Personality Disorder and People
with Learning Disabilities
Dr Simon Crowther
Overview
• Personality Disorder (PD) and people with Learning Disabilities
(LD)
• A model for PD and LD
• Case examples
• Challenges
Personality Disorder (PD)
Definition of PD
“Deeply ingrained and enduring behaviour patterns, manifesting
themselves as inflexible responses to a broad range of personal
and social situations.” World Health Organisation
3 P’s model- Persistent, Pervasive and Problematic (DoH, 2012).
Prevalence of PD in LD (Alexander et al, 2002)
- Community teams- 7%
- Secure settings- 50/60%
Personality Disorder Clusters
Cluster A:
Cluster B:
Cluster C:
Odd and Eccentric
Dramatic and Erratic
Anxious and Fearful
• Schizoid
• Paranoid
• Schizotypal
• Antisocial
• Borderline
• Histrionic
• Narcissistic
• Avoidant
• Dependent
• Obsessive
Compulsive
Personality Functioning Continuum
General Public
Healthy
Personality
Functioning
Some
Problem
Traits
Many
problem
Traits
Personality
Disorder
Offenders
Diagnostic Cut-off
PD and LD
Diagnosing PD in people with LD is a contentious issue…
- Assessment problems
- Validity problems
- More stigma
But PD is a clinically important issue…
Tor (2008)- diagnosis of ASPD associated with placements in
higher security, serious and repeat offending and poorer long
term outcomes
Alexander et al (2006)- LD offenders with PD discharged from
MSU were x9 times more likely to re-offend
PD and LD
Diagnosis solutions?
Only diagnose people with LD in the mild/moderate range
(Lindsay et al, 2005).
Only diagnose those with ‘cluster B’ Personality Disorder (Naik
et al, 2002).
PD and LD
The initial evidence suggests that interventions beneficial
for people without LD can also be helpful for people with
LD…
• Cognitive Analytic Therapy (CAT)- Lloyd & Clayton (2013)
• Dialectical Behaviour Therapy (DBT)- Morrissey &
Ingamells (2012), Brown et al (2014).
• Therapeutic Communities (TCs)- Taylor & Morrissey
(2012), Taylor et al (submitted).
PD and LD
In the literature on working with people with PD two
themes are prominent:
1. That the environment around the person is supportive,
healthy and enabling (MoJ)
2. The importance of delivering treatment in an
integrated and coordinated manner- John Livesley
(2003)
What works with PD
For people with a diagnosis of PD their difficulties exist in their
relationships with others.
Healthy and supportive relationships are crucial to treatmentbut this is easier said than done!
Current relationships and interactions are a focus of the
treatment approach.
Every interaction, from the mundane to the emotionally
charged, is an important opportunity for reflection and learning.
What works with PD? (Livesley,
2003)
5%
Person
Interactions
Therapy
45%
50%
PD treatment framework
Principles
Engagement and
Assessment
‘Team’ approach
All members of
the team have a
role
Formulation and
Goal setting
Formulation and
goal setting as
central
Treatment
Enabling
Environment
Moving on
First 3-6 months in
the PD care
pathway
12-18 months in the
care pathway
Principles of the approach
• An ‘enabling environment’
• Use of psychological formulation to understand
complex behaviour and risk.
• Whole team philosophy
• Training and support for the staff team
An ‘Enabling Environment’
Psychologically Informed Planned Environments (PIPEs). (NOMS
& DoH, 2012).
• An emphasis is placed on the importance and quality of
relationships.
• Staff are provided with further training to have an increased
psychological understanding of their work and of complex
behaviour.
• Service structures aim to promote healthy relationships and
offer opportunities to work through relationship difficulties.
An ‘Enabling Environment’
Development of psychological
psychological formulations
thinking
‘Every interaction matters’
Occupational therapy sessions structure the day.
Social participation and group activities .
Personal responsibility and self-efficacy
through
Psychological Formulation
All clients are offered a formulation as part of the assessment
process.
Two types of formulation are used in this service…
Case formulation- to develop an understanding of the key
relationship problems that we need to support the person with.
Risk formulation-to develop an understanding of key risk
behaviours, how this might play out with others and what
support is needed to minimise this.
Psychological Formulation
Case formulations
PD as PTSD- re-enacted in current relationships
Formulations aim to make sense of overwhelming and confusing
behaviour.
Formulation as a support guide for staff team and to suggest
most appropriate interventions.
Formulations should predict difficulties in engagement.
Psychological Formulation
Risk Formulations
The key risk areas assessed using a structured professional
judgement assessment. (SPJ)- HCR 20 v3, RSVP, etc.
Service user involvement in the process.
Should identify strengths and protective factors.
Should lead to prediction of how the behaviour could happen in
current context and a mitigation plan.
Whole team philosophy
A ‘core team’ for each service user- i.e. service user-key workercase manager-MDT.
Shared goals that everyone works towards achieving.
A shared understanding of the service user that everyone uses.
A belief in the team approach, including an ability to work
democratically and consistently.
The use the communication forums to resolve conflict and
disagreements.
The staff team
A different role from what they may be used to.
Helping the staff team
understanding of their work.
develop
a
psychological
The importance of regular and consistent support sessions.
A ‘culture of curiosity’ and reflective practice.
‘Ad hoc’ supervision.
PD- integrating treatment
Safety
Containment
• The safety of self and others
• Containment of emotional and
behavioural instability
Control and Regulation
• Reducing symptoms and improving
coping skills
Exploration and Change
• Changing beliefs, behaviour and
interpersonal style
Integration and
Synthesis
• Developing a more adaptive lifestyle
PD- integrating treatment
Safety
Containment
• Engagement, structure, supervision,
formulations
• Motivational work, goal setting,
communications skills
Control and Regulation
• Skills based approaches
• Improving coping strategies
Exploration and Change
• Exploratory therapy
• Offence focused therapy
Integration and
Synthesis
• Relapse prevention planning
• Increased community presence
MSU
LSU
Case examples…
‘Mark’
‘John’
Rage against women
and ‘the system’
Controlling
e.g. offending, rule
breaking, challenging
authority
Controlled
“I have to be in
control.”
Using anger to get
what I want
Minimizing any
problems
Just focusing on the
positives
Abusing
Angry
Abused
Hurt Child
Abused/Damaged
No-one cares about me.
Can’t trust anyone. Push
others away. Blame
others
Rejecting
Cut off
Admiring
Admired
Overwhelming feelingsUsing drugs, alcohol and
pornography and self harm
Rejected
‘Mark’- working with the staff
team
Goal 1- Acknowledging my risk e.g. being able to talk about the risk I
could present in the future and how I am going to manage this.
I find it hard to talk about my risk of reoffending. I don’t like thinking
about it because it makes me feel bad, and instead I try and focus on
the positives. I also worry that talking about my risk of reoffending will
make others feel worried and that they might keep me here longer.
However, I will need to be able to talk about risk so that people feel
confident that I can manage this in the future.
Rating- 5/10
‘Mark’- working with staff team
Plan for Goal 1
1. Engage in therapy work regarding sexual feelings.
2. To start to talk to trusted others about my risk of reoffending.
3. To try and not be defensive when others talk about my risk.
Evidence of progress….
Signs that I am in this
place
BATTLING
Punishing,
Attacking
I shout, threaten and
pace up and down.
I make complaints
and threaten to get
people sacked
Look out for
people taking the
‘p*ss’
Punished,
Hurt, Angry
I refuse to ‘back
down’
Others
‘punish and
control me’
Which make
me think I
need to be in
control of
myself and
others
Painful feelings from
childhood-
Signs that I am in this
place
I use intimidation
and threats to get
what I want
I ‘look out’ for
people ‘taking the
p*ss’
I start to feel
fed up and
unfairly treated
and think- F*ck
it! I should be
able to have
whatever I
want!”
GETTING A BUZZ
Abusing/
Rule
breaking
Asking for things that
I won’t get/are
unrealistic
Abused
“ALTER EGO”
Controlling
Signs that I am in this
place
‘Sneaking
around’/changes to
my usual routine
Signs that I am in this
place
I put my needs first
Not being open
about my feelings
Becoming defensive
when talking about
risk
I keep other people
at a distance
Controlled
Weak, Vulnerable
Punished
Others get
worried, and
punish/
control me’
which makes
me think I
need to be in
control of
myself and
others
John- working with the staff
team
Goal 2
To cope with feeling frustrated, disappointed or let down
When I feel frustrated, disappointed or let down I can ‘go off on
one’, becoming angry very quickly and making threats towards
others.
Rating- 2/10
John- working with the staff
team
Plan for Goal 2
(a) To practice coping strategies when I feel like this- and to
learn coping strategies for this if I don’t have any
(b) To stop myself from ‘punishing’ people when I have these
feelings.
(c) To repair relationships when I have punished or threatened
others.
Evidence of progress….
John- working with the staff
team
Goal 4
To show care and support to others
I find it hard to think about others, and put my needs first.
When my behaviour has an impact on others I can say things
like, “I don’t care about anyone others than myself”.
Rating- 1/10
John- working with the staff
team
Plan
(a) To put other people first sometimes
(b) To make compromises with others
(c) To show support for people I live with
(d) To think about how other people feel
Evidence of progress…
Challenges
It can be emotionally intense.
Low motivation, hopelessness and despair is common.
Training and supervision is vital.
It takes time to set up services and for people to feel
comfortable working this way.
The treatment pathway through services for people with LD and
PD needs further development (and funding!)…
Working with people with PD
“Providing effective care and treatment for people with
personality disorder is one the most challenging in the field of
mental health…but…working with this client group can provide
staff with a tremendous sense of job satisfaction and growth”
(Murphy and McVey, 2010)
References
Alexander, R., T., Piachaud, J. Odebiyi, L. & Gangadharan, S., K. (2002).
Referrals to a forensic learning disability, British Journal of Forensic
Practice, 4, 29-33.
Alexander, R. T., Crouch, K., Halstead, S. & Piachaud, J. (2006). Longterm outcomes from a medium secure unit for people with intellectual
disability, Journal of Intellectual Disability Research, 50, 305-15.
Alexander, R. T., Green, F., N., O’Mahony, B., Gunarantna, J., I.,
Gangadharan, S., K. & Hoare, S. (2010). Personality disorders in
offenders with intellectual disability: a comparison of clinical, forensic
and outcome variables and implications for service provision, Journal
of Intellectual Disability Research, 54. 650-658.
Lindsay, W.R., Gabriel, S., Dana L., Young, S. & Dosen, A. (2005).
Personality Disorders. In: Diagnostic Manual of Psychiatric Disorders
for Individuals with Mental Retardation, National Association for Dual
Diagnosis, Kingston, NY.
References
Livesley, J. (2003). Practical Management of Personality Disorder,
Guilford Press.
Lloyd, J. & Clayton, P. (2013) .Cognitive Analytic Therapy for People
with Intellectual Disabilities and their Carers, Jessica Kingsley.
Murphy, N. & McVey, D. (2010). Treating Personality Disorder: Creating
Robust Services for People with Complex Mental Health Needs.
Morrissey, C. Taylor, J. & Bennett, C. (2012). Evaluation of a therapeutic
community intervention for men with intellectual disability and
personality disorder, Journal of Learning Disability and Offending
Behaviour, 3, 52-60.
Morrissey, C. & Ingamells, B. (2011). Adapted dialectical behaviour
therapy for male offenders with intellectual disability in a high secure
environment: six years on, Journal of Learning Disabilities and
Offending Behaviour, 2, 10-17.
References
Naik, B., I., Gangadharan, S., K. & Alexander, R., T. (2002).
Personality disorders in learning disability- the clinical
experience. British Journal of Developmental Disabilities, 48, 95100.
Taylor, J. & Morrissey, C. (2012). Integrating treatment for
offenders with an intellectual disability and personality disorder,
The British Journal of Forensic Practice, 14. 302-315.
Taylor, J., Crowther, S., Sothern, C., & Stronach, C. (submitted).
Therapeutic Communities for People with Intellectual Disability
and Complex Needs, Advances in Mental Health and Intellectual
Disabilities.