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PERSONALITY DISORDER A WELSH PERSPECTIVE JENIFER CLARKE-MOORE Nursing Officer Dept of Public Health and Health Professions
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
CURRENT SITUATION • 22 >8 Local Health Boards • 14 >7+1 NHS Trusts • Urban v rural • Partial devolution
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
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
“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
Health Inspectorate Wales (HIW) MAY 2004 - HIW published two homicide independent external review reports. • Diagnosis of personality disorder • Lack of service provision
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
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.
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
Borderline personalitydisorder (BPD) Borderline Personality Disorder: treatment and managementNational Clinical Practice Guideline National Collaborating Centre for Mental Health Commissioned by the National Institute for Health and Excellence
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.
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.
Clinical Practice RecommendationsExperience 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.
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
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
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
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
Treatments • Psychological therapies, therapeutic communities, arts therapies, and complementary therapies in the management of borderline personality disorder
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
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.
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.
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.
Management of crisis • Healthcare professionals should consult the crisis plan and use the recommended psychological approach • Short term drug treatment • Management of insomnia
Configuration and organisation of services • Mental Health Trusts to ensure that professionals working in secondary services, including CAMHS, CMHT`s 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.
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
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
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.
GWYLFA THERAPY SERVICE Services for people who have a diagnosis of a “personality disorder” GWENT HEALTH CARE TRUST
PERSONALITY DISORDER SERVICEWHAT WORKS? • Dynamic psychotherapy, DBT, Therapeutic Community Tx, Schema Focused Tx. • CT and CAT show some promise. • Pharmacotherapy - target specific problem areas - Soloff’s Medication Algorithm:- • Cognitive/perceptual • Affective • Impulse dyscontrol • No magic bullet • Drugs alone insufficient to treat PD
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.
GWYLFA THERAPY SERVICEKEY FUNCTIONS • Consultation/ advice/ support/ supervision service to CMHT’s. • 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
GWYLFA THERAPY SERVICE SERVICE MODEL Out of Area Services Clinical Service Consultation Service Community Mental Health Team/ In-patient services
Liaison with local services. • Consultation service. • Systemic interventions. • Assessment. • Formulation. • Intensive therapeutic programme. • Training. • User group. 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 OAP’s GWYLFA THERAPY SERVICES
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”.
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.
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.
GWYLFA THERAPY SERVICESTAFF 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)
GWYLFA THERAPY SERVICEPHYSICAL RESOURCES • Central to user population – Newport probably the best. • Consulting rooms. • Group rooms. • Admin office.
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.
GWYLFA THERAPY SERVICES SKILLS BASE • Dialectical Behaviour Therapy. • Psychoanalytic Psychotherapy. • CBT. • CAT. • Individual and group work. • Staff supervision and consultation.
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.
Types of intervention received by patients in clinical service - 31st March 2008
Patients who have been discharged from the Gwylfa Therapy Clinical Service.
GWYLFA THERAPY SERVICE. Services for people who have personality disorder. Copies of slides from GTS Administrator:- Helen.Speirs@Gwent.wales.nhs.uk GWENT HEALTH CARE TRUST