The Peaks Unit: Developing an Integrated Treatment Model

1. The Peaks Unit: Developing an Integrated Treatment Model Dr Todd Hogue Paper presented at: Care not containment: Interventions for mentally disordered individuals 24-25 June 2004, Royal Moat House Hotel Nottingham, UK todd.hogue@nottshc.nhs.uk

2. DSPD: The Challenge • Untreatable? • Psychopathy • Personality Disorder • Difficult to manage Impulsive Aggressive Manipulative Predatory Volatile Attention Seeking Needy Violent Vulnerable Emotionally Labile Self Harming Dr Todd Hogue, The Peaks Unit, Rampton Hospital

3. What Kind of Patients? • A couple of examples… Dr Todd Hogue, The Peaks Unit, Rampton Hospital

4. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

5. 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 1 - JP Dr Todd Hogue, The Peaks Unit, Rampton Hospital

6. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

7. 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 Case 2 - JU Dr Todd Hogue, The Peaks Unit, Rampton Hospital

8. The Task • An integrated approach to assessment and treatment Dr Todd Hogue, The Peaks Unit, Rampton Hospital

9. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

10. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

11. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

12. What is an integrated model? • Whole person assessment • Multiple assessments • MDT working • Team decisions • Agreed targets • Information fed into Individual Development Plan (IDP) Dr Todd Hogue, The Peaks Unit, Rampton Hospital

13. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

14. INDIVIDUALISED ASSESSMENT • Whole Person Approach • Comprehensive Assessment • Identify Dynamic Factors • Target deficits/Criminogenic needs • Treatment Hierarchy/Prioritise needs Dr Todd Hogue, The Peaks Unit, Rampton Hospital

15. Patient Focused • Client Centred • Needs and deficits • Strengths and abilities • Patient involvement • Motivational structure • Collaborative Dr Todd Hogue, The Peaks Unit, Rampton Hospital

16. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

17. Integrated Treatment Plan • Integrate assessment information • Case formulation • Shared treatment formulation • Individual development plan • Coherent and consistent documentation Dr Todd Hogue, The Peaks Unit, Rampton Hospital

18. 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. Dr Todd Hogue, The Peaks Unit, Rampton Hospital

19. Clinical Intervention Diagrammatic Representation A S S E S S M E N T W A R D First stage assessment Dr Todd Hogue, The Peaks Unit, Rampton Hospital MOTIVATION Building the relationship and therapeutic alliance

20. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

21. Clinical Intervention Diagrammatic Representation S T A N D A R D I S E D A S S E S S M E N T A D M I S S I O N T O T R E A T M E N T W A R D Good lives Dispositional A S S E S S M E N T W A R D Motivation Symptomatic Situation - environment Regulation/ control Interpersonal Self / cultural issues Risk/Offence Behaviour First stage assessment Second stage assessment Recorded in Integrated Treatment Plan: Individual Assessment Information Section Individual Development Plan for engagement with the assessment process Dr Todd Hogue, The Peaks Unit, Rampton Hospital MOTIVATION Building the relationship and therapeutic alliance

22. 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) Individual Assessment Information Dr Todd Hogue, The Peaks Unit, Rampton Hospital

23. Clinical Intervention Diagrammatic Representation S T A N D A R D I S E D A S S E S S M E N T A D M I S S I O N T O T R E A T M E N T W A R D Good lives Dispositional A S S E S S M E N T W A R D Motivation F O R M U L A T I O N Symptomatic Treatment Needs & Pathway What & Why? How? When? N1 (need) H1 (hypothesis) T1 (treatment) Situation - environment Regulation/ control Interpersonal Self / cultural issues Reviewed and agreed by therapy team. Transferred to Integrated Treatment Plan: Individual Formulation Section Risk/Offence Behaviour First stage assessment Second stage assessment Recorded in Integrated Treatment Plan: Individual Assessment Information Section Individual Development Plan for engagement with the assessment process Dr Todd Hogue, The Peaks Unit, Rampton Hospital MOTIVATION Building the relationship and therapeutic alliance

24. 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” Dr Todd Hogue, The Peaks Unit, Rampton Hospital

25. Clinical Intervention Diagrammatic Representation I N D I V I D U A L D E V E L O P M E N T P L A N S T A N D A R D I S E D A S S E S S M E N T A D M I S S I O N T O T R E A T M E N T W A R D Good lives Dispositional A S S E S S M E N T W A R D Motivation F O R M U L A T I O N Prescribing Multidisciplinary Intervention Symptomatic Treatment Needs & Pathway What & Why? How? When? N1 (need) H1 (hypothesis) T1 (treatment) Monitoring Behaviour Situation - environment Regulation/ control Evidencing Change Interpersonal Self / cultural issues Reviewed and agreed by therapy team. Transferred to Integrated Treatment Plan: Individual Formulation Section Risk/Offence Behaviour First stage assessment Second stage assessment Recorded in Integrated Treatment Plan: Individual Assessment Information Section Recorded in Integrated Treatment Plan: Individual Development Plan Section Individual Development Plan for engagement with the assessment process Dr Todd Hogue, The Peaks Unit, Rampton Hospital MOTIVATION Building the relationship and therapeutic alliance

26. Individual development plan • Focuses on treatment need • Aim of interventions • Objectives Group Individual Environmental • Specified “success criteria” • Regular – identified review process • Evidenced evaluation Dr Todd Hogue, The Peaks Unit, Rampton Hospital

27. Clinical Intervention Diagrammatic Representation I N D I V I D U A L D E V E L O P M E N T P L A N S T A N D A R D I S E D A S S E S S M E N T A D M I S S I O N T O T R E A T M E N T W A R D Good lives Dispositional A S S E S S M E N T W A R D Motivation F O R M U L A T I O N Prescribing Multidisciplinary Intervention Symptomatic Treatment Needs & Pathway What & Why? How? When? N1 (need) H1 (hypothesis) T1 (treatment) Reviewed by Therapy Team (CPA) Monitoring Behaviour Situation - environment Regulation/ control Evidencing Change Interpersonal Self / cultural issues Reviewed and agreed by therapy team. Transferred to Integrated Treatment Plan: Individual Formulation Section Risk/Offence Behaviour N2 (need) H2 (hypothesis) T2 (treatment) First stage assessment Second stage assessment Recorded in Integrated Treatment Plan: Individual Assessment Information Section Recorded in Integrated Treatment Plan: Individual Development Plan Section Individual Development Plan for engagement with the assessment process Dr Todd Hogue, The Peaks Unit, Rampton Hospital MOTIVATION Building the relationship and therapeutic alliance

28. Individual treatment formulation Includes: • Responsivity & therapeutic engagement issues • Clear hierarchy of need • Identified treatment options • Clear alternatives pathways Dr Todd Hogue, The Peaks Unit, Rampton Hospital

29. 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 Dr Todd Hogue, The Peaks Unit, Rampton Hospital

30. 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 todd.hogue@nottshc.nhs.uk Dr Todd Hogue, The Peaks Unit, Rampton Hospital