Personality disorder integrated care pathway
1. The individual wishing to have structured admissions should be made aware that they are
an alternative to crisis admissions.
2. The number of structured admissions per year will be identified at the start of each year and
will be linked to the care plan based upon individual need. The composition of the team
should remain consistent across admissions, as far as possible.
3. The maximum number of structured admissions per year is four. The program can also
commence with three structured admissions per year. The annual number of admissions
reduces by one each year. Once the individual progresses to a single admission in a year,
needs will be reassessed.
4. Though structured right from the start, these admissions do not happen automatically. Each
admission will be on the merit and benefits of the previous one - how this has helped the
individual cope with stress, how the coping strategies learnt have been made use of when in
crisis etc.
5. There will be no medical input during admission except for technicalities of admission and
discharge.
6. The focus is on de-stressing and learning ways to manage distress in the context in which it
arises, rather than medicalising the issue.
7. If there are difficult dates or anniversaries, admissions can be planned around theses dates.
Planning needs to be done before structuring the admissions.
8. Intense Nursing, Occupational Therapy and Physiotherapy input will be provided as
planned before each admission.
9. No other psychology/ psychotherapy session will be possible during the admission week, if
some one is already in psychological treatment, the individual is expected to rearrange
those sessions which occur during the period of admission. This should not prove
problematic as structured admission weeks are known to the individual from the start of the
year.
10. Structured admission is from Monday- Friday morning, no passes are usually allowed during
this period. Patients are encouraged to keep visitors to a minimum during the admission
period, as this can negatively impact upon the de-stressing process and contribute to
valuable loss of time which could otherwise be spent working with the team.
11. Structured admission is from Monday- Friday morning, no passes are usually allowed during
this period. Patients are encouraged to keep visitors to a minimum during the admission
period, as this can negatively impact upon the de-stressing process and contribute to
valuable loss of time which could otherwise be spent working with the team.
12. Individuals undertake not to engage in self harming behaviours, alcohol or drug use during
admission. Such behaviours could lead to early discharge.
13. The individual is expected to take responsibility for their own treatment.
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Structured Admissions Program
This program was developed for patients with personality disorder who had multiple crisis admissions. It allows patients and the treating team to schedule:
- 4 one-week admissions in year 1,
- 3 one-week admissions in year two, 2 one-week admissions in year 3 and,
- 1 one week admission in year 4, providing that crisis admissions are avoided.
Each admission will have a specific goal or goals which will be worked towards using a CBT-type framework.
These admissions are not used for other purposes, for example medication changes etc. The program is arranged by the user’s sector consultant psychiatrist. Continued contact with the Community Mental Health Services must be maintained and the person must have a named key-worker in the community. Essentially the Structured Admissions Program is a team approach, with all the team members and the individual aiming towards an increase in structure, stability, confidence and independence.
The agenda for each admission will be discussed and agreed at a multidisciplinary meeting of the patient together with relevant community and hospital based clinicians at least 4 weeks before the admission. Clinicians should be cautious of adapting this intervention without fully considering the behavioural contingencies and risk-benefit balance of any adaptation. The Structured Admissions Program as originally conceived represents a Phase 1 intervention.
The evidence base for this intervention is comprised of non-experimental, descriptive evaluation. There should be a clear clinical rationale for considering this intervention over other Phase 1 interventions such as DBT or STEPPS with more robust evidence bases. There is unlikely to be any added benefit in an individual engaging in both a psychological therapy like DBT and the Structured Admissions Program. In fact, there may be theoretical conflict.