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PROPOSAL FOR
A THERAPEUTIC DAY SERVICE.

A locally based, small-group oriented, 5-day, daytime therapeutic community.

• Patients with personality disorder-type problems are high users of psychiatric outpatient, inpatient and emergency services as well as general practice, accident and emergency and social services.

• Managing patients in this group places stresses on infrastructure and staff. They have long-term problems and prove difficult to contain in Community Mental Health Teams.

• This area currently has no means of dealing with these patients effectively.

• There is convincing evidence for the effectiveness of intensive psychotherapeutic day services in this area.

• Refer such patients outside this area, with little control over cost and effectiveness.

• Continue with current arrangements with lack of coherent and effective care and treatment.

• Implement proven model in this area making effective use of existing skills and resources.

• A psychotherapeutic day service specialising in the containment and treatment of patients with Axis II disorders to meet these needs at reasonable cost with a favourable cost-offset.

• The unit should be set up with rigorous assessment procedures in place to monitor effectiveness.

• The unit would provide an opportunity for staff to experience effective working with this group and to train in managing their particular problems.

2. BACKGROUND

• There is at present a gap in the provision of services for adults with severe and enduring mental illness who would benefit from intensive medium-term treatment, but who cannot be adequately contained and treated as outpatients. This group includes patients with non-forensic severe personality disorders as well as chronic treatment resistant affective disorders, somatoform disorders, and other intractable neuroses. A psychotherapeutic day service specialising in the containment and treatment of patients with Axis II disorders would meet this need at reasonable cost with a favourable cost-offset.

• Although such services are often targeted at patients with emotionally unstable personality disorder/borderline type, other personality disorders are common in referral groups.

• Patients with other intractable non-psychotic mental disorder are also commonly referred and treated in these units.

• Patients in these groups who cannot be adequately treated with pharmacotherapy and community support or outpatient psychotherapy are often frequent users of NHS services. They use primary (GP) and secondary (Community Mental Health Teams) services, and many are repeatedly admitted to psychiatric inpatient units.
• One of the characteristics of this group is that they often evoke high levels of anxiety in carers, relatives and professionals. They tend to have relatively frequent, often escalating, contact across a spectrum of services including mental health, social services, accident and emergency, general practitioners and the legal and penal systems. They present in various ways but to mental health services often with the following factors:

recurrent deliberate self harm

various, often fluctuating, symptoms of clinical depression and anxiety

eating disturbances

interpersonal problems, which may include violence

substance abuse

behavioural difficulties, including criminal offences.

somatic symptoms without physical pathology

A pattern of short-term and crisis-driven service responses is ineffective, costly and, for many patients, counterproductive. The personal, social and health service costs for patients are high in terms of "ineffective work patterns, chaotic family and interpersonal functioning, the social inheritance of mental disorder, the social and personal costs of substance abuse, and the inappropriate utilisation of health care services" according to Roth & Fonagy's Department of Health sponsored review ('What works for whom? A critical review of psychotherapy research', Guilford 1996). They suggest that more intensive longer-term treatment responses be used.

2. PROPOSAL

The core service need can be met by the provision of an intensive Psychotherapeutic Day Unit. This service would provide a range of group oriented psychological therapies aimed at enabling patients to cope more adaptively with their intense emotional states and problematic interpersonal relationships, helping them develop the capacity for self-management. The overall programme will be managed within a therapeutic community framework, which provides containment of the patients' distress and promotes their acceptance of personal responsibility. This model is the most widely accepted and practised approach with this group of patients and is based on that of the Henderson Hospital, which has been commissioned as the national provider for the small proportion of these patients who can only be treated within a residential environment.

2. Advantages of the non-residential model

The non-residential model has several advantages over the residential model. Patients are able to maintain existing relationships within their home area, which are likely to be important in the period following treatment. Housing provision can also be maintained. At the same time dependency is discouraged, and there is an opportunity to practice newfound social skills and confidence in a non-protected environment over the weekends and evenings. Finally, the non-residential model is substantially less expensive than providing overnight care.

Based on ideas of collective responsibility, citizenship and empowerment, therapeutic communities are deliberately structured in a way that aims to encourage responsibility and avoid unhelpful dependency on professionals. Patients are seen as bringing strengths and creative energy into the therapeutic setting, and the peer group is seen as all-important in establishing a strong therapeutic alliance. The work with each patient will be designed to be at multiple levels of psychological functioning: individual personality structure, social relationships, basic skills of living and working, and family relationships. Patients will work in a range of groups, some exploratory/analytic, some cognitive/behavioural and psychoeducational/problem focussed. Family services, psychiatric medication consultation, outreach and follow-up will provide additional support. Length of stay will be from 12-18 months. Aftercare/follow-up will include liaison with employment and housing bodies.

4. Support outside operational times

Informal mutual support networks outside operational times (overnight and at weekends) have been found to be effective in containing patients until the community reconvenes, involving minimal use of out of hours services. Use of psychiatric inpatient facilities, emergency and out of hours psychiatric services, and Accident and Emergency all typically reduce as a function of how far the individual has progressed through the service. Although patients would usually retain their RMO, involvement with them would be expected to be minimal once the patient was engaged in the programme.

Referrals would be accepted from general practitioners, psychiatrists and other members of community mental health teams, mental health professionals in specialist services (such as Psychological Therapies Service and Clinical Psychology), social workers, and doctors in specialties other than psychiatry.

There is convincing evidence that a psychotherapeutic day service can meet the needs of this patient group, and that gains from medium term intensive treatment are retained as measured by subsequent reduced service usage and psychological distress. This has been recognised by the NHS National Specialist Commissioning Advisory Group, which noted that 'There is now good evidence in the effectiveness of the therapeutic community model' in the treatment of patients with personality disorders (not just Borderline PD). This appraisal has led to NSCAG designation for two new residential therapeutic communities, as it is now regarded as a 'proven effective service' (Annual Report 1998-1999). The related 'partial hospitalisation' day service model has provided the most convincing evidence of efficacy of any treatment modality for patients with personality disorder.

2. BENEFITS

The Trust business plan for the year 2000/2001 prioritises measures to reduce psychiatric readmission rates and continued reduction on inappropriate OATS. Implementation of this proposal would contribute to both these aims.

• Reduction of inappropriate in-patient bed usage
• Reduction in inappropriate and stressful service demands on Community Mental Health Teams
• Reduction of demand for expensive placements (OATS) and for other local specialist treatment facilities
• Cost offset for Community Mental Health Teams.
• Training placements for SHOs/SpRs, CPNs, ward nurses, psychology students (day or block placements)

2. To patients

· Stabilised patterns of work and family functioning

· Independence of service support

· Reduced risk of suicide, self-harm and substance abuse

· Developmental and support needs appropriately addressed through highly valued talking treatments.

3. To Health and Social Services

• Reduction in attendances at GP surgeries
• Improved risk management of suicide, violence and legal/complaint actions
• Reduction in a wide range of other attendant social costs including demands on Child Protection and Probation
• Intervention in the cycle of inter-generational production of mental disorder
• Cost offset for GPs.

The unit would make substantial contributions in the following areas targeted by the National Service Framework (NSF).

• Involvement of service users in planning and delivery of care (Developing the NSF, p5): this is a central tenet of therapeutic community operation.
• Development of services to reduce the psychiatric admission rate (Performance assessment, p12), particularly targeting deliberate self-harm (p22)
• The balance of hospital beds with day services (Service models, p12)
• Services as close to the patient's home as possible (Standard 5, p11)
• Improved access to psychological therapies and rehabilitation services (Performance assessment, p12)

A thorough evaluation of the proposed unit is considered essential. Research findings and clinical expertise will be widely disseminated throughout Health and Social Services across the Trust.

A typical weekly itinerary might look as follows.

Sufficient to accommodate 18-24 patients, including a single large room and accommodation for 3-4 small groups.

Consultant Psychiatrist in Psychotherapy

Clinical staff and group convenors with a range of backgrounds and skills for community groups, analytic, cognitive/behavioural and other small groups, large group.

Administrative staff: medical secretary/receptionist

Consultant: £64,000

Clinical staff (including group convenors): 34 sessions @ £3,000 per session=£102,000

Administrative staff: medical secretary/receptionist 2xWTE's @£12,000=£24,000

Non-staff costs: approximately £20,000 (based on a similar unit in Reading); dependent on availability of existing building /lease, running costs related.