PERSONALITY DISORDER A WELSH PERSPECTIVE

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PERSONALITY DISORDER A WELSH PERSPECTIVE

• JENIFER CLARKE-MOORE
• Nursing Officer
• Dept of Public Health and Health Professions

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Aims of Session

• Provide an Overview of Government Strategies and
  discuss high level changes in Wales
• Consider the implications of NICE Guidelines on
  Borderline Personality Disorder 2008

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CURRENT SITUATION

• 22 gt8 Local Health Boards
• 14 gt71 NHS Trusts
• Urban v rural
• Partial devolution

4
Health Strategies/Policies (examples)

• One Wales joint manifesto
• Wales a Better Country
• Designed for Life Creating world class Health
  and Social Care for Wales in the 21st Century
• Informing Healthcare
• Healthcare Standards for Wales Making the
  Connections, Designed for Life
• 'Building Strong Bridges' - Strengthening
  partnership working between the Voluntary Sector
  and the NHS in Wales

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Health Strategies/Policies..

• National Service Frameworks
• Diabetes
• Older People
• Coronary Heart Disease
• Children, Young People and Maternity Services
• Renal
• Adult Mental Health Services
• Strategy for Older People in Wales
• Healthy Ageing Action Plan

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Raising The Standard

• A Revised NSF and Action Plan for Adult Mental
  Health Services in Wales
• A response to
• NHS Reorganisation
• Designed for Life
• Review of Health Social Care (Wanless)
• Review of the mental health NSF
• Health Commission Wales Review
• Strategic Review of Secure Services (Homicide
  Inquiries)
• Projected Implications of the draft Mental Health
  Bill
• Recognition of the Workforce agenda

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Health Inspectorate Wales (HIW)

• MAY 2004 - HIW published two homicide
  independent external review reports.
• Diagnosis of personality disorder
• Lack of service provision

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Findings

• There was a lack of integrated and co-ordinated
  services in each case.
• Inadequacies in the provision of services for
  those individuals with a personality disorder and
  criteria set for access to mental health services
  that exclude such individuals from receiving
  appropriate support and treatment

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FINDINGS

• The lack of a proactive approach to the provision
  of care, treatment and support where individuals
  are difficult to engage with.
• An immaturity in the application of the Care
  Programme Approach and Unified Assessment
  Process, including inadequate attention to the
  assessment, identification and management of
  risk.
• Poor communication and systems for the sharing of
  information across agencies and between
  organisations.

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• The Welsh Assembly Government should ensure that
  commissioners and providers of mental health
  services in Wales examine the current provisions
  for the care and treatment of those suffering
  from a personality disorder and that
  commissioners put in place relevant services
  where there are currently none provided

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Borderline personality disorder (BPD)

• Borderline Personality Disorder treatment
  and management National Clinical Practice
  Guideline
• National Collaborating Centre for Mental Health
• Commissioned by the
• National Institute for Health and Excellence

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Specific aims of this guideline

• evaluate the role of specific psychosocial
  interventions in the treatment of borderline
  personality disorder
• evaluate the role of specific pharmacological
  interventions in the treatment of borderline
  personality disorder
• integrate the above to provide best-practice
  advice on the care of individuals with a
  diagnosis of borderline personality disorder
• promote the implementation of best clinical
  practice through the development of
  recommendations tailored to the requirements of
  the NHS in England and Wales.

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The guideline will also be relevant to the work,
but will not cover the practice, of those in

• occupational health services
• social services
• forensic services
• the independent sector.

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Clinical Practice Recommendations Experience of
care

• Access to services
• People with borderline personality disorder
  should not be excluded from services because of
  their diagnosis, gender or because they have
  self-harmed.

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Developing an optimistic and trusting relationship

• Explore treatment options in an atmosphere of
  hope and optimism, explaining that recovery is
  possible attainable
• Build up a trusting relationship, work in an
  open, engaging and non-judgmental manner, and be
  consistent and attainable
• Be aware of sensitive issues, including
  rejection, possible abuse and trauma, and the
  stigma often associated with self-harm and BPD

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INVOLVING CARERS

• When assessing a person with personality
  disorder, healthcare professionals should
• Encourage carers to be involved where the
  individual has agreed to this
• Ensure that the involvement of carers does not
  lead to withdrawal of, or lack of access to,
  services

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Undertaking assessments

• When assessing professionals should
• Explain the process of assessment clearly to
  enable the individual to have some control in the
  process
• Offer post-assessment support
• Use non-technical language
• Explain the diagnosis and the use and meaning of
  the term BPD

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Managing endings and transitions

• Ending or withdrawal of treatments services is
  structured and phased over time
• The care plan maintains effective collaboration
  with other care providers during endings and
  transitions, and includes the opportunity to
  access services in times of crisis

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Treatments

• Psychological therapies, therapeutic
• communities, arts therapies, and
• complementary therapies in the
• management of borderline
• personality disorder

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Clinical practice recommendations

• Role of psychological treatment
• Healthcare professionals should offer choice of
  modalities (for example individual or group)
  must be well-structured, coherent theory of
  practice, therapist supervision
• Women with BPD, reducing self harm a priority may
  consider DBT
• Brief psychotherapy interventions (less than 3
  months) should not be used for BPD

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Research Recommendations

• Randomised trial of complex interventions (DBT
  and MBT) versus high-quality community care
  delivered by general mental health services
  should be undertaken
• Exploratory randomised controlled trials of
  outpatient psychosocial interventions ( ie schema
  focused, CAT, therapeutic communities) for
  quality of life, psychosocial functioning etc.

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Development of an agreed set of outcome measures
for BPD

• A consensus building exercise should be conducted
  to determine the main clinical outcomes that
  should be assessed in future studies
• Recommendations for specific measure of these
  outcomes should be selected that are valid,
  reliable and have already been used in this
  patient group.

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The role of drug treatment.

• Drug treatment should not be used specifically
  for BPD or for the individual symptoms or
  behaviour associated with the disorder
• Antipsychotic drugs should not be used for the
  medium and long term treatment of BPD
• A randomised placebo-controlled trial should be
  conducted to investigate the effectiveness of
  mood stabilisers.

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Management of crisis

• Healthcare professionals should consult the
  crisis plan and use the recommended psychological
  approach
• Short term drug treatment
• Management of insomnia

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Configuration and organisation of services

• Mental Health Trusts to ensure that professionals
  working in secondary services, including CAMHS,
  CMHTs are trained to assess risk and need, and
  provide treatment and management in accordance
  with this guidline.
• Training should be provided by specialist PD
  teams based within mental health trusts.

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Development of MD Specialist teams/services

• Provide assessment and treatment services for
  people with BPD who have particularly complex
  needs and/or high levels of risk
• Provide consultation/advice to primary and
  secondary care services
• Offer a diagnostic service when general mh
  services are in doubt about the diagnosis and/or
  management of BPD

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• Develop systems of communication and protocols
  for information sharing among different parts of
  MH services including Forensic, LD and CAMHS
• Advise on an appropriate range of social and
  psychological interventions, including access to
  peer support, safe use of drug treatment in a
  crises for co morbidities and insomnia
• Support, lead and participate in the local and
  national developments of potential treatments,
  including multi-centre research

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• Oversee the implementation of this guideline
• Develop training programmes on the diagnosis and
  management of BPD and that address problems
  around stigma and discrimination
• Specialist PD services should involve people with
  PD and carers in planning service developments.

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Thank-you

• Jeni.clarke-moore_at_wales.gsi.gov.uk

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GWYLFA THERAPY SERVICE

• Services for people who have a diagnosis of a
  personality disorder
• GWENT HEALTH CARE TRUST

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PERSONALITY DISORDER SERVICEWHAT WORKS?

• Dynamic psychotherapy, DBT, Therapeutic Community
  Tx, Schema Focused Tx.
• CT and CAT show some promise.
• Pharmacotherapy - target specific problem areas -
  Soloffs Medication Algorithm-
• Cognitive/perceptual
• Affective
• Impulse dyscontrol
• No magic bullet
• Drugs alone insufficient to treat PD

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PERSONALITY DISORDER SERVICEWHAT WORKS?

• Main features of effective treatment-
• Well structured.
• Apply effort to enhance compliance.
• Clear therapeutic focus.
• Theoretically highly coherent to P and T.
• Relatively long term.
• Encourage powerful attachment relationships
  (which are worked within).
• Well integrated with other services.

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GWYLFA THERAPY SERVICE PHILOSOPHY

• Respect, fairness, compassion, understanding,
  acceptance and validation.
• Enable patients to take control of
  responsibility for their lives.
• Equals and collaborative.
• Provide meaningful interventions choices.
• Use a variety of treatment approaches.
• Respect patients right to choose not to
  participate in treatment ? risk management plan.

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GWYLFA THERAPY SERVICE KEY FUNCTIONS

• Consultation/ advice/ support/ supervision
  service to CMHTs.
• Specialist assessment reporting to teams.
• Clinical service for a small number of BPD
  severely distressed patients who cannot be
  managed at CMHT level.
• Involvement in assessment to ongoing liaison/
  monitoring of patients who are referred to Out of
  Area PD Services.
• Training and staff development

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GWYLFA THERAPY SERVICE SERVICE MODEL
Out of Area Services
Clinical Service
Consultation Service
Community Mental Health Team/ In-patient services
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GWYLFA THERAPY SERVICES

• Liaison with local services.
• Consultation service.
• Systemic interventions.
• Assessment.
• Formulation.
• Intensive therapeutic programme.
• Training.
• User group.

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GWYLFA THERAPY SERVICES

• Information resource.
• Out of Area Referrals-
• Assessment.
• Recommendations re which of area
• treatment.
• Liaison/ monitoring.
• Agree therapeutic focus, goals, length,
• return asap.
• Knowledge base about OAPs

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GTS - REFERRAL CRITERIA TO CONSULTATION SERVICE

• Diagnosis of PD or a suspected Personality
  Disorder, including dual diagnosis with other
  psychiatric illness e.g. PD Bipolar Disorder.
• Challenging or Tx interfering behaviour over
  protracted period.
• Resistant to change over protracted period.
• CMHT have run out of ideas - are stuck.

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GTS - REFERRAL CRITERIA TO CLINICAL SERVICE

• Diagnosis of Borderline Personality Disorder or
  significant features of Borderline Personality
  Disorder.
• Repeated and risky Deliberate Self Harm.
• Suicide risk high.
• CMHT have exhausted local options.
• Gwylfa service have been involved in ongoing
  consultation/ team support.
• Referral to Gwylfa Clinical Service agreed with
  PDS Staff during Care Planning Meeting/ Case
  Discussion.
• Patients on enhanced CPA.

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FEATURES INDICATING THAT A PATIENT IS BETTER
MANAGED BY ANOTHER CLINICAL SERVICE

• Actual ongoing risk to others that would be more
  effectively managed by Forensic Services.
• Learning Disability.
• Aspergers Syndrome.
• Acquired Brain Damage.
• High levels of drugs and/or alcohol abuse that
  prevents engagement in psychological treatment.
• Acute stages of co-morbid psychiatric illness.

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GWYLFA THERAPY SERVICE STAFF IN CORE TEAM

• Consultant Clinical Psychologist (1WTE)
• Consultant Nurse (1WTE)
• Consultant Psychotherapist/Psychiatrist (0.4 WTE)
  
• Principal Clinical Psychologist (1WTE)
• PhD Research Student (1 WTE)
• Administrator (0.5 WTE)

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GWYLFA THERAPY SERVICE PHYSICAL RESOURCES

• Central to user population Newport probably the
  best.
• Consulting rooms.
• Group rooms.
• Admin office.

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GWYLFA THERAPY SERVICE BROAD MODEL OF PD

• Trauma.
• Invalidation.
• Failure in mirroring/ poor attachments.
• Emotionally sensitive.
• Highly emotionally reactive.
• Leads to problems in development of personality
  and behaviour.

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GWYLFA THERAPY SERVICE THERAPEUTIC TARGETS

• Severe behavioural problems (DSH) ? behavioural
  control (no DSH).
• Cut off Quiet desperation ? reviving emotional
  experience. Working through trauma addressing
  dissociation.

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GWYLFA THERAPY SERVICES SKILLS BASE

• Dialectical Behaviour Therapy.
• Psychoanalytic Psychotherapy.
• CBT.
• CAT.
• Individual and group work.
• Staff supervision and consultation.

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GWYLFA THERAPY SERVICES TRAINING
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PROBLEMS/ ISSUES NEEDING SERVICE DEVELOPMENT

• Treatment intensity limits the clinical
  service. Day patient therapeutic community would
  increase impact.
• Lack of supported housing prevents GTS providing
  local service. Joint schemes needed.
• No clinical service to men where are they?
• Mental Health Act likely to increase demand.

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Referrals
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Patients in clinical service Mar 08
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Types of intervention received by patients in
clinical service - 31st March 2008
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Patients who have been discharged from the Gwylfa
Therapy Clinical Service.
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COST SAVINGS
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GWYLFA THERAPY SERVICE.

• Services for people who have personality
  disorder.
• Copies of slides from GTS Administrator-
• Helen.Speirs_at_Gwent.wales.nhs.uk
• GWENT HEALTH CARE TRUST