Title: See the PERSON in PERSONality Disorder Civil or Forensic 22 June 2006 John D McGinleyLindsay Johnson
1See the PERSON in PERSONality Disorder Civil
or Forensic22 June 2006John D McGinley/Lindsay
Johnson The State Hospital/Caledonian University
2See the person in personality disordercivil and
forensic
- Losing the person
- Attitudes
- Legal issues
- Clinical issues
- Political issues
- Finding the person
- User focus
- Traumatic experiences
- Emotional intelligence
- Moral maturity
- Clinical governance
3PERSONALITY DISORDERS
- ICD 10 DSM IV
- Paranoid Paranoid
- Schizoid Schizoid Cluster A
- Schizotypal
- Dissocial Antisocial
- Emotionally unstable/borderline Borderline
- Histrionic Histrionic Cluster
B - Narcisistic
- Anxious(avoidant) Avoidant
- Dependent Dependent Cluster C
- Anankastic OCD
- __________________________________________________
________ - Emotionally unstable/impulsive Passive-aggressiv
e - Depressive
- Mental retardation
4DSM IV TR - Personality Disorder
- Personality traits are enduring patterns of
perceiving, relating to, and thinking about the
environment and oneself, that are exhibited in a
wide range of social and personal contexts. Only
when personality traits are inflexible and
maladaptive and cause functional impairment or
subjective distress do they constitute
Personality Disorders. (APA, 2000, p. 686)
5DSM IV TR - Diagnostic Criteria
- An enduring pattern of inner experience that
deviates markedly from the expectations of the
individuals culture. This pattern is manifested
in two (or more) of the following areas - Cognition - i.e., ways of perceiving and
interpreting self, other people and events - Affectivity - i.e., the range, intensity,
lability and appropriateness of emotional
responses - Interpersonal functioning
- Impulse control
6DSM IV TR - Diagnostic Criteria
- The enduring pattern is inflexible and pervasive
across a broad range of personal and social
situations - The enduring pattern leads to clinically
significant distress or impairment in social,
occupational, or important areas of functioning - The pattern is stable and or long duration and
its onset can be traced back at least to
adolescence or early childhood - The enduring pattern is not accounted for as a
manifestational consequence of another mental
disorder
7Clinicians Attitudes to Personality Disorder
- Those patients viewed as not really ill tend to
be ignored - (MacIIwaine, 1981)
- Few psychiatric staff prefer to care for this
patient group and tend to dislike this
population (Moran Mason, 1996) - ..plentiful evidence exists that staff become
alienated from disliked patients. (Bowers,
2002) - ..therapeutic pessimism about PD is widespread
among psychiatric professionals, adding to
profoundly negative attitudes towards PD
patients.. - (Bowers, 2002)
- Recommend no change to current psychiatric
practice regarding compulsory detention
(Personality Disorder Report, Forensic Network
2005)
8Personality Disorders legal and clinical
issuesMH (Care and Treatment) (S) Act 2003
Criteria
- Mental disorder
- mental illness
- personality disorder
- learning disability
- 2. Medical treatment
- prevent worsening
- alleviate symptoms
- available
- 3. Significant risk to person or safety of others
- Compulsion necessary
- 5. Impairment of ability to make decisions about
treatment (civil application only)
9Personality disorders political issue DSPD
Criteria England and Wales
- Criterion 1. Severe PD Significant disorder
of personality - Criterion 2. High risk More likely than not to
commit an offence that might be expected to lead
to serious physical or psychological harm from
which the victim would find difficult or
impossible to recover - Criterion 3. Functional link The risk presented
appears to be functionally linked to the
personality disorder
10Personality disorders political and clinical
issue DSPD Criterion 1 Severity of personality
disorder
- Very high psychopathy PCL-R score 30
- High psychopathy PCL-R score 25-29
- DSM IV-TR PD x 1 (Not APD
- Comorbid PD DSM IV-TR PD x 2
11Personality disorders clinical and political
issue DSPD criterion 2 level of risk
- More likely than not
- Personality disorder
- IPDE
- SCID-1
- Actuarial risk instruments
- VRAG violence risk
- Static 99 sexual risk
- Structured clinical judgement
- HCR 20
- Risk Matrix 2000
-
- Dynamic risk
- VRS
- SARN
12Personality disorders political and clinical
issue DSPD criterion 3 functional link
- Clinical formulation
- Functional analysis
- Patterns of past offending
- Risk type
- Presence of risk related behaviours
13Personality disorders clinical issues co
morbidity
- the co morbidity of Axis II diagnoses and the
degree of heterogeneity within diagnostic groups
raise as yet unresolved questions concerning the
validity of a diagnostic approach - (Roth and Fonagy, 1996)
- Both clinical practice and available research
suggest strongly that an individual can suffer
from both Axis I condition as well as personality
disorder simultaneously - (Lenzenweger Clarkin, 2005)
14Personality Disorders clinical issues
Assessment
- Case and file review
- Categorical model DSM IVTR Axis II SCID-1
- Dimensional model DSM V?
- Self report IPDE
- Statistical Neo-Pi-R (5 factor model)
- Clinical Psychopathy Checklist (PCL-R)
- Emotional intelligence
- Intelligence quotient
- Moral reasoning
- Trauma assessment
- Risk assessment
- Baseline measures (e.g. addictions anger)
- Overall formulation
- Outcome measures
15See the PERSON
- Inner self
- Consciousness
- Subjective experience
- Spiritual
- Mindfulness
- Consistency of thoughts (schema), feelings
(emotions), behaviours (expression) - More than sum of traits
16Personality disorders clinical issues
Treatment idiopathic
- Multiple domains of psychopathology
- Requires combination of interventions tailored to
individual needs. - Common Factors in all cases different
manifestations - Require general and individually tailored
strategies within all treatments - Complex psychological and biological etiology
- Psychological and biological treatment aim to
enhance adaptation - Psychosocial adversity influences the contents,
processes and organisation of the personality
system. - Address all consequences of adversity
- Livesley 2001
17Personality disorders clinical issues
Treatment effectiveness
- Best conceptualised in integrative and
biopsychosocial perspective. - Assessing treatability or amenability to
treatment is critical to maximizing treatment
planning and outcomes. - Effective treatment of personality disorders is
tailored treatment. - The lower the level of treatability, the more
combining and integrating of treatment modalities
and approaches is needed. - The basic goal of treatment is to facilitate
movement from personality-disorder functioning to
personality-style functioning. - Sperry 2003
18Personality disorders clinical issues
Psychotherapeutic models
- Supportive therapy
- Psycho-educational
- Psychodynamic
- CBT/CAT/DBT
- Milieu therapy
- Community
- Pharmacological
Fit treatment to uniqueness of the
person relationships, integration,
combinations, environmental control, staff
consistency multidisciplinary collaboration
19Maladaptive and inflexible thinking
Schema Focused Therapy
Personality disorders Clinical Issues
Psychotherapeutic eclecticism
Poor integration of concept of self or others
Psychodynamic Therapy
Attachment and emotional developments
Psychodynamic Therapy
Reformulation in collaboration
Cognitive Analytic Therapy
Skills training
Cognitive Beh. Therapy
Therapeutic alliance and validation
Dialectical Beh. Therapy
Motivational engagement
Cognitive Beh. Therapy
20Personality disorders clinical issues
Treatment Difficulty in Engaging
- Enduring and relatively stable patterns
- Maladaptive interpersonal behaviour
- Persistent over time
- Label and stigma attached to experience and
distress - Difficult to motivate into engaging in
treatment - Resistant to therapeutic change.
- Previous failed attempts at change.
- Excluded by low motivation and untreatability
- Progress requires coordinated clinical and
social support - Progress requires immersion suitable milieu
- Maintenance requires social integration
- Maintenance requires extended support
21Personality disorders clinical issues
Personality and risk
PD Dynamic Risk Factor
Maintain Clinically relevant behaviours
Sustained Integrated care pathway
Motivate Engage Learning Change
Functional relevance Formulation
Risk assessment-----risk management-----risk
reduction-----public safety Person
engagement-----treatment progress-----community
re-integration
22PERSONALITY DISORDERS CLINICAL ISSUES PERSON
Focused (PFPI)
- needs of the PERSON holistic
- restore self respect
- contract, cooperation, engagement
- match needs with treatment
- adapt to suit PERSON
- system of integration of person experience
- develop new treatments
- evaluate effectiveness
- right place, right time, right treatment
23Emotional Impairment and psychopathy
- Psychopathy identifies one form of pathology
associated with high levels of antisocial
behaviour individuals who present with a
particular form of emotional impairment - The Psychopath emotion and brain
- James Blair et al (2005)
24Emotional intelligence
- Self awareness
- Motivation
- Self regulation
- Empathy
- Social skills
- Goleman 1998
25Emotional competence framework
- Self awareness
- Emotional awareness
- Accurate self assessment
- Self confidence
26Emotional competence framework
- Self regulation
- Self control
- Trustworthiness
- Conscientiousness
- Adaptability
- Innovation
27Emotional competence framework
- Motivation
- Achievement drive
- Commitment
- Initiative
- Optimism
28Emotional competence framework
- Empathy
- Understanding others
- Developing others
- Service orientation
- Leveraging diversity
- Political awareness
29Emotional competence framework
- Social skills
- Influence
- Communication
- Conflict management
- Leadership
- Change catalyst
- Building bonds
- Collaboration and cooperation
- Team capabilities
30Person and moral maturity 1. Stages
- Pre-conventional stage
- State 1 Punishment/obedience
- State 2 Instrumental relativist
- Conventional stage
- State 3 Good boy-Nice girl
- State 4 Law and order
- Autonomous stage
- State 5 Social contract
- State 6 Universal ethical principle
- Kolberg
31Person and moral maturity 2.Qualities
- Stage development is invariant
- Cannot comprehend beyond next stage
- Cognitive attraction to next stage
- Development depends on cognitive disequilibrium
32Personality Disorders Clinical
GovernanceUnderstanding Personality Disorder
BPS June 2006
- Treatment core services in mental health and
forensic settings - Access to specialist multi-disciplinary
personality disorder teams - Multi-agency collaboration
- Clinical and forensic psychologists clinical
leaders - Training of team and agencies essential
awareness of specialisms - Structured assessments
- Focus on formulating persons needs
- User views, user research and user involvement
33Personality Disorders Clinical Governance Royal
College of Psychiatrists Council Report CR 71,
February 1999
- It is the responsibility of psychiatrists to
offer treatment where ever possible - Improve teaching of psychiatry trainees
- Prioritise limited capacity of psychiatric
services - Develop preventive interventions in child and
adolescent services - Develop clearer definition of treatment goals
- Ensure multidisciplinary cooperation
34Personality Disorders ethical issuesChallenge
assumptions
- Harder to engage
-
- Higher attrition rates
-
- Poorer outcome
-
- More clever psychopath!
-
- Service abusers rather than users
- Untreatable
- Alienation disliked patients
- Split the team!
-
35Hope and developments
- Service users stories of hope
- New century re-birth of hope and raising
expectations - Hearing voices networks
- See me
- Proud of our experience
- Improving alliance with service users
- Improved assessment procedures
- Developing effective treatment paradigms
- Collaborative relationships practitioner (the
expert by training) and service user (the expert
by experience)
36ConclusionsPerson distressed by a personality
disorder deserves consideration under mental
health legislation for care and treatmentWhen
assessing the impact of a mental disorder, in all
circumstances, all persons being assessed should
be screened for personality disorder
37WORKSHOP 2
- Covert versus Overt
- Personality Disorder diagnosis?
- What are the barriers to the effective
involvement of service users and staff? - Lindsay Johnston and John McGinley
38See the PERSON in PERSONality Disorder Civil
or Forensic22 June 2006John D McGinley/Lindsay
Johnson The State Hospital/Caledonian University