Day Unit

Halliwick Psychotherapy Day Unit is located within St Ann's Hospital, Tottenham, London, and forms part of the services of Barnet, Enfield and Haringey Mental Health NHS Trust.

It is recognised as a specialist treatment unit focusing on the needs of individuals with severe emotional and behavioural disturbance. It has been awarded NHS Beacon Status for good practice in the treatment of Personality Disorder.

Up to 20 places are provided for the residents of Haringey and Enfield. The majority of patients referred have already been treated within the general psychiatric services and have received more than one diagnosis. Most patients attract a dual diagnosis of severe affective disorder and personality disorder and have a long history of debilitation, trauma and emotional distress. Their distress is often presented in maladaptive ways, such as self-mutilation, taking overdoses of medication and engaging in other self-destructive actions. Most individuals have failed to respond to treatments within a general psychiatric setting and have spent some time on inpatient units with little improvement.

Aims of Treatment

There are five major aims of the treatment programme:

• Engagement in a therapeutic relationship
• Reduction in psychiatric symptoms
• Reduction in self-destructive and suicidal behaviour
• Improvement in social and interpersonal functioning
• Development of an internal sense of stability and trust

The first task is for staff to engage with an individual to ensure a trusting relationship is built up. Most patients referred to the unit are distrusting of services and are in such a state of despair that they do not believe any treatment can be effective. We are very active from the outset of treatment in addressing social/logistical obstacles to treatment, agreeing short-term goals with patients, and identifying the likely areas of frustration and motivation that may cause patients to want to drop out of treatment. We also have a very active policy of outreach to patients to try to maintain a dialogue, and promote reflection on the factors that may have prompted a withdrawal from treatment.

The second aim is to reduce psychiatric symptoms. Medication is used according to evidence-based prescribing guidelines. Aspects of the programme target specific psychiatric symptoms, such as affect control, anxiety, and dissociation.

Thirdly, it is important to reduce self-damaging and suicidal behaviour. Staff and patients develop an individualised system of continually monitoring such impulses. At the same time the compulsive reasons for such acts are explored. Moreover, there is a skills based part of the programme, which specifically aims to equip patients with greater tolerance of distress and alternative ways of managing impulses.

With regard to hospital admission, we have a strict programme of ensuring patients cannot be admitted through emergency channels without a member of the Day Unit staff being contacted. If a patient requires admission, this is arranged through the Day Unit staff who liase with the inpatient team. A patient leaves hospital at the earliest possible moment. Compulsory admission is avoided if possible and patient-determined admission and discharge encouraged.

Our fourth aim is to improve social and interpersonal function. This is done through an extensive programme of group psychotherapy. Some groups explore the factors contributing to difficulties in social and interpersonal functioning, whilst other groups focus on more specific aspects of patient's difficulties and are problem-orientated.

Finally, the aim of individual and group psychotherapy is not only to help in social adjustment and to reduce psychiatric symptoms but also to bring about permanent changes in an individual's personality and inner world in order to promote lasting psychological maturation, rather than just symptom amelioration. Conflicts within the minds of individuals lead to the formation of psychiatric symptoms and disturbance in relationships. The identification of these conflicts and their understanding within a therapeutic relationship provides relief of symptoms and allows personal maturation, which is long lasting.

Treatment Approach and Programme

Treatment is delivered by a team of nurses, doctors and occupational therapists under the supervision of a consultant psychiatrist in psychotherapy. The programme is based on a modified psychoanalytical approach, comprising group psychotherapy sessions five days-per-week (see below for programme timetable), and one individual psychotherapy session per week.

The key principles of the approach adopted with this patient group are:

• Team cohesion so that patients receive a consistent, reliable response which is important in the process of developing a sense of internal stability in the patient
• Promotion of thinking and reflection with patients about self in relation to others at all times
• Validation of patients' experiences with emphasis on identifying its affective and relationship context
• Neutrality in response to self-damaging and suicidal behaviour

A detailed manual of the treatment approach described here is in the process of being written.

Click here to view the group timetable.

Click here to view the Patients' Introductory Leaflet.