Structuring Treatment and Services for People with

Personality Disorder

Dr Tim Agnew, Consultant Psychiatrist for NHS Highland Personality Disorder

Service.

Overview

• Tiers of service provision

• Phases of treatment

• Stages of change

Phase-based Treatment of PD

• Phases of treatment

• Some examples from Highland

• Discussion

A phase-based approach Integrated

problem-focused approach for PD (Livesley, 2003)

Dialectical behaviour therapy for BPD (Linehan,1992)

Stage-based treatment of traumatic disorders (Herman, 1992)

Treatment of hysteria (Janet, 1889)

Safety Containment

Phase 1 (Behavioural stabilisation) Regulation

and control

Behavioural dyscontrol to behavioural control

Behavioural stabilisation

Stabilisation, symptom oriented treatment

Quiet desperation to emotional experiencing

Phase 2 (Exploration and change)

Exploration and change

Problems in living to ordinary happiness and unhappiness

Trauma reprocessing

Exploration of traumatic memories

Phase 3 (Integration and synthesis)

Integration and synthesis

Incompleteness to capacity for joy

Integration Personality reintegration, rehabilitation

A phase-based approach• 1a. Safety:

– Interventions to ensure the safety of the patient and others

• 1b. Containment: – Interventions based primarily on general therapeutic

strategies to contain behavioural and affective instability. May be supplemented with medication if appropriate.

• 1c. Control and regulation: – Interventions to reduce symptoms and improve self-

regulation of affects and impulses eg behavioural, cognitive and pharmacological.

A phase-based approach• 2. Exploration and change:

– Interventions to change the cognitive, affective and situational factors contributing to problem behaviours eg cognitive, behavioural, psychodynamic and interpersonal.

• 3. Integration and synthesis: – Interventions designed to address core

pathology and forge a new sense of self along with more integrated and adaptive interpersonal systems.

Focus of interventions

DBT STEPPS Day Service

Crisis Admission

Crisis Intervention

Structured Admission

Safety +++ + + +++ +++ + Containment +++ ++ ++ +++ +++ +++ Regulation and control

+++ +++ ++ -/+ +++ +++

Exploration and change

+++ +++ +++ - - -

Integration and synthesis

+ ++ +++ - - -

Phase 1: Behavioural Stabilisation

• Changes to DBT service

• Introduction of STEPPS

• (Most mental health services!)

Tiers of service provision

STEPPS

• October 2011 - Introduction of STEPPS to CMHTs

• Systems Training for Emotional Predictability and Problem Solving

• Tier 2 service

Changes to DBT service

• Referral system changed to address some of the problems of the old system and allow appropriate focus of limited DBT resource

Changes to DBT service• No longer traditional referral-waiting

list set-up• Each sector allocated places on

program• When the place is soon to become

available (within 8-12 weeks), community services are informed

• Asked to identify and refer the patient most in need of DBT for the sector

Changes to DBT service

• CPA now a requirement before patient seen for pre-treatment– Ensures a clear, regularly reviewed,

comprehensive treatment plan including more than DBT alone

– Formalises patient’s role in their own care– Assists effective transition from DBT to future

treatment phases

Changes to DBT service

• DBT therapists will attend CPA review

• Present to support the patient to interact in the most effective manner with their care team

• Not simply giving information which the patient is equally well, or better placed, to provide

Phase 2: Exploration and change

• Trauma reprocessing as a Phase 2 intervention

• Psychological Trauma Service Development (PTSD) Group

• Aims of PTSD Group

Aims of PTSD Group

• Promote awareness, identification and treatment of trauma-related conditions and the supporting of education of the workforce towards these aims

• Development towards a trauma-informed service• Development of specialist trauma services• Identification of existing services for all phases

of trauma work• Identification of pathways and links between

these services and people

Day Service for people with Personality Disorder

• Phase 2: Exploration and change

• Phase 3: Integration and synthesis

Who is it for?

• Any person with personality disorder (not only borderline) of 18yrs plus

• Need to be sufficiently behaviourally stable

Who is it not for?

• People who do not have a personality disorder

• People with risk issues that would preclude safely working in community environment

• People with factors which would preclude working in a cognitive and behavioural way

How is it accessed?

• Referrals from Mental Health Services

• Referral to be completed with, and signed off by, the service user

• PDQ-4 to be completed by the service user

Summary

• Phase 1: Behavioural stabilisation– Safety– Containment– Regulation and Control

• Phase 2: Exploration and change

• Phase 3: Integration and synthesis

Summary

• Phase 1 (Behavioural Stabilisation)– Changes to DBT service (Tier 3)– STEPPS (Tier 2)

• Phase 2 (Exploration and change)– Trauma services development – Day Service (Tier 3)

• Phase 3 (Integration and synthesis)– Day Service (Tier 3)

What next?

• Tier 1 – Education and awareness

• Tier 2– Education and awareness – Consultation/ liaison

• Tier 3– Early intervention/ CAMHS transitions

Thank you

• Discussion and questions