Integrative Psychotherapeutic Group Work - a way forward

in the treatment of personality disorders

Gill Attwood & Lisle Scott

Thames Valley Initiative

Facts and Figures

• Population of 770,000• 62-68% aged between 18-64• 5-10% 0f population have a Personality

Disorder 25% of GP attendees have PD• 50-70% of mental health patients have

PD (Moran)

• Estimated population of Oxfordshire with PD is 38,500-77,000

(Moran)

OCNS Staff

• Multi-disciplinary team• Psychiatrists, Psychotherapists, Nurses,

Social Workers, OTs, XbX’s, Administrators• 12 whole-time equivalent• Working with-in a framework of multi-

modality• Hold CPA responsibility for members in

therapy and post therapy for six months.

Tier 1• Open referral system• Everyone seen – mostly with-in own

geographic area, in various settings, GP surgeries, CMHT bases, Voluntary day centres etc

• Initial engagement, not full assessments

• Assertive engagement – includes individual time limited psychotherapy

Tier 1- Options Group

• 4 across the county• Staffed by clinicians, XbX’s and

attended by members of the therapy group for each area

• Attendance 4 wks-12months• 2 hours a week• TC structure• Identify issues to work on

Tier 2 – Spoke services

• 3 across the county• Plus one for older people• Staffed by Clinicians• Using an integrative

psychotherapeutic approach

Tier 3 – Full-time TC

• 4 ½ days a week• 18 month commitment• Democratically run by members• Multi-psychotherapy approach,

Analytical groups, CBT, Psychodrama, Creative group, Medication group, SCID II group

Tier 4 Moving-on

• 8 sessions across 16 weeks• Start 2 months before completing therapy• Finish 2 months after ending therapy• Social re-integration programme• Focus on work, education, and

preventative strategies• Remain in the care of OCNS for 6 months

after completing therapy• STARs programme after 6 months –

employed in training and research areas, including a mutual support network

Other OCNS Endeavours• Comprehensive student placement package-

taking up to 5 students at any one time• Friends and Family group – 12 week education

programme plus on-going support group• Consultation group – weekly in various locations

for professionals working with those who have PD• Ethnic minorities group about to be set up• Exploring the possibility of a spoke service in the

local prison• Supervision of Mind group programme• Training and education strategy – to include

support to out-side agencies, and support to staff to develop skills

• Commitment to research and audit

What does integration mean?

• Psychodynamic Psychotherapy +• Sociometric Theory and Practice +• Psychodrama/Action Methods +• Cognitive Behavioural Therapy +• Cognitive Analytic Therapy +• Biological Psychiatry

How do we Integrate these?

• 1 weekly Analytic Group+

• 1 weekly Integrative Therapy Group contained within Community Meetings using democratic TC principles

+• Fortnightly administrative individual

sessions: SCID, Outcome measure tools, CPA.

How do we Integrate these?

• Coupled with the integrative model is a responsiveness to the needs of the group, providing themes for exploration within the group

• Depending on the theme, the leading psychotherapeutic approach is chosen, enabling the mapping of difficulties usually on paper, using CAT, CBT or Sociometric tools.

• The theme is then explored further using psychodramatic techniques, in conjunction with psychodynamic interpretation

Containment

• 24 hour peer telephone support• Consistent boundaries • Self regulation within a democratic

framework • Clear entry and exit processes• Mechanisms for psychiatric

emergencies

Continuity

• Start in pre-therapy group for up to 12 months – with a staff link

• Care transferred to OCNS at 3 months

• Constant core staff team• Graduated social re-integration

program • Six month follow-up

The Group03/05 – 03/07

Entry into therapy 18

PD Diagnosed using SCID-II with 2+

Drop outs 1 at 2 months

Expulsions 1

Successful, planned exits 7

Evaluation - MDS

GP attendance

100 30 70%

CMHT attendance

172 4 97.6%

Psychiatric admissions

138 4 97.4%

Suicide attempts

3 0 100%

Self Harm 82 10 87.8%

Service area Annual prior Annual since Reduction to joining the group joining the group

Evaluation - CORE

Entry into Therapy

10.4 28.9 23.3 4.1

Exit from Therapy 2.7 10 5 0.1

73.9% 65.35% 78.53% 96.55%

W P F R

Cost Savings – 7 completers

Service area

Annual prior to joining

Annual since joining

Reduction in service use

Calculation based on PSSRU data*

Annual cost savings

Inpatient admission days

138 4 97.1% £195 x 134days

£26,130

A & E attendance

Medication

4

£3642,59

0

£768,57

100%

78.9%

£77/contact £308

£2874,02

CMHT Contacts

Crisis Res./ Day Hosp.

£23,220

182

£540

77

97.6%

57.7%

£135/contact

£135/contact

£22,680

£14,175

GP visits 100 30 70% £56.40 x 7.0

£394,80

Total annual savings

£67,111.82

Cost Off-set

Annual capacity - 30Total annual savings - £287 622Service cost - £32 538

Total annual savings - £255 084

Conclusion

Perhaps the results speak for themselves, BUT it is

NOT simply about economic benefit!

These individuals have experienced a dramatic

improvement in quality of life.

Feedback

• “I am now able to live independently – I no longer need my son to be my carer”

• “I never thought I could survive without benzo’s”

• “The group gave me the confidence to facilitate a session and return to college”

• “I never believed I could be angry and be okay”

Tying the Strands Together

• Carey – healthcare professional• Presented in numerous vignettes –

cited as one of most challenging to other health professionals

• Skilfully avoids personal work by working hard on interpretations for others

Situation Feelings NAT’s Evidence

Previous small group

Hurt

Angry

I’m not being heard again.

What’s the point of trying – it’s better to say nothing.

I’m not good enough.

They haven’t listened because I haven’t got what I want.

They challenge my answers therefore they don’t accept them.

They’re always right because they’re staff.