Mental health and personality disorder services in Essex

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1 A charity leading innovation in mental health Registered Charity No: Mental health and personality disorder services in Essex Specialists in sustainable recovery St Andrew s Essex

2 Sustainable recovery for independent lives As part of the UK s largest mental health charity, St Andrew s Healthcare in Essex is committed to the successful rehabilitation and long-term recovery of patients with complex mental health and personality disorder (PD) needs. It also offers psychiatric intensive care for females and males*. Our multi-disciplinary teams (MDTs) have the expertise to see beyond a patient s presenting diagnosis and treat the underlying issues that can affect a person s ability to achieve independence and long term recovery. Our service pathways and MDT intervention support a patient s journey by offering therapeutic programmes tailored to each individual. Overview: specialised services for mental illness and PD, including complex needs 57 gender-specific low secure beds (including a 6 bed female transition unit) for adults aged 18+ psychiatric intensive care unit (PICU) offering rapid admission for acute mental illness, a relapse of an enduring mental illness or an exacerbation of a chronic mental illness specialist, full-time MDTs experience in the assessment and treatment of complex and challenging patients cognitive behaviour therapy (CBT) framework for psychological skills development, enhanced by a uniquely modified social therapy milieu 5 million investment during the last three years to significantly enhance therapeutic environments modern facilities that meet patients social, cultural, spiritual and pastoral needs, including an arts and crafts workshop, gym, café and shop supported by an extensive pathway of care across St Andrew s Healthcare Our specialist teams tailor the most appropriate therapeutic interventions to support each patient in their pathway, and on to the least restrictive environment. Richard Clark, Hospital Director 17 months 159 patients is the average length of stay for patients discharged in 2014 *1 63 discharged in the past three years *2 % 5 % reduction in incidents of aggression within the first six months of stay *3 less than 5% of patients returned to our services following discharge *4 204 patients cared for in the last three years *2 * Opening 2015 *1 Minus PICU *2 December *3 Q2 compared to Q1 of patients with a LOS of 24 months. Data from Jan 2011-March 2014 *4 Re-admission rates of patients discharged between December

3 Understanding the individual At the core of our service is a therapeutic culture which, we believe, is the key to understanding patients and supporting them in their recovery. Psychological therapy is at the centre of the clinical process for everyone in our care. Our MDTs deliver tailored interventions to engage patients in their own therapy and recovery, based on their personal interests and goals. Our unique approach uses Cognitive Behavioural Therapy (CBT) and is informed by Dialectical Behavioural Therapy (DBT) as an overarching framework for psychological skills development. This framework is enhanced by our specialist MDT and a social therapy milieu approach, which creates a predictable and safe environment that aids a patient s recovery. Each patient is fully supported by a full-time MDT with expertise in assessing and managing patients with complex mental health needs. Regular 1:1 and group sessions with each member of their MDT enable them to benefit from a holistic therapeutic model of care which fosters personal reflection and develops social interaction. During each interaction a patient s behaviour is reviewed in order to accommodate new developments with the aim of encouraging their transition into the community at the earliest opportunity. Available onsite, our MDTs support each patient with: Community liaison supporting re-integration back to area with accommodation and vocational guidance from the local community team Psychiatric interventions which include specialist assessment and treatment medical assistance from a General Practitioner (GP) individual and group psychological therapy which includes CBT (delivered by trained CBT therapists) and DBT informed approaches Physical healthcare assistance that aims to look after the physical health and wellbeing of patients Psychiatric Nurse led sessions which continuously build and support positive behaviour Diet advice helping patients to lead a healthy lifestyle or achieve specific health-related goals occupational Therapy that includes sensory therapy and community integration skills education intervention developing learning skills that allow patients to reach their full potential family contact/involvement and community transition support from dedicated Social Workers Vocational therapy providing opportunities both on-site and within the local community the right medication from a fully qualified and experienced pharmacy team We place the patient at the centre of their care and at the centre of decision making. Dr Mark Morris, Clinical Director

4 Our specialist services Our specialist services are gender specific, providing the optimal environment for individual recovery. These include male and female PD, mental illness and PICU wards*. * male PICU opening 2015 Our Values Our work is founded on the following values: therapeutic intervention should be tailored to individual needs interventions should be evidence based a positive and supportive atmosphere aids recovery social milieu contributes to positive living and learning environments empowering patients to take control of their own therapy contributes to positive recovery developing motivation and enhancing patient compliance improves the effectiveness of treatment.

5 Mental health Our service in Essex has 15 years of experience in managing men and women with complex mental illness. Our facility includes 35 low secure beds for males, and 22 low secure beds for females, including a transition unit, to help facilitate the next steps towards community re-integration. Men s low secure Our 18 bed admission ward provides dedicated care for men with challenging behaviours and those who require intensive relational security. This ward offers complex assessment of mental health issues before developing a rehabilitation framework of care. Women s low secure An admission ward for females who require management and treatment of complex mental health needs. We care for men and women aged 18+: with a primary diagnosis of mental illness or a combination of mental health problems who may have a history of: challenging and/or offending behaviour alcohol or substance abuse repeated failed attempts at community integration and/or previous movement between the mental health or criminal justice systems who meet the criteria for detention under the Mental Health Act 1983 (amended 2007) who require a low secure or open service. These criteria are a guide for assessing suitability; each patient will be considered individually. Core therapeutic activities include: Cognitive Behaviour Therapy (Foundation and Advanced) CBT allows patients to explore the link between their thoughts and feelings and their influence on behaviour. Many patients are shaped by their early experiences; as a result their core beliefs about themselves, others and the world are very negative, causing high levels of anxiety and distress. CBT aims to put positive interventions into place, through exercises, role plays and homework tasks, which will help patients to reduce distress, solidify their learning and achieve their goals. Community meetings Chaired by patients, these meetings allow patients to discuss with staff any issues relating to their treatment during their stay at St Andrew s. A key element of community meetings is to allow patients to practice communication and problem solving skills in a social environment. 17 months 59 % * Q4 compared to Q1. Data from Jan 2011-March 2014 is the average length of stay for patients discharged from our mental health services in 2014 reduction in incidents of aggression within the first year of stay* Basic and Advanced social skills Our social skills courses consist of practical exercises and role play. They enable patients to develop skills, such as being able to listen to others and absorb what they are saying, make requests, express positive and negative feelings, talk appropriately to other people, deal with conflicts and develop community living and work skills. Foundation substance abuse and Advanced relapse prevention Our alcohol and drug therapy courses help patients understand the effects of substances on mood, wellbeing and mental health. Through discussion, practical exercises and role play, patients will gain the skills to practise responsible behaviour around alcohol and drug use. Our MDT support patients to develop their own timetable, scheduling a minimum of 25 hours social, educational and occupational therapeutic activity per week. This helps engage the patient in their treatment plan from the beginning.

6 Personality disorder We deliver a specialised low secure service for men and women with personality disorder. The service provides gender-driven programmes tailored to the complex treatment needs of people living with PD, and is designed to accelerate their return to community living. Men s low secure 17 bed admission, treatment and recovery for patients with personality disorder and complex needs. Women s low secure 16 bed admission, treatment and recovery for complex needs. Women s transitional unit 6 bed transitional unit focusing on recovery and continued progress towards community re-integration. We offer a real life re-learning and corrective re-experiencing opportunity for those in our care. Henck van Bilsen, Head of Programmes We care for men and women aged in low secure environments: with a primary diagnosis of PD, complex needs and dual diagnosis who meet the criteria for detention under the Mental Health Act 1983 (amended 2007) who may have a history of: challenging and/or offending behaviour alcohol or substance abuse These criteria are a guide for assessing suitability; each patient will be considered individually. repeated failed attempts at community integration and/or previous movement between the mental health or criminal justice systems.

7 11 months is the average length of stay for patients discharged from our PD services in % reduction in incidents of aggression within the first six months of stay* *Q2 compared to Q1 of patients with a LOS of 12 months. Data from Jan 2011-March 2014 Core therapeutic activities include: Dialectical behavioural therapy (informed) DBT is a comprehensive Cognitive Behavioural Therapy (CBT), designed for individuals with complex mental disorders and is used to inform our treatment of patients with PD. DBT-informed and CBT therapies help treat short term management and adjustment issues and then achieve longer term goals such as behavioural change, social re-adaptation and reduced re-offending. DBT is applied through a mindfulness practice programme and 1:1 therapy sessions to help patients develop skills in self-regulation and functional performance, helping them to lead more positive lives. Compassion focussed therapy CFT is used to help patients who experience high levels of shame and self-criticism to develop alternative and more compassionate ways of relating to themselves and others. Measured through The Fears of Compassion scale, the therapy equips patients with individual strategies and skills, using experiential exercises and reflective opportunities, to overcome difficulties and to cultivate self-compassion and kindness towards others. Schema therapy groups These groups enable patients to explore early maladaptive schemas which include self-defeating thoughts or behaviours that lead to unhealthy life patterns. The groups allow patients to openly discuss their experiences, thoughts and behaviours in an attempt to break schema-driven life patterns and help a patient meet their core emotional needs. Delivering therapy, 24/7 Our clinical environment is designed in such a way that patients receive a therapeutic learning experience 24 hours a day. We can adapt the learning environment to provide patients with increasing autonomy as they progress, supporting their transition to step-down and community living. We engage patients in treatment programmes, designed to enable them to reach an optimum level of function in their day-to-day life.

8 Psychiatric Intensive Care Unit (PICU) Our PICU services offer rapid access to high quality, psychiatric intensive care in clinically safe and supportive environments. We provide individual treatment programmes designed to reduce risk and stabilise a patient s mental state before transferring them back into less secure or community settings to continue their recovery process. Female locked PICU 10 bed rapid stabilisation and mental health assessment. Male locked PICU New for bed rapid stabilisation and mental health assessment. Due to open in Open 24 hours a day, 7 days a week An admission decision will be made within one hour by the clinical team. Admissions are accepted 24 hours a day. Referring is easy Call at any time and ask for our Essex PICU Service. 44 is days the average length of stay for our female PICU patients* *Patients discharged in 2014 We care for women and men* aged 18+ who: are suffering from an acute mental illness, a relapse of an enduring mental illness or an exacerbation of a chronic mental illness may be displaying challenging behaviours as a result of a mental illness demonstrate significant risk, including aggression to self and others, absconding and/or vulnerability require relatively short term intensive care in a safe environment meet the criteria for detention under the Mental Health Act 1983 (amended 2007) require a locked PICU service. These criteria are a guide for assessing suitability; each patient will be considered individually. *Opening 2015

9 Case study: Deciphering Dean Prior to his arrival at St Andrew s Essex, Dean had served a number of custodial sentences for repeated criminal offences. His most recent years had been spent moving between psychiatric prison wings and secure mental health facilities. On admission, the assessment team noted strong elements of social isolation which partly contradicted the nature of his index offences. Whilst other patients congregated in shared areas, Dean would remain alone in his room to avoid crowds and distance himself from other people. He would sway from side-to-side, pace back and forth in his room with his head down and avoid eye contact with ward staff and other patients. During the assessment period, the multidisciplinary team worked hard to connect with Dean and understand him as a person. He presented as floridly psychotic with hallucinations and paranoid delusions, which made any engagement with him particularly difficult. The clinical team spent time talking with Dean about his interests and aspirations and trying to unearth the background to his behaviour. During these sessions it became apparent that Dean was modelling a lifestyle he witnessed in violent movies and computer games as a way of securing greater wealth and allowing him to retreat from society. He sought to escape his socially anxious life and this had also led to a problem with alcohol. As a result, minor offences such as theft had rapidly increased in severity as he aspired to the wealthy lifestyle he craved. The team in Essex explored Dean s social isolation and saw this as an underlying indicator of his challenging behaviour. As part of his therapy Dean was enrolled in Cognitive Behavioural Therapy and Dialectical Behavioural Therapy (informed) sessions and began weekly 1:1 meetings with a trained CBT therapist. To empower Dean to take control and engage in his therapy the team applied their innovative incentive scheme, with behavioural reinforcement designed to encourage positive behaviour as Dean met agreed objectives. CBT aimed to address Dean s present behaviours, helping Dean to look beyond his mental diagnosis and to understand and tackle his problems in a more positive way. During sessions he would talk about his discomfort around groups of people and how his anxiety was embedded in the belief that people were constantly critical of him, affecting his ability to gain employment at a younger age. Gradually Dean was encouraged to challenge his social anxiety through a controlled series of behavioural exercises and role play. The objective was to test other people s responses and also Dean s own predictions of how people perceived and responded to him, starting with minor tasks and building up to more challenging scenarios. His predicted negative outcomes did not materialise and he was able to take another positive step towards social inclusion. Dean attended 28 sessions of CBT during his first year at St Andrew s Essex. He still reports feelings of anxiety but on the ward he has made some impressive behavioural improvements. Dean now joins other patients in breaks, attends community living skills groups, introduces therapy sessions to rehabilitating patients and was granted unescorted community leave. At each step the team at Essex continues to support Dean as part of a positive social therapy milieu, constantly developing his anxiety response in different settings through a series of CBT and Occupational Therapy (OT) homework tasks. Dean is expected to transfer to an open facility closer to home where he can continue his progress towards a sustainable recovery in a less restrictive environment.

10 Our specialist multi-disciplinary team Our multi-disciplinary teams in Essex are specialists in their chosen areas and are passionate about supporting patients to achieve sustainable recoveries. Richard Clark BSc (Hons) OT Hospital Director Dr Mark Tarn BM MSc MRCPsych Lead Psychiatrist Richard has over 18 years of post-qualification experience working in specialist healthcare services as both an Occupational Therapist and senior manager. He has worked across a range of security levels incorporating adult, adolescent, and older adult services both male and female. These have included a variety of diagnostic groups such as acquired brain injury, learning disability, mental health, personality disorder, autistic spectrum disorder, dementia and Huntington s Disease. Mark works in our female PD service and has extensive expertise in psychological trauma having previously served in the British Army for 25 years. He has dual accreditation in forensic and general adult psychiatry. His interests include occupational mental health and medically unexplained symptoms. Dr Mark Morris BA, MBA, MBChB, MRCPsych, BPAS, s12mha Consultant Psychiatrist in Psychotherapy Dr Piyal Sen MBBS, DPM, FRCPsych, DFP Consultant Forensic Psychiatrist Mark is a Psychotherapist with a background in PD, forensic work and the strategic development of clinical services. He leads on our PD approach and is contributing to the development and management of our clinical direction. Piyal has vast experience of working with both men and women with PD, and has a special interest in sex offenders. He ran one of the few medium secure hospital units in the country offering specialised treatment for sex offenders, many of whom were stepping down from high security. Henck van Bilsen BPS, BABCP, HPC Head of Programmes Amanda Spooner Lead Nurse Henck has over 30 years experience as a Clinical Psychologist. He specialises in CBT and is an accredited member and trainer for the British Association for Behavioural and Cognitive Psychotherapies (BABCP). Henck leads in our unique delivery of therapies. Amanda is the Lead Nurse for Essex and has worked here since it opened in She has worked clinically across both male and female services, specialising in the care and treatment of patients with personality disorder. Her interests include innovations in nursing practice and management of risk in secure settings. Dr Sohom Das MBChB, BSc, MSc, MRCPsych Consultant Forensic Psychiatrist Dr Olufunke Otuwehinmi MBBS MRCPsych Consultant Psychiatrist Sohom is responsible for our mental health ward managing male patients with forensic risk histories, and related legal issues, this follows his completion of the North East London Forensic Psychiatry Higher Training Scheme. Sohom has worked in a range of forensic settings, including prisons, court diversion and high, medium and low security. Olufunke is responsible for our psychiatric intensive care unit, managing patients with severe enduring mental illness and complex personality disorder presenting in acute crisis. She has over 20 years experience in general psychiatry with expertise in acute inpatient and psychiatric intensive care.

11 Advancing clinical effectiveness As a charity and academic centre, St Andrew s Healthcare is committed to conducting an active programme of clinically relevant research to improve the understanding of mental illness, its causes and effective treatment. St Andrew s staff, in collaboration with leading UK universities, undertake an active research programme across all our sites. Our Essex staff are empowered to complete specialist research and to publish tools that contribute to the improvement of mental healthcare. Here is a selection of the research that our leading Essex MDTs have published. Books Sen, P. and Morris, M. Personality Disorder in: Dickens, G., Picchioni, M. and Sugarman, P. (eds) Handbook of Specialist Secure Inpatient Mental Health Care, Gaskell Publications (in press). Van Bilsen, H., and Thomson, B. (2011) CBT for Personality Disorders, Sage, London. Publications Sen, P. and Ramaswamy, D. (2011) A Balanced Approach to Race in the Treatment of Personality Disorder. Advances in Psychiatric Treatment, 17: Sen, P. and Irons, A. (2010) Personality Disorder and the Mental Health Act 1983 (amended 2007). Advances in Psychiatric Treatment, 16: Sen, P. and Adeleke, D. (2007) Sex Sells, but Does it Help? A Survey of Media Coverage in a Medium Secure Unit Treating Sex Offenders. Mental Health Review Journal, 12(3): Van Bilsen, H. (2005) Making Treatment for Personality Disorders Effective: Back to Basics. BABCP Magazine-Research Digest. Vol. 33. For more information on our research, please visit standrewshealthcare.co.uk/research 330 We have contributed to over 330 high profile research publications since 2010* *

12 Our care pathway With 79 beds from low secure to locked, St Andrew s Essex offers gender specific mental illness services, dedicated PICU provision and specialist PD services for men and women. Low secure THERAPY & REHABILITATION Hadleigh 17 beds STABILISATION & ASSESSMENT Colne 16 beds Danbury 18 beds Audley* 12 beds Maldon 6 beds RECOVERY & RE-INTERGRATION Frinton 10 beds Locked Mens Womens Womens Mens Mens Womens Personality Disorder Mental Illness PICU 24/7 PICU for rapid stabilisation and mental health assessment Discharge *Due to open 2015 Discharge/Community living Registered Charity No: Getting in touch For more information about our Essex services or to make a referral: t: e: enquiries@standrew.co.uk w: standrewshealthcare.co.uk/essex St Andrew s Essex Pound Lane North Benfleet Wickford, SS12 9JP t: _0615 Individuals pictured are models and are used for illustrative purposes only.