Annette (35) was admitted to John Munroe Hospital under Section 3 of the Mental Health Act in March 2017 from an NHS Mental Health rehabilitation unit. Annette had a diagnosis of Emotionally Unstable Personality Disorder and an extensive history of deliberate self-harm and suicidal behaviour. Her contact with mental health services dated back to her teenage years, with her first hospital admission occurring at the age of 16 to a CAMHS facility. At the age of 18, Annete made a serious suicide attempt after being discharged from hospital and was subsequently detained under Section 3 of the Mental Health Act. Following this, she had spent most of her life in various hospitals, with one period within supported accommodation, which had ended due to further suicidal behaviour.
Previous reports and documentation indicated that Annette’s engagement with treatment had been limited and her tendency had been to avoid confronting difficult thoughts and feelings. She had continued to exhibit frequent self-harming behaviour and had displayed low motivation and poor self-esteem and confidence.
Upon admission to John Munroe Hospital, Annette was gradually introduced to the MDT and engaged in assessment with both Occupational Therapy and Clinical Psychology. Although Annette was motivated and was able to identify clear future goals, it was evident that she found therapeutic interventions overwhelming as they elicited a range of complex fears and responses. Therefore, a gradual and measured approach was adopted in relation to her care and treatment, steadily building up her tolerance and capacity to engage in therapeutic interventions. As a result, it was noted that Annette’s avoidance of challenging themes progressively diminished as a barrier to engagement.
Following comprehensive multidisciplinary assessment, a team formulation identified a range of adverse childhood experiences which had contributed to the development of Annette’s mental health difficulties. Perpetuating factors included: the impact of limited developmental opportunities on her capacity to manage relationships and build coping skills, anxiety about recovery, unprocessed past trauma, low self-worth and negative self-appraisals, an insecure attachment style and dissociative symptoms.
Collaborative multidisciplinary working facilitated Annette to enhance her coping resources, develop safe and trusting attachments and identify the function of her self-harming behaviour.
Annette was offered weekly Clinical Psychology sessions, which incorporated a Schema-Focused and Attachment Narrative model of treatment, with DBT-informed skills training. Annette’s motivation and commitment to engage in her therapy remained consistently high and her ability to confront difficult and overwhelming themes was gradually increased. She was able to reflect in a thoughtful and insightful manner upon the origins of individual maladaptive schema in her early experiences and worked hard to form more helpful and positive behaviours. Annette was able to develop her skills in distress tolerance, emotion regulation, interpersonal effectiveness and mindfulness, which she used to manage distressing intrusive symptoms as well as to cope more effectively with daily stressors. The adoption of a Limited Reparenting approach by the MDT enabled Annette to test out some of her negative cognitions and experience secure and trusting attachments, which in turn strengthened her own feelings of hope and identity.
Annette engaged in regular Occupational Therapy sessions which focused upon developing her functional skills and coping strategy enhancement. Annette benefitted greatly from these sessions which contributed to improving her confidence, self-esteem and range of ADL skills.
Over the course of her admission, the frequency and severity of Annette’s self-harm reduced and she had increased community access. Following an admission of 18 months, Annette was discharged into supported accommodation