At time of admission, Margaret was a 57-year-old lady living in South Wales with a lifelong trauma history.
With an exceptionally supportive husband and family, Margaret is highly intelligent and had enjoyed a successful professional career, but nevertheless she is still fighting with past events in her life.
Difficulties connected to childhood trauma led her to develop self-harm as a way of coping, resulting in numerous hospital admissions over more than 20 years. She would go through phases of small improvements, but without the underlying issues ever being fully addressed she would regularly relapse.
Margaret’s was eventually diagnosed as Emotionally Unstable Personality Disorder, and as time progressed her self-harm caused increasing concern about risks to her life.
Her feelings of low self-worth, hopelessness and distress at times lead to suicidal thoughts and behaviours. She would ligate, overdose on medication and had been found walking on train lines and attempting to drown herself. Whenever she was at home she wouldn’t leave the safety of her room.
When at her lowest, her community mental team were concerned that her intrusive thoughts and threatening actions and statements suggested she might pose a threat to others as well as herself. Additionally, there had been a break down in her relationship with the team.
As a consequence, it was decided to admit Margaret to Heatherwood Court hospital under Section 3 of the Mental Health Act, where she was placed in a locked rehab ward.
What did Margaret and her Commissioners hope to achieve?
Margaret’s commissioner’s principal objectives were to provide Margaret with access to psychological and therapeutic support, as well as access to an environment where her risks could be better managed and understood with a view to a safe community discharge.
On admission, Margaret’s MDT asked her what she herself hoped to achieve, and she replied that she wanted:
- To have a healthy relationship with her husband and family,
- To be able to go out and function in society again,
- And critically, she wanted to feel safe again and to be able to trust that people were not out to harm her.
What did the team at Heatherwood do to support Margaret’s recovery?
Heatherwood were able to provide Margaret with the support of a specialised team that have experience of dealing with people with complex needs who receive a diagnosis of EUPD.
After Margaret’s initial assessment, it was determined that there was no need to amend her medication but that she should be encouraged to engage with psychological therapists and take a psychosocial recovery route. Margaret was introduced to Cognitive Behavioural Therapy (CBT) which she had never had before. Margaret was highly motivated to engage in her recovery path, but she had never felt that she had been offered a treatment that was tailored to her personal needs.
Her CBT was formulated around the target of helping her better manage her mood and anxiety. Clinically, it was felt that this was key in supporting a safe discharge since her concerns around personal safety were a major trigger for Margaret’s most distressing symptoms.
As the formulation was linked to supporting with what had become a phobic response to spending time outside of her home, psychological treatment was integrated with Occupational Therapy. Whilst a number of members of her MDT were skilled in delivering CBT it was noted that she engaged particularly well with one of our Occupational Therapists, so it was agreed that this OT should take the lead in delivering the CBT, with the Clinical Psychologist supervising and overseeing the work delivered. This excellent working dynamic was undoubtedly key to Margaret’s speedy progress.
Margaret was also introduced to smart goal planning. She really committed to this approach as it provided the objective validation she needed and improved her feelings of self-worth. Smart goal planning allowed her to feel listened to, to have choices rather than having decisions imposed on her, and ultimately to have control over her treatment plan.
As a result of her clear engagement with her recovery plan, the team, in partnership with Margaret, identified that she was safe enough to take positive risks. She was enabled to go home on leave, and this was built up from one day to two days to an overnight 3-day weekend leave, with Margaret returning to Heatherwood mid-week.
Margaret was enormously proud of her progress. During her weekends at home, she would actively go out and practice the skills that she’d been learning during her group and individual sessions. She set herself small achievable goals and gradually exposed herself to her phobias. As an example, she progressed from visiting a supermarket and sitting in the car while her husband shopped, to going in to the shop with her husband, to finally confidently going in and shopping on her own. Each week when she returned to Heatherwood she would be beaming with joy and anxious to share all her successes.
An often-overlooked aspect to a patient’s recovery is the involvement of family. With Margaret’s consent, the “triangle of care” model was used, and her husband would join MDT meetings, so he was also fully involved in Margaret’s recovery pathway and was able to offer indispensable support in the structured use of leave and Margaret’s transition back into the community.
What were the outcomes for Margaret?
Due to the individualised care delivered by a clinical team that were skilled in working with her complex difficulties, Margaret only needed to stay at Heatherwood for 4 months before she was able to step-back down and return to her husband and home.
She liked that she felt respected and actively involved in setting personal goals and managing her own recovery. Her team quickly built trust with her; she appreciated their collaborative approach and that they would actively listen to her and be willing to adapt to her needs.
Her relationship with her community team has been restored, she is happy to engage with them, and she is being offered further psychological treatment in the community. She has gone a long way to addressing her social phobias and no longer hides in her room; she feels safe to be out in the community again.
Most importantly for Margaret she is less anxious about the detrimental affects her psychological difficulties might be having on her relationships and she can see a happy future again for both her and her family.
In Margaret’s own words: “Thank you all so much for making me feel valued enough to make me feel that I could make changes to my life that are sustainable and will ensure a better quality of life for the future.”