Personality Disorder:

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Personality Disorder No Longer a Diagnosis of
Exclusion? NWFAN 6th Annual Conference The
Lowry Centre 9th November 2006

NWFAN is a partnership between the University of
Manchester, Mersey Care, Lancashire Care and
Bolton, Salford and Trafford NHS Trusts
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• THE NEEDS OF WOMEN
• (AT RISK OF) RECEIVING A DIAGNOSIS OF
• PERSONALITY DISORDER
• Dr Gill Aitken
• Care Services Improvement Partnership North
  West Development Centre
• Gill.aitken_at_northwest.csip.org

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• ..much of what services subsequently offer will
  be dictated by the diagnosis/es that youve been
  given ..(the label) often fails to tell the
  story as we would tell it we believe when women
  are given the space to tell their own stories,
  the consequences for them and the whole of
  society are very different to the consequences of
  the current practice of labelling women as
  borderline personality disordered
• Clare Shaw/Women on the Margins (2005) An
  activist/user perspective
• on challenging Policy on Borderline
  Personality Disorder (Social Perspectives
  Network Paper 7 Women Mental Health.
  www.spn.org.uk

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Overview

• Policy, Implementation Contexts
• Why women?
• an inequalities perspective
• womens lives and trauma
• trauma and personality disorder
• women, trauma personality disorder
• Organisational Responses/Developments to date?
• Implications for Planning/Delivering Services?
• Some questions to ask ourselves?

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GENDER WOMENS ISSUES EXPLICITLY ON THE AGENDA

• Recent Policy, Implementation Legislative
  Contexts
• Into the Mainstream/Mainstreaming Gender Womens
  Mental Health Strategy Implementation Guidance
  (2002 2003)
• Supporting Women into the Mainstream Day
  Services Commissioning Guidance 2006
• Women at Risk The Mental Health Needs of Women
  in Contact with the Criminal Justice System 2006
• Tackling the health effects of domestic and
  sexual violence and abuse 2006
• Supported by the forthcoming public sector gender
  duty (April 2007)

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GENDER WOMENS ISSUES less visible?

• e.g.
• Personality Disorder No Longer a Diagnosis of
  Exclusion (NIMHE, 2003)
• Personality Disorder Capabilities Framework
  (2003)
• Personality Disorder Regional Capacity Plans
  (2005)
• Though reference to attend to gender sensitivity,
  and differential needs and risks to and from
  women and men, and workforce
• Overall supported byThe White Paper (2006) Our
  health, our care, our say

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Why Gender Womens Issues Important

• GENDER is
• fundamental to our sense of who we are, the
  roles we adopt, and the ways in which we
  experience and perceive others and in which they
  perceive us
• Department of Health (2003)
• different and unequal access to resources and
  opportunities of society relative to men
• Politically Socially Economically
• Shaping everyday experiences, including contact,
  pathways experiences as workforce members
  and/or as service users

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Why Gender Womens Issues Important

• Lower social status more restrictive role
  expectations (particular around primary carer of
  others)
• Exposure to adverse abusive and violent
  experiences
• Restricted access to economic, political and
  social resources of society
• unequal distribution of power and life chances
  between men and women
• See also N. Thompson (1996). People skills.
  Dealing with Diversity. Basingstoke Macmillan.
  Sensitive practice is not enough Anti-oppressive
  practice is also necessary.

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Why Gender Womens Issues Important

• Most women still have very different life
  experiences from most men because womens lives
  are different from mens they need different
  things from public
• services. Meeting their needs often means
  changing the content of services and how they are
  delivered
• Equal Opportunities Commission(2004)

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Why Gender Womens Issues Important

• Impact of trauma and neglect (cumulative)
  aversive life (including gendered) experiences
• on persons development and functioning, ways of
  coping and sense of self

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Why Gender Womens Issues Important

• Trauma
• Direct perpetrated violence, war experiences,
  interpersonal violence, debilitating illnesses,
  destruction of communities (experienced as
  individual and as communities)
• Indirect secondary trauma e.g. with whom one
  identifies in significant way, witnessing
  trauma, repeatedly receiving information about
  violence
• Insidiousimpact shapes a worldview rather than
  shatters assumptions about the world
• e.g. Maria Root (1992) in Reconstructing the
  Impact of Trauma on Personality, in L Brown M
  Ballow (eds) Personality and Psychopathology
  Feminist Reappraisals. New York The Guildford
  Press229-265

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Why Gender Womens Issues Important

• Role of Trauma aversive life experiences gt
  adversely impact on personality (and social)
  functioning?
• yet to be understood more fully
• People experiencing trauma gt
• Experience a whole range of distress
• Receive a range of diagnostic labels
• Not experience distress which interferes with
  functioning
• Not receive labels
• Personality disorder diagnoses not necessarily
  underpinned by trauma

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However

• Women account for 75 diagnoses of Borderline
  Personality Disorder.
• Logan (2002)
• 62 women in High Secure 42 women in prison
  with violent history (self/others) receive this
  diagnosis
• 49 diagnosed with both antisocial borderline
  personality disorder
• 35 3 diagnoses of personality disorder
• co-morbidity with mental illness, substance
  dependency

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Why Gender Womens Issues Important

• Borderline personality disorder linked to
• Poor impulse control, unstable mood and identity
  disturbance, substance misuse, threats of
  violence to self and others symptoms of anxiety
  depression
• What we also know, is women more likely to engage
  with self injurious behaviour, although men more
  likely to commit suicide.
• What we know is that women in prison high rates
  of substance misuse growing concern

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Many women say

• (may or may not be shared by individual women)
• Womens life experiences being psychiatrised
  NEEDS LED VS DIAGNOSIS LED services
• Women specific History of Womens Day Centres
  Therapy Centres e.g, Voluntary Sector Dedicated
  Womens Housing and floating Sexual Abuse teams
  (e.g. Richmond Fellowship Imagine ) Further
  potential with Mainstreaming Women Day Services
  Commissioning Guidance (2006)
• Mixed Gender Therapeutic Community Service North
  Day Services in partnership with Mental Health
  Trusts etc

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Many women say

• Inattention to womens experiences and coping
  strategies as survivors of childhood adult hood
  and trauma gt Violence Abuse Pilots - National
  Leads Liz Mayne/Chris Holley
• gt Scoping Exercise to Assess Weight of Evidence
  in conjunction with NICE to develop Harm
  Minimisation approaches to Self Injury Guidance
  National Leads Karen Newbiggin/Malcom Rae

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Why Gender Womens Issues Important

• Inattention to service philosophies, models of
  therapeutic care,therapeutic regimes, service
  configurations, workforce-women patient relations
  in re-enacting (however unintentionally) trauma
  and oppressive/infantalising practices
• gt Pilots for Enhanced Medium Secure Services for
  Women
• Pilots for Hi Support Residential Services for
  Women at risk of diagnosis of Personality
  Disorder/who Self Injure,
• Mixed Gender Therapeutic Community Pilots
  Residential/Outpatients for People diagnosed with
  Personality Disorder (e.g. Itinerant Community
  Lancs Cumbria Therapeutic Day Services (e.g.
  TCSN in partnership with Mental Health Trusts)

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Why Gender Womens Issues Important

• was sexually abused from childhood .. Ran away
  always was
• returned home .. I wasnt (name) was labels,
  labels, labels.
• Presented to AE over 38 times, no one talked
  with me, I was a
• difficult woman. When I gave birth brought
  back memories of the
• abuse .. On the same day was asked by nurses to
  look after (another
• child) who was on different ward and who was
  being difficult when I got
• home was expected to cook straight away .. I was
  tired .. I wanted to burn
• my past away set fire to my bedroom sentenced
  to prison ... Started
• cutting, spent long periods in segregation ..
  Transferred to secure unit with
• diagnosis of personality disorder and
  schizophrenia ..went up to 20 stone ...
• Felt shit about myself wanted to talk to staff
  but then I didnt was
• there N years
• White minority ethnic women .. Reported being in
  an a long term abusive relationship with male
  partner. Referred by GP whose letter noted a
  difficult woman.

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WOMENs NEEDS Planning Implications for
Services

• Monitoring and informed gendered analysis of
  statistics and analysis of presence absence
• Many adult women will have experienced being
  done to rather than alongside with, not heard
  or listened to and the reality of their lived
  lives not acknowledged or understood.
• Gender women may not have a positive sense of
  being a woman, low expectations, little sense of
  entitlement or power to exercise choice or
  communicate needs and rights in direct ways.
  Experience of first contact key, experience of
  every contact key!
• May present in crisis at different entry
  points/different services, have chaotic
  lifestyles and/or ongoing struggles to manage
  finances, housing, childcare, difficulties in the
  relationships with partners, relations with
  communities.

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WOMENs NEEDS Planning Implications for
Services

• SAFETY, CONTROL CHOICE
• Physical, psychological/emotional histories of
  violation of body and mind poverty ?isolation
• Women have the right not to engage with services
  implications if MHA employed then how this
  undertaken in way that communicated to support
  transparency, predictability, that the woman not
  out of control, and routes out of hospitalisation
• of gender of workers
• of dedicated single gender services/activities
• of dedicated single gender accommodation and
  range of housing options with alternatives to
  hospitalisations and to choose which feels most
  safe
• Of which services, forms of support and forms of
  talking, expressive/creative, complementary and
  medication therapies AND WHEN

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WOMENs NEEDS Planning Implications for
Services

• SAFETY, CONTROL CHOICE
• Physical, psychological/e/motional histories of
  violation of body and mind poverty ?isolation
• gt housing, public transport, childcare
  financial e.g. needs of women refugee/asylum
  seekers
• Where are services located women may need
  support around real practical issues before being
  able to engage with other forms of service
  provision.

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WOMENs NEEDS Planning Implications for
Services

• SAFETY, CONTROL CHOICE
• Physical, psychological/emotional histories of
  violation of body and mind poverty ?isolation
• Residential/day services
• Control over privacy and who enters environment
  .. Men, other residents and staff
• Control over sense of safety/sleep
• ? 24-hour access to someone/service (to be
  planned with woman)
• Inpatient or hospital admissions to be reframed
  as different from previous hospitalisations and
  as a strategy for a woman to take control of her
  life and not as being out of control.
• (see also Maxine Harris (1997) Modifications in
  service delivery. In M Harris C. Landis (eds)
  Sexual Ause in the Lives of Women Diagnosed with
  Serious Mental Illness. London Harwood
  Academic.

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WOMENs NEEDS Planning Implications for
Services

• SAFETY, CONTROL CHOICE
• ? General Role of advanced directives/decisions
• care planning /care coordination
• case management
• ?Challenge for services/system creating safe,
  coherent and non-chaotic systems at all levels in
  which responsibility is not taken from the woman.
• ?Challenge for workers Assume at all times you
  are talking with a competent intelligent woman
  (Bryony Moore, 1999 Borderline Personality
  Disorder Time to Let Go. Presented at Raeside
  Self Injury Group, Midlands Arts Centre).

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WOMENs NEEDS Planning Implications for
Services

• Practically Therapeutically (gendered
  understandings)
• Women as Mothers, Parents (or Not)
• Maintaining, developing, creating
  family/friendship/community networks
• Differences among women, identifications,
  support, connections
• Valued and meaningful activities (to women) from
  social skills to vocational to employment to
  leisure and recreational

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WOMENs NEEDS Planning Implications for
Services

• Therapeutic coherence / what is wanted by a woman
  /what is possible
• Often not understood or experienced as part of
  recovery process
• (? Tensions re general absence in
  literature/evidence base holding onto what we
  know or have available to risking different
  approaches evaluation has to be embedded)
• Not having coping strategies problematised/prevent
  ed when not feel safe, anxious, overwhelmed when
  not offered alternatives potential
  consequences/risks to self others though
  important to identify as well as options for
  woman
• Workers who want to work with women and who
  relate with humanity. Who acknowledge and
  understand the lived reality of womens lives.
  Who can relate them with dignity and respect and
  in open ways and to convey hope and recovery NB
  friendly NOT FRIENDS

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• Women want workers who are safe, reliable,
  skilled in their roles, and aware of gendered
  issues
• Women with experience of aspects of women lived
  experiences support, in roles which are valued
  and offer possibilities of hope and recovery and
  for self development.

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Finally?

• Development of Personality Disorder Services
  focus on men (danger to others/forensic link?)
• How much is invested in services to men at risk
  of diagnoses of personality disorder and how
  much for women
• .
• Are womens needs being acknowledged/met how
  and where in the system or are womens needs
  being sidelined?
• What lessons can we learn from the value of past
  and existing and developing services to women at
  risk of diagnosis of personality disorder, what
  questions and outcomes are we asking and who are
  the WE who are asking
• How empowering and transformative are services to
  women?

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Finally?

• Would all services to women necessarily need to
  be under the auspices of Personality Disorder
  label or under a needs led service configured
  around the issues upon which womens lives and
  coping are grounded?
• Could there be funding for a range of forms of
  opportunities (self help, facilitated self help,
  individual, group work (creative,talking,
  expressive), into existing services or dedicated
  womens spaces or centres, or community spaces
  across the dimensions of inequaities (e.g.
  cultural heritages, sexual orientation, age )
  where women may meet
• Could a Day Service Therapeutic Community model
  be adapted to work in dedicated women only
  services (e.g. womens centres )
• INVOLVE WOMEN AND KEEP ASKING WOMEN TO EVALUATE
  SERVICES, AND HOW THE SERVICES BENEFIT THEM

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Slides will be available for download on
Monday 13th November at www.medicine.manchester.
ac.uk/ psychiatry/NWFAN/

NWFAN is a partnership between the University of
Manchester, Mersey Care, Lancashire Care and
Bolton, Salford and Trafford NHS Trusts