We use a psychodynamically informed therapeutic community model to provide treatment for those diagnosable with personality disorder. The service operates using a tiered structure that allows the users to move between the structures in a seamless manner. The service works on the principles of individual agency and empowerment using a flattened hierarchy; this puts the service user at the centre of their own care and recovery. We encourage self-referral allowing service users to immediately have agency for their recovery. All treatment is provided in groups where service users are encouraged to take on roles of responsibility to ensure the effectiveness of group.
Co-Production
From start: Yes
During process: Yes
In evaluation: Yes
Evaluation
Peer: No
Academic: Yes
PP Collaborative: Yes
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Gillian Attwood - Team Leader, Oxford Health NHS FoundationTrust
We use a psychodynamically informed therapeutic community model to provide treatment for those diagnosable with personality disorder. The service operates using a tiered structure that allows the users to move between the structures in a seamless manner. The service works on the principles of individual agency and empowerment using a flattened hierarchy; this puts the service user at the centre of their own care and recovery. We encourage self-referral allowing service users to immediately have agency for their recovery. All treatment is provided in groups where service users are encouraged to take on roles of responsibility to ensure the effectiveness of group.
We operate 5 Therapeutic Communities across 2 counties these make up the medium and high intensity treatments, while the low intensity treatments consists of individual assessments, 5 Options/Getting Ready groups 1 connected to each of the TC’s and 4 Mentalization Based Therapeutic Community (MBTC) this is a 10 week course designed to help users develop mentalizing skills.
In addition we support Adult Mental Health Teams to develop Structured Clinical Management (SCM) to enable them to work more effectively with service users who have a diagnosis of personality disorder, who are not willing to engage with Complex Needs Service.
Once someone has completed therapy they are eligible to move in to STARS which is an ex-service user group, this sits within TVI (Training and Vocational Initiatives in Personality Disorder), which in turn sits alongside CNS. STARS co-produce training and development initiatives with clinicians as well as supporting the clinical work.
A number of STARS join as they are passionate about giving something back to the organisation and CNS, as they believe that they would not have survived without the intervention.
Wider Active Support
The Oxfordshire Mental Health Partnership supports an holistic approach to helping people with personality disorder. The partnership is formed up of six organisations; Oxford Health NHS Foundation Trust, Response, Oxfordshire Mind, Connection Support, Elmore Community Services and Restore.
Each of the partner organisations work together collaboratively to provide meaningful engagement, and development of appropriate approaches for those with personality disorders, as well as giving support to those who are finding it difficult to engage in CNS.
CNS also works in partnership with TVI and STARS, to maintain development of clinical services and offer training to partnership organisations. Oxfordshire Mental Health Partnership support their staff from each organisation to attend trainings that are co-produced and focus on working with those with PD
Co-Production
CNS is founded on service user and carers involvement, from the shape of the service as a whole, to individual groups, to recruitment, to engagement and to training.
The ethos of TC’s is co-production of an individual’s treatment within therapeutic groups and social learning. Each of the TC’s have regular programme reviews, the agendas are set by both service users and staff, and any topic is up for discussion before a vote is taken as to whether a change should occur. For example: one of the TC’s ran a skills group that happened fortnightly, with a business meeting on the alternating week. TC members wanted to increase the skills group to weekly, a discussion was had around where the business meeting would go, everyone took part and a solution was agreed that the business meeting would move to another day, this created a reduction in a social activity but enabled the skills group to become weekly. This was reviewed at the following programme review and agreed that it worked better.
The high intensity TC’s which are 2 days a week are members of Community of Communities (CofCs) this is a quality improvement and accreditation programme. As part of the membership both TC’s have annual peer reviews and 3 yearly accreditation reviews with members and staff from other TC’s. Members from the CNS TC’s also review other TC’s, thus ensuring quality and governance standards.
STARS help run Introduction Groups with clinicians, giving new referrals an opportunity to hear the ex-service user’s experience of being part of the service. STARS also do sessions in the Moving on Groups to help those who are coming up to leaving to think about what activities they may be able to engage with outside of the TC.
The recruitment process for new staff involves service users and staff. The shortlisted candidates attend a TC where the members organise an activity for them to critique interpersonal styles, knowledge and commitment to the work, each member than votes on the candidate they feel is most suited to the work. These scores are passed on to the interview panel to help inform their decision. The candidates also attend a team meeting where again an activity is organised usually a game to enable staff to consider their ability to work as part of a team, and then staff vote on the person they feel is the best fit for the team, these are then passed to the interview panel. The interview panel is made up of senior staff and 2 TC members from the TC that the candidates visited.
All training and development work undertaken by CNS and TVI is co-produced and delivered by clinicians and STARS. These include one day trainings through to the yearlong course ‘People Personality and Pathology’
Looking Back/Challenges Faced
In 2015 the funding for the service was devolved from the Department of Health to local commissioning, this resulted in a decrease in available funds. The service users worked very hard on behalf of the service to ensure that there was adequate funding to maintain the service.
As part of the rationalisation the Oxfordshire and Buckinghamshire service merged to create a single service, and management posts were rationalised. It felt important that clinical posts were maintained to ensure the continuation of clinical services. The impact of the changes were challenging for service users and staff, as members from one TC had to merge into another TC and two staff teams had to come together as one, while both services had many similarities there were also some differences in their structures. Both Service users and staff had to work together to overcome these challenges and two years on we are continuing to meet these challenges together as we develop an equitable service for everyone who needs it.
Sustainability
The management team is made up of four the Programme Director, the Team Leader, the Deputy Team Leader and the Consultant Psychiatrist in Psychotherapy. All four have equal responsibility, and are able to step in to each other’s shoes. In addition we have a number of Clinical Specialists who hold responsibility for clinical leadership within each locality; they also take on some operational responsibilities, thus ensuring that anyone of them would be able to step up into a management role from their leadership roles.
Evaluation (Peer or Academic)
The service has published a number of academic papers that show the effectiveness of the treatment including the first randomised controlled trial using a TC model all 3 of the below papers have authors who are currently or have worked in the service, the evaluations have been completed with support from service users:
Pearce, S., Scott, L., Attwood, G., Saunders, K., Dean, M., De Ridder, R., & Crawford, M. (2017). Democratic therapeutic community treatment for personality disorder: randomised controlled trial. The British Journal of Psychiatry, 210(2), 149-156.
Ruscombe-King, G., Mackenzie, L., Pearce, S., & Saunders, K. (2017). “I know you think I think–therefore I am”. Mentalisation based therapeutic community: a description. Therapeutic Communities: The International Journal of Therapeutic Communities, 38(1), 1-9.
Maughan, D., Lillywhite, R., Pearce, S., Pillinger, T., & Weich, S. (2016). Evaluating sustainability: a retrospective cohort analysis of the Oxfordshire therapeutic community. BMC psychiatry, 16(1), 285.
Outcomes
Personality disorder is prevalent with in the general population (4.4 – 13%) depending on which epidemiology paper you read. It is often considered as being untreatable as it does not respond too many of the conventional mental health treatments. CNS works with people towards recovery, STARS will say that CNS gives hope, where there wasn’t any.
Since its formation there have been significant reductions for those who engage in the service in mental health bed use, use of medication, GP and A&E attendances, suicidal and self-harm acts. These reductions are based on the annual internal audits that the service carries out.
Sharing
We worked with one of the AMHT’s in Oxford health FT to develop an MBTC within the AMHT for service users who did not feel ready to come into CNS. We also work with AMHT’s to develop Structured Clinical Management by giving specific training and supervision, to enable the AMHT’s to provide an evaluated approach to working with service users who have PD.
We offer in-reach and consultation to the acute wards as well as other professionals including partners within the Oxford health partnership and GPs A number of other trusts from around the country have requested our support in the planning of their PD pathways and services. We do this by meeting with them along with STARS to share our experiences.
Professionals are able to visit each of our TC’s by putting a request in writing to the TC they wish to visit. The TC members will then arrange the visit, giving the opportunity for professionals to experience first-hand the work that is done.
STARS frequently share their experience of being in the service during training.
