The Peaks Unit: Developing an Integrated Treatment Model Dr Todd Hogue Paper presented at: Care not...

The Peaks Unit: Developing an Integrated Treatment Model

Dr Todd HoguePaper presented at:

Care not containment: Interventions for mentally disordered individuals

24-25 June 2004, Royal Moat House Hotel

Nottingham, UK

[email protected]

DSPD: The Challenge

• Untreatable?• Psychopathy • Personality Disorder

• Difficult to manageImpulsive Aggressive Manipulative Predatory

Volatile Attention Seeking Needy Violent

Vulnerable Emotionally Labile Self Harming

What Kind of Patients?

• A couple of examples…

Case 1 - JP

• Age – 31• Wounding: Life 7yr min• Mother – mental health

problems• Farther – alcoholic and

violent• Q: brain damage at birth• 2-3 hyperactive/

behavioural problems

• Family separation 6yrs

• 6 sexual abuse?• 7 challenging behaviour• 9 special school/homes

– Threaten knife, impulsive, aggressive, social isolation

• 11 repeat self-harm• 12 violent attack – family• 17 violence, threat with

knife, fire setting, cruelty to animals

• 20 attempt - strangle resident

• 20-23 aimless lifestyle, heavy drinking, casual sex

Case 1 - JP

• History:– Assaults, breech of peace,

affray, imp-police– Repeat institutional

violence and threats to kill• Index:

– wounding with intent– alcohol – paid for sex– violent urge to kill– Strangles, assaults– Victim escapes

• Violent fantasies• Voices / visions• Religious fixation: Jewish• Gender dysphoria –

attempted self castration• Poor institutional

behaviour– Moved, seg, hospital unit

• Neuropsychological problems?

• Little “treatment”• PD: Borderline, ASPD,

Paranoid

Case 2 -JU

• Age – 33• Rape – 6yrs• ‘raging’ family violence• 6 - in care • 7-9 attempts to foster

or return home• Early conduct disorder• Boarding school to 16

• 16+: acquisitive offences

• 19: endanger life – arson

• 27: assault partner, controlled drugs

• Index offence– Drug induced psychosis?– Belief of Ying/Yang– Rape of stranger(?) – Allows her to go

Case 2 - JU

• Axis I– ADHD, cannabis,

amphetamine dependence, A-I psychotic disorder

• Axis II – Schizotypal, Antisocial,

Borderline, Histrionic, Narcissistic

• High Psychopathy• High / very high risk

• Substance use• Callousness• Impulsivity• Failure to manage violence• Limited treatment – none

on sexual offending• Denial of sexual motivation• Released on licence –

failed• Likely to be detained

beyond sentence length

The Task

• An integrated approach to assessment and treatment

Personality Disorder

An enduring pattern… deviates markedly from the expectations of the individual’s culture.

Manifested in: – cognitive, – affective, – interpersonal functioning – impulse control

… inflexible and pervasive across personal and social situations

... leads to clinically significant distress or impairment… pattern is stable and or long duration … onset traced to adolescence or early childhood

Risk / Violence Assessment

• Identifying risk factors: the RISK of WHAT happening with WHO in WHAT SITUATION(S)

• How does the individual function?– Interpersonal– Intrapersonal– Core beliefs– Bio-Physiological

• Linking individual functioning with risk factors

The Risk - Personality Link

• Look for repeating patterns reflective of risk and consistent over time

• Risk predictors > dynamic factors > personality• Hypothesise individual factors linked to risk and

personality • Predict interaction style of PD as it relates to

parallel risk related behaviour• Repeatedly revisit formulation of risk / PD link

What is an integrated model?

• Whole person assessment

• Multiple assessments

• MDT working

• Team decisions

• Agreed targets

• Information fed into Individual Development Plan (IDP)

Conceptual Background

• An Integrated Approach to Treatment – Livesley (2003)

• Good Lives – Ward (2002)

• Hierarchy of Need – Linehan (1993)

• Therapeutic Community Principles• Case Formulation • Structuring Clinical Judgment

– Goal Attainment Scaling

INDIVIDUALISED ASSESSMENT

• Whole Person Approach

• Comprehensive Assessment

• Identify Dynamic Factors

• Target deficits/Criminogenic needs

• Treatment Hierarchy/Prioritise needs

Patient Focused

• Client Centred

• Needs and deficits

• Strengths and abilities

• Patient involvement

• Motivational structure

• Collaborative

Pragmatic difficulties with traditional ways of working

• Single model (Medical)

• Hierarchical decision making

• Multiple formulations

• Different perceptions of patients

• Little patient involvement

• No central resource or document

Integrated Treatment Plan

• Integrate assessment information

• Case formulation

• Shared treatment formulation

• Individual development plan

• Coherent and consistent documentation

Integrated Regime

• A “normalised” day

• Multidisciplinary working across interventions

• Consistent clinical teams

• Therapy teams – linked to each patient

• Routine / timing to facilitate clinical practice

• Agreed team decisions.

ASSESSMENT

WARD

MOTIVATIONBuilding the relationship and therapeutic alliance

First stage assessment

Clinical Intervention Diagrammatic Representation

DSPD Core Assessment

Three critical components

• High Risk – More likely than not• Severe Personality Disorder

– Very High Psychopathy– High Psychopathy & 1 PD – 2 different PDs

• Functional Risk / PD Link

STANDARDISED

ASSESSMENT

ASSESSMENT

WARD

ADMISSION

TO

TREATMENT

WARD



Individual Development

Plan for engagement

with the assessment

process

Risk/Offence Behaviour

Second stage assessmentRecorded in Integrated

Treatment Plan: Individual

Assessment Information

Section

Good lives

Motivation

Symptomatic

Dispositional

Situation -environment

Regulation/ control

Interpersonal

Self / cultural issues


Individual Assessment Information

• Physical health• Symptomatic factors• Situational/

Environmental factors• Regulation / Control

factors• Neuropsychological

assessment

• Dispositional traits• Interpersonal factors• Self system• Risk / Offending

issues• Mental health factors

(axis I)

STANDARDISED

ASSESSMENT

ASSESSMENT

WARD Reviewed and

agreed by therapy team. Transferred to

Integrated Treatment Plan:

Individual Formulation

Section

ADMISSION

TO

TREATMENT

WARD




Plan for engagement

with the assessment

process

Treatment Needs & Pathway

What & Why?How?

When? N1 (need) H1 (hypothesis) T1 (treatment)

FORMULATION





Section

Good lives

Motivation

Symptomatic

Dispositional


Regulation/ control

Interpersonal



Individual Case formulation

• Case formulation model• What, why, how & when • Areas of strengths and weaknesses • Multiple issues, systems and formulations• Hypotheses (testable)• Integrate motivational issues• Diagrammatic representation• Agreed “Team formulation”

STANDARDISED

ASSESSMENT

ASSESSMENT

WARD Reviewed and




Section

ADMISSION

TO

TREATMENT

WARD


Prescribing Multidisciplinary

Intervention

Monitoring Behaviour

Evidencing Change

INDIVIDUAL DEVELOPMENT

PLAN

Recorded in Integrated


Development Plan Section



Plan for engagement

with the assessment

process


What & Why?How?


FORMULATION





Section

Good lives

Motivation

Symptomatic

Dispositional


Regulation/ control

Interpersonal



Individual development plan

• Focuses on treatment need• Aim of interventions• Objectives

GroupIndividualEnvironmental

• Specified “success criteria”• Regular – identified review process• Evidenced evaluation

STANDARDISED

ASSESSMENT

ASSESSMENT

WARD Reviewed and




Section

N2 (need)H2 (hypothesis)T2 (treatment)

Reviewed by Therapy

Team (CPA)

ADMISSION

TO

TREATMENT

WARD


Prescribing Multidisciplinary

Intervention

Monitoring Behaviour

Evidencing Change

INDIVIDUAL DEVELOPMENT

PLAN

Recorded in Integrated


Development Plan Section



Plan for engagement

with the assessment

process


What & Why?How?


FORMULATION





Section

Good lives

Motivation

Symptomatic

Dispositional


Regulation/ control

Interpersonal



Individual treatment formulation

Includes: • Responsivity & therapeutic engagement issues • Clear hierarchy of need• Identified treatment options• Clear alternatives pathways

Structuring Clinical Judgment:Clinical Progress

• How to evidencing change• Pulling information from different sources

together• Clear criteria and understanding –

treatment needs and targets• Clearly defined goals• Goal Attainment Scaling (GAS) Model• Structure to guide clinicians

Summary

• Matches integrated model principles• Multidisciplinary • Actively involves and includes the patient• Shared Team view of:

– Patients’ needs and strengths– Shared “team” formulation – Hierarchy of treatment provision– Clear treatment pathways

• Single source documentation

[email protected]

The Peaks Unit: Developing an Integrated Treatment Model Dr Todd Hogue Paper presented at: Care not...

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