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Personality Disorder Therapeutic Environment

The Acorn Programme delivers a comprehensive (full) programme of Dialectical Behaviour Therapy (DBT) within an accredited Therapeutic Community. We were winner of the Specialist Provider of the Year at the 2014 Independent Healthcare Apex Awards.

Who we work with

The women we work with often meet the criteria for:

  • Borderline Personality Disorder
  • Complex Post Traumatic Stress Disorder

They usually experience repeated attendance at A&E, recurrent crisis admissions and chaotic lifestyles. Some have had extended admissions to acute services, but require further support to transition successfully into the community. The women have often been unable to cope with community based therapy services such as DBT or day therapeutic communities requiring additional containment to address the patterns of behaviour and relating to others that prevent them finding a ‘life worth living’.

Our Approach

We offer a three-strand model in which we treat the person not the diagnosis. Our mantra is simple: Turn up, Tune in and Tell the Truth.

Comprehensive DBT Programme

The Acorn Programme delivers a comprehensive (full) Dialectical Behavioural Therapy programme in accordance with NICE Guidelines CG78.

The five functions of a comprehensive DBT programme are met through the provision of:

1. Weekly Skills training group, delivered by DBT trained staff, to enhance client capabilities by formally teaching them mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance skills (1.5 hours)

2. Weekly Individual DBT Intervention with a DBT therapist to improve client’s motivation and reduce factors impeding progress (1 hour)

3. Skills coaching in person or via telephone to support women to have additional help to generalise skills (as frequently as required - please see Acorn Unit Guide for further details)

4. DBT is embedded within the entire group programme to ensure the environment is structured to promote client’s skilful behaviour. All qualified staff are trained at a minimum of DBT Foundation level, and support workers attend a 2 day DBT Skills Essentials Workshop.

5. Weekly DBT Consultation meeting to enhance therapists’ capability and motivation and to ensure consistent adherence to the DBT model (1 hour)

Occupational Engagement

Occupations bring purpose and meaning to life. They include things people want to, need to, and are expected to do. They may include things we do for pleasure, restoration or to be productive. Often the women we work with may have occupational glimpses of how the future may be, yet struggle to enact their ideas.

This strand of the Acorn Programme focuses on helping women to find a balance that meets their unique occupational needs, and that can be transferred post-discharge to support a sustained recovery.  There are several elements including a continually evolving Life skills group based on the needs of the current group members, a project group which includes opportunities to engage in voluntary work within the organisation, a cooking group (as required) and individual specialist Occupational Therapist assessments. Occupational Engagement Support Workers provide support to engage in meaningful, socially inclusive occupation. This floating support varies based on individual needs, and includes both emotional and practical support to build a ‘life worth living’.

As the women cook for each other at weekends they are supported to achieve a Level 2 Food Safety and Hygiene for Catering Certificate (including City and Guilds accreditation). There are also opportunities to complete formal qualifications in First Aid. 

Living-Learning Environment

The Acorn Programme takes the core attachment values of a Therapeutic Community and applies them in a model which focuses on the rehabilitation and reintegration of the women back into the community.

Established in 2000, The Acorn Programme was the first community accredited by the Royal College of Psychiatrists through the Community of Communities in 2007.

Community of Communities

Working in groups helps women with the interpersonal difficulties associated with complex trauma to practise intensely the interpersonal effectiveness skills learnt within our comprehensive DBT programme. Trust is a significant issue that arises and the experience of groups enables women to learn to recognise what others are experiencing, mentalise and form and maintain relationships through the process of living with others who have similar difficulties. Much learning can come from understanding one another, and supporting each other in the process of change. Therapy comes from participation in the whole programme and women must be committed to embracing this. It should be noted that alongside group therapy work, women also engage in individual therapy work.

Within the living-learning environment, women share their daily life with others, and take responsibility for sharing decisions about how to live together. We expect the women to contribute to keeping the treatment safe and therapeutic, both by acting responsibly themselves and by helping others think about the effect of their behaviour on the unit.

We encourage a ‘culture of enquiry’ in which everyone can question the conduct of any other individual or group of individuals, psychological processes (‘I wonder what made you do that’), and managerial issues. Such questioning is an important learning opportunity, for those asking the questions and for those questioned.

Everything that happens in the community is open for discussion. We have a principle: ‘if you have a secret, you have a problem’. For many people the letting go of the need to keep parts of their lives hidden is a major part of their therapy.

The Acorn Journey

Referral

A referral would need to be made by a health professional currently working with the individual, which would usually be an individual’s current hospital team or current Community Mental Health Team (CMHT). One of our admission criteria is that an individual has an allocated Care Coordinator from their local CMHT. Our admissions are usually NHS funded by an individual’s local Clinical Commissioning Group (CCG) – the CMHT would need to approach the NHS funders about making the referral. Although our assessments are offered free of charge, we would need to ensure the responsible CCG were aware of the referral being made.

Assessment

An assessment for the Acorn Programme would need to take place here at The Retreat. It is formed of three main elements: firstly, an individual appointment with either our Consultant Psychiatrist or Clinical Psychologist; a tour of the unit and lunch with the Community; and a group with the Community to learn more about the therapy, understand the individual’s difficulties and what the individual hopes to achieve from the programme. The visit is intended to give the individual an idea of what therapy on Acorn would be like: although this can feel daunting it is an important part of understanding how it might be to be on Acorn. We would write to the individual following the assessment, and ask she writes to us. Our report would enable her team to apply for funding. If funding is agreed, an admission date would be scheduled. 

Pre-admission

In the two weeks prior to an admission date, the individual makes daily contact with staff from the unit to support her to achieve the pre-admission boundaries of not engaging in self-defeating behaviours. In our experience, the hope of coming to the Acorn programme to address their underlying difficulties can enable women to achieve something they have not previously been able to do.

Admission

The first two weeks of the programme are known as ‘pre-commitment’ when women have the opportunity to see what it is like to live at Acorn. Acorn is not for everyone and it is essential that the women who use the programme are able to make an informed decision about being here. If it does feel right, towards the end of the second week, the individual reads a commitment statement and from this point on engages in the programme in its entirety. A full outline of the therapeutic programme and a description of the groups and individual work is detailed in the Acorn Handbook.

Interventions Provided

  • Dialectical Behaviour Therapy
    • DBT Skills Group
    • DBT Individual Intervention
    • DBT skills coaching
  • Support Meetings
  • Intensive group psychotherapy programme including
    • Small psychotherapy group
    • Twice daily community meetings
  • Individual psychotherapy
  • Art therapy
  • Eye Movement Desensitization and Reprocessing (EMDR) when clinically appropriate
  • Dietetics
  • Occupational Therapy
  • Social Work
  • Living-Learning environment

Transition and Discharge

The full Acorn Programme lasts 8 to 12 months and during this time women acquire the skills they need to live in the community and manage their distress so they are able to engage in a meaningful life worth living. Periods of leave to their home area enable women to test out and consolidate these skills. 

Post-discharge

The graduate group is facilitated on a monthly basis for women who complete the programme.

The Team

The team includes registered mental health nurses, a Consultant Psychiatrist, a Consultant Clinical Psychologist, and an Occupational Therapist, as well as input from other professionals such as a Social Worker, an Involvement Worker, a Dietitian, and sessional therapists for art and other creative therapies. The team members are all trained in DBT to varying levels and are experienced in working therapeutically with this client group.

Outcomes

  • Reduction in self harm
  • Reduction in inpatient admissions
  • Reduction in dissociation
  • Improved ability to manage emotions
  • Improved healthy relationships
  • Improved quality of life
  • 2016 Clinical Outcomes

The Acorn Community shares its practice with others through publication of papers, presentations at conference and other relevant meetings. We have published clinical outcomes in peer-reviewed journals & conferences. Our Consultant Psychologist was lead author of the recent Guideline for the treatment and planning of services for complex post-traumatic stress disorder in adults, published by the UK Psychological Trauma Society.

For further information or to make a referral please call Amy Bedingham on 01904 420910 or email info@theretreatyork.org.uk.

Eligibility Criteria

  • Meet the diagnostic criteria for either:
    • Personality Disorder
    • Complex Post Traumatic Stress Disorder
  • Working age females.
  • Informal and Formal (must be able to work towards being informal before admission in order to fully engage with the programme).
  • Motivation to change; willingness to engage in group programme and therapy.
  • Has a Care Co-ordinator from the Community Mental Health Team (CMHT).

 Exclusion Criteria

  • Psychotic disorders
  • BMI below 17
  • Moderate to severe Learning Disabilities
  • Recent violence or aggression to others

 

 

 

Useful Documents