Personality Disorders: No Longer a Diagnosis of Exclusion

1
Personality Disorders No Longer a Diagnosis of
Exclusion?
2
A note of thanks

• This presentation has been somewhat modified in
  the light of a number of very helpful comments.

3
Caveat

• All findings are provisional.

4
Rationale

• Previous experiences working in
• Substance misuse
• Criminal justice

5
Preparatory Research

• DSPD reform agenda of the UK government.

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Current Research

• PhD
• Social work orientation
• Advisory group

7
Design and Implementation

• Extensive literature review
• Semi-structured interviews
• Front-line workers
• Key informants
• Service users

8
Relevant Recent Reports and Inquiries

• MWCS reports re the care and treatment of Mr L
  and Mr M (2006) followed by Mr G (2007).
• The report into the early impact of the
  legislation by (Atkinson et al, 2007).

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Possible Titles for This Presentation

• Personality Disorders no longer a diagnosis of
  exclusion?
• Or more controversially
• Personality Disorders still not my problem?

10
Service Planning

• Limited response based upon specialised services.
• This appears to have been largely confined to the
  health service.

11
Staff Support and Training

• Where available also largely confined to health
  service staff.
• Exception MHO additional training following the
  report into the care and treatment of Mr L. and
  Mr M.

12
Policies and Procedures

• These are a necessary but not sufficient
  criterion for change.

13
Service Provision and Delivery

• The continued absence of appropriate
  psychological interventions appears to be an
  ongoing problem.
• Future resource planning does not appear to
  anticipate an expansion in the provision of these
  services.

14
What Else Would You Really Expect?

• All change or status quo?
• The Report of the Millan Committee has quite
  rightly been heralded as providing the basis for
  one of the most progressive examples of mental
  health legislation to be found anywhere namely
  the Mental Health (Care and Treatment) (Scotland)
  Act 2003.

15
Cont

• The report of the Millan Committee reflected the
  breadth of views received during the extensive
  consultation process. The following few slides
  are intended to highlight the balanced and
  realistic view, which characterised the
  Committees recommendations concerning
  personality disorders.

16
Cont..

• there are attractions in reverting to the
  position prior to 1999, when personality disorder
  was not mentioned in the Act. However, it would
  not be realistic to ignore the fact that the 1999
  Act has given a new emphasis to the question of
  personality disorder (pg 44).

17
Cont

• The report then states that
• we are of the view that people with personality
  disorder require and deserve appropriate
  services, and so should be included within the
  scope of mental disorder (pg 44).

18
Cont..

• The Millan Committee expressed the view that in
  general, the effective treatment of personality
  disorders normally require the co-operation of
  the patient (pg 39).
• Furthermore that in most cases compulsion would
  not be appropriate because of the presence,
  rather than absence of capacity or absence of
  impaired judgement.

19
Cont

• The Committee recognised that the most likely
  outcome of the continued inclusion of personality
  disorders within mental health legislation would
  therefore be that in the vast majority of
  instances services would be provided on an
  informal basis.

20
Cont

• Within its report, the Millan Committee
  acknowledged considerable concerns regarding the
  quality and availability of mental health
  services (pg 179) the Committee also however
  took the view that mental health legislation
  itself was not an appropriate vehicle to remedy
  this, largely because the majority of people
  receiving services will not be subject to
  compulsory measures (pg 179).

21
Cont

• The report of the Millan Committee therefore
  contains the clear aspiration that people with a
  diagnosis of personality disorders, should not
  simply be included within the scope of mental
  health law but rather that they should receive
  appropriate services.

22
Cont

• The fact however that the vast majority of people
  with personality disorders are likely to continue
  to receive services on an informal basis, means
  that the status quo may prove difficult to
  change.
• Considerable investment and the use of
  specific delivery mechanisms will be necessary.

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Law of Unintended Consequences

• Emergence of a two-tier system Formal v Informal
  care and treatment.
• Driven by the requirements and obligations
  contained within the current Act in respect of
  formal care and treatment.

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Filtering Out

• Filtering out is a predictable consequence of the
  Significantly Impaired Decision-Making Criterion.
• N 133 i.e. 4 STDOs PD (MWCS, 2008).
• N 50 of these PD sole diagnosis.

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Unintended Consequences again!

• The profile of people with personality disorders
  receiving services on a formal basis is therefore
  likely to be skewed by a focus upon risk and
  dangerousness.
• This may serve to reinforce existing stereotypes.

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The Forensic and General Divide

• Despite the rejection of the DSPD agenda a
  growing divide based upon assumptions concerning
  risk and dangerousness is apparent.

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Another Tier

• In terms of the civil provisions of the Act those
  perceived as risky or dangerous are more likely
  to receive a formal service response.
• MDOs with personality disorders are receiving an
  increasingly formal and robust service response.

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Champagne and White Cider

• the detained population gets the champagne
  service and the non-detained population gets the
  white cider service
• (Atkinson et al, 2007)

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Reaction and Progress

• PD was included explicitly in Scots law as a
  reactive measure rather than as a genuinely
  progressive and inclusive one.
• This was implicitly acknowledged within the
  report of the Millan Committee, who then advanced
  a positive case for inclusion.

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Inclusion a Utopian Aspiration?

• The inclusion of people diagnosed with
  personality disorders based upon their needs
  appears to remain substantially aspirational.
• This is despite legislation that has been rightly
  heralded as highly progressive.

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Rights and Obligations

• As long as personality disorders remain part of
  the diagnostic lexicon, the reciprocal right to
  services will continue.
• The issue of the right to treatment has been
  defined as a basic human right
• cont..

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United Nations Resolution 46/119

• Fundamental freedoms and basic rights
• 1. All persons have the right to the best
  available mental health care, which shall be part
  of the health and social care system.
• (emphasis added)