Therapy (MBT) teaching · ‘Check Out’ Thursday · ‘Check In’ · Large Therapy Group · Lunch · Art Group / Alternatively other electives · ‘Check Out’’ Friday · The Leavers Programme ‘Check In’, which is the first thing to occur every morning, involves each person in the Group speaking about their feelings in advance of the session. The community member speaking holds on to a NAViGO brain (promotional stress reliever) which encourages the rest of the Group to listen carefully during that time. Weekly Community and Business meetings are Chaired and minuted by Service Users. Members manage their own rules and revisit boundaries on a monthly basis. Wider Active Support: The sheer nature of the service itself and the privacy afforded to service users, makes it difficult for NAViGO to have active partners actually within The Sequoia per se. However, we work very closely with the Royal College of Psychiatrists and the Community of Communities to always ensure our service is second to none and fully aligned with best practice. Other ‘partners’/stakeholders who help us to drive the service forward/maintain the equilibrium for service users are:- · Royal College of Psychiatrists CCQI – Community of Communities · Acute Adult (internal partner) · Community Services · Children’s services · PIP (Benefits Agency) · Care- Coordinators We do however, work very closely with our own crisis team and encourage when possible each member to turn to group rather than contact emergency services. Co-Production The whole service revolves around inclusivity and is managed using democracy trying to ensure inclusion and empowerment. For example:- · The members decided on a ‘Strikes’ system – e.g. if a member’s attendance drops below 80% then they receive a ‘Strike’; if they partake in alcohol or substances they receive a ‘Strike’ or suspension from the programme; challenging behaviour in the Community (or externally) has the same result. Once a TC member reaches 3 Strikes, the rest of the Community call a meeting (which includes the person involved) and enquire if the programme is working for them, making suggestions on how they might change behaviours/manage conflict. · If anyone from the TC presents in Crisis Service the night before a session then this is always discussed in the Community the following day to manage and promote responsibility and empowerment. · The Community excludes anti-social behaviour and people doing it are confronted by the rest of the Community. · The Community choose and prepare their own menus; sharing and eating this in a family atmosphere · The attendance policy was 60% but over time it has been increased to 80% and is set by the Community members themselves. · The Community sets its own boundaries and rules; collectively ensuring adherence. | 
