Treating Personality Disorder

Creating Robust Services for People with Complex Mental Health Needs

Naomi Murphy, Des McVey, Naomi Murphy, Des McVey

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781136896736
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

This book considers personality disorders and how they are treated within the institutional context of prisons and hospitals and offers practical guidance on assessment, formulation and integrated treatment planning.

Treating Personality Disorder offers contributions from professionals in psychiatry, nursing and psychology as well as prison officers and service managers and areas of discussion include:

• delivering integrated treatment to people with personality disorders
• issues and challenges for the clinical professional
• the role of the psychiatrist in treating personality disorder

Treating Personality Disorder will provide a timely and valuable guide for all professionals involved in the treatment and management of serious personality disorders within an institutional framework.

Chapter 1
Introduction

Des McVey and Naomi Murphy

Personality disorder is a mental health condition that generates significant distress for the people who have the condition and also for those who are involved with them whether personally or professionally. It is also a condition that generates controversy. Classification and diagnosis of the condition remain areas of intense academic debate, as does whether or not this condition is treatable. Despite these disagreements, there is agreement that a significant percentage of the world’s population present with maladaptive cognitions, behaviours and emotional states in attempts to manage their world and their interpersonal relationships, which result in them being diagnosed as personality disordered. Their use of maladaptive coping strategies means that people with this diagnosis are disproportionately involved with the criminal justice system and/or mental health services. People with such maladaptive coping strategies are also significantly represented in areas of life that require skill or creativity. This can be evidenced through the many talented musicians, actors and athletes featured in the media who present with self-destructive interpersonal relationships and lifestyles. It could be credibly argued that these artists express their distress through the creativity of their art or performance.

People with this disorder experience significant psychological distress which they manage by utilising dysfunctional coping strategies including: addictions (e.g. drugs, gambling, sex), violence, self-neglect, self-injury (in its many forms), suicide and homicide. Those who interact with them often become distressed by the impact of these behaviours and by the intensity of underlying emotions, such as sadness, fear, disgust, shame and anger, that the behaviours are designed to mask or avoid. This can be so aversive that those closest to them become overwhelmed and feel manipulated and/or hopeless and consequently denigrate the person with the condition, making pejorative statements that indicate they are not deserving of care or support. Indeed, within both the criminal justice and health services, these clients may be experienced as so problematic that they are repeatedly shuffled from one service to another.

In prisons, those with the most need of containment are often regularly moved from prison to prison as they are considered uncontainable. In the health services, people with this diagnosis are unique in that they are often admitted for treatment and then angrily discharged when they present with the very symptoms that are intrinsic to their condition. Services that do provide treatment will often be so selective in their admission criteria that those in the most distress, and thus presenting with the more severe symptoms, are excluded from the service. Until recently, this has been one of the few conditions that mental health professionals could opt out of treating by deeming the individual as untreatable. This must be a despair-inducing scenario for any human being when those with physical disorders with no known cure (e.g. terminal cancer) are none the less ‘treated’ and in receipt of care until their death. Professionals and clients alike have used the ‘treat-ability’ clause to engineer a discharge from services which has on occasion resulted in the individual committing violent offences against others or killing themselves.

Over the past decade, the British government has invested significantly in both the criminal justice and mental health services in order to develop interventions that will provide hope, treatment and recovery for people who have this condition even in its most severe form. New legislation requires that treatment must be available for those detained due to this condition and clinicians can no longer hide behind the issue of ‘treatability’.

This book is written by clinicians who have many years of experience in providing effective services to these clients in the community, hospitals and prisons. It provides health professionals, health service managers and prison staff with in-depth information as to how to successfully establish and deliver such services and how to adapt current skills in order to deliver effective treatment that will relieve the clients’ distress and reduce the risk that they pose to themselves and others. Pitfalls and areas of difficulty that will be encountered are considered and a theoretical understanding of the causes of these difficulties and practical strategies that can be implemented in order to avoid or minimise such experiences are offered. All contributors have focused not only on what needs to be done, but also how to do it. The book includes chapters dedicated to all the specific components essential to providing such a service and gives clear and cohesive advice about how to develop a seamless service whilst maintaining an overarching clinical philosophy. Importantly, teamwork is stressed throughout and chapters explicitly highlight the specific roles for professionals involved.

This book could be considered as controversial as many other aspects of personality disorder since it is argued that to develop an effective service means confronting commonly held beliefs about service delivery. It exposes the current illogical approaches taken by many service providers, clinicians and researchers in their attempts to develop a greater understanding of this condition and its treatability. The aim is not to be overly critical or attacking but to encourage readers to reorganise their thinking and incorporate strategies that will enable them to provide truly accessible, meaningful interventions and thus facilitate real recovery.

The purpose of this book is to show the potential and methods for treatment of people with personality disorder in different institutional contexts, where containment or management of personality disordered individuals has tended to be the response of mental health service providers. The key to successful treatment lies in the understanding of the special challenges presented by such individuals and in the provision of complex sophisticated treatment in the context of a cohesive integrated treatment model, as well as in the teamwork of the different professionals involved and in the organisation and resources of the service within which treatment is given.

This book challenges the prevailing belief that this client group can make little therapeutic gain by offering an approach to treatment that fosters optimism among staff and clients. The authors offer improved clarity and understanding of the complexities of providing treatment to this client group by focusing upon the process of treatment and principles that, when adhered to, may improve the outcome of this process. All chapters highlight opportunities to maximise the potential of both staff and clients within existing services. The book includes a treatment structure that enables treatment to be organised in a coherent, integrated framework and enables practitioners to assess, formulate and plan effectively for treatment of clients with multiple, complex needs. All of the chapters suggest methods to overcome the obstructions to treatment and challenges that these clients pose. The book incorporates consideration of risk and destructiveness to enable those staff working with forensic clients to address offending behaviour simultaneously with other problem behaviours. All authors advocate for a transdisciplinary team approach whereby each discipline has a clear role and its own unique contribution to make towards treatment. Within this approach, every interaction between every client and every staff member has therapeutic potential. Although the majority of the volume is aimed at improved clinical services, an overview of the management structures essential for the provision of clinical excellence is also provided.

Chapter 2 provides an overview of the difficulties faced by clinical staff and prison service personnel in working with clients on a daily basis. The chapter explores how these difficulties have contributed to service providers avoiding their responsibilities, and summarises action that can be taken to develop a service that is accessible and responsive to people with personality disorder whilst maintaining a staff group who feel safe enough to perform their roles confidently and competently.

Within Chapter 3, the process and content of robust assessment and formulation for clients with multiple, complex needs, including potential risk to self or others, are described within a suggested framework. The chapter covers not only formal methods of assessment that can be useful with this client group, such as psychometric tests, but also other ways of enhancing assessment, such as observations, collateral information and countertransference. Difficulties in assessing clients where motivation to participate in the assessment process is minimal or fluctuating are also addressed. The authors argue for the production of a written formulation that is accessible to the individual client and the staff team involved in his or her care, highlights potential obstacles to treatment that will need to be overcome, and predicts vulnerability to increased ‘acting out’ behaviour.

People with personality disorder are often excluded from treatments and programmes by virtue of their diagnosis. Many services paradoxically require that clients reform their behaviours prior to being considered as appropriate for intervention, for example the client must resist using aggression. The rationale behind this is that the client will be unable to conform to the requirements of many treatment approaches. Other service providers offer treatment only to those who meet one discrete disorder, for example the provision of dialectical behaviour therapy to people with borderline personality disorder. Within Chapters 4 and 5, the characteristics essential for a more accessible treatment programme are described. A significant issue pertaining to treatment services for people with personality disorder is that of maintaining treatment integrity when staff are operating from diverse theoretical influences. The authors of Chapter 4 identify eight theoretical principles that underpin the treatment needs of an eclectic client group with varying needs and motivation. They describe an overarching framework within which clinical interventions can be organised and structured to provide an integrated service that ensures adherence to these principles.

Within Chapter 5, the authors describe features that are essential if services wish to treat rather than merely manage personality disordered clients. They describe the importance of working towards an emotionally intimate relationship with these clients and suggest three key strategies if this is to be achieved: maintaining optimum affective arousal; working with the logical perspective of the client; and using explicit communication. Although controversial, the chapter offers the reader new techniques that will allow for meaningful and valid therapeutic relationships that encourage growth within the principles of most psychological models.

Most services for people with personality disorder are annexed onto traditional psychiatric and prison-based services and are required to adhere to the customary practice within the host institution. The authors of Chapter 6 discuss the challenges faced by organisations offering a service to personality disordered individuals within such a context and highlight how many customary practices are ineffective when applied to this client group. The authors also suggest a framework for effective service provision that adheres to the National Service Framework of good practice for mental health services established within the UK.

Working within a multidisciplinary team has increasingly become a key part of the role of most mental health professionals and the editors believe that one of the salient factors for delivery of an effective programme for the treatment of personality disorder is that of an effective team. Without a robust team in situ, the risks to the integrity of any approach are raised significantly. One cannot overestimate the importance of this infrastructure in the development of a service. The author of Chapter 7 discusses not only the advantages of working within a multidisciplinary team but also some of the challenges that can arise which are exacerbated in teams providing specialist services for personality disordered clients. She advocates for such services to adopt a higher level teamworking approach, transdisciplinary teamworking, and provides guidance on how to transform existing teams into high performing transdisciplinary teams.

Chapters 8, 9, 10, 11 and 12 discuss the unique contribution made by each profession within the transdisciplinary team. The authors of the first four of these chapters describe a clear and active role for their professional group within the treatment of personality disorder that does not entail having to train as a psychological therapist. The author of each chapter identifies how traditional practice is often focused upon the management of the client and the client’s symptoms rather than change-oriented treatment addressing the cause of the individual’s difficulties. Each author describes unique challenges encountered by members of their professional group and describes a course of action to enable the professional to improve the effectiveness of their contact with the client group. These chapters also provide a benchmark against which managers of services can appraise the effectiveness of their team. The author of Chapter 12 is not concerned with the role of the psychologist as assessor or therapist. Instead she focuses upon the opportunity for the psychologist to maximise the therapeutic potential of the team by using his or her knowledge of psychological theory and practice to enable others to improve the effectiveness of their interventions and to facilitate the harmonisation of care across the team.

The author of the final chapter describes some of the essential components of a service where staff are able to develop key skills and knowledge and have access to good systems for support and supervision. Within this chapter she also describes some of the barriers to effective support and supervision and suggests strategies for overcoming these.

All of the authors contributing to this book are experienced in working with clients with personality disorder across the full spectrum of services and are passionate about ensuring the highest standards of care. They are all practising clinicians who are successful in facilitating change in the most challenging of clients. We hope the reader will also feel confident and positive about rising to the challenge of treating these clients and be optimistic about the possibility of making their own contribution to treating people with personality disorder after reading this book.

Chapter 2
The difficulties that staff experience in treating individuals with personality disorder

Naomi Murphy and Des McVey

Introduction

Personality disordered patients evoke strong negative emotions and attitudes among many health care professionals. Such is their unpopularity that Fallon’s inquiry into Ashworth Hospital (1999) observed that the legal concept of ‘psychopathic disorder’, created to cover patients with personality disorder when they fall within the remit of mental health law, is a term of ‘abuse’. Cavadino emphasised the futility of re-labelling the concept of ‘moral insanity’, arguing that ‘the more modern term is simply a prime example of moralism masquerading as medical science’. He continues,

Perhaps we should strip away the mask completely, and for the term ‘psychopath’ substitute the word ‘bastard’. For ‘predominantly aggressive psychopath’, read ‘stroppy bastard’. For ‘predominately inadequate psychopath’: read ‘useless bastard’. Would much be lost in the descriptive power of the terms? Would not much be gained in the honest expression of the essentially moral judgement and dehumanizing contempt with which we view ‘the psychopath’?

(Cavadino, 1998, p. 6)

This distaste of mental health service providers led to personality disordered people being denied access to services on grounds of lack of ‘treatability’ without any obligation for apparent lack of treatability to be evidenced or for alternative forms of treatment to be sought. In the UK, this led to several high profile cases in the 1990s where men diagnosed with personality disorder but considered untreatable caused public concern. This was followed by the Labour government investing considerable resources to ensure that mental health services are accessible and meaningful for those people with personality disorder as well as for those with mental illness. This chapter explores the difficulties that led to some service providers avoiding their responsibilities, and summarises action that can be taken to develop a service that is accessible to people with personality disorder, and which is well manage...