Personality Disorder
Integrated Care Pathway
(PD–ICP)
10: Community Care
July 2015
Acknowledgements
This document was produced by a partnership of NHS Highland staff, volunteers, service users
and staff from other public and third sector organisations.
The NHS Highland Personality Disorder Service will coordinate future reviews and updates of
this document.
NHS Highland would like to thank everyone involved in the creation of this document.
July 2015
Contents
10 Community Care
10.1 Introduction ....................................................................................................................
10.2 Primary Care .................................................................................................................
10.2.1 When to refer to mental health services ............................................................
10.2.2 General Principles ..............................................................................................
10.3 Community Mental Health Teams ..................................................................................
10.3.1 Role of the CMHT in the treatment of Personality Disorder ...............................
10.3.1.1 Assessment, Diagnosis and Formulation ...........................................
§1
Phase of treatment ..........................................................
§2
Symptoms ........................................................................
§3
Personality Traits ............................................................
§4
Needs Assessment .........................................................
§5
Risk Assessment .............................................................
§6
Environmental Context ....................................................
10.3.1.2 Treatment and Management ..............................................................
§1
What constitutes treatment of personality disorder
within a CMHT? ..............................................................
§2
Care planning ..................................................................
§3
Co-occurring disorders ....................................................
§4
Crisis planning ................................................................
§5
Phase of treatment ..........................................................
§6
Care Programme Approach .............................................
10.3.1.3 Risk management ...............................................................................
10.3.1.4 Supervision ........................................................................................
10.3.1.5 Social Network Involvement ................................................................
References ..............................................................................................................................
10. Community Care
10.1 Introduction
Personality disorder is a common disorder affecting upwards of one in ten of the general population. Of these people, around a quarter will be treatment-seeking, while about three quarters
while be treatment-resisting (will not seek treatment or will actively avoid treatment).
Most treatment of people with personality disorder occurs in the community. As with most
conditions, large numbers of people with milder forms of the disorder will be managed within
primary care, smaller numbers with more severe difficulties will be managed in secondary care
and a yet smaller number with the most severe difficulties will receive input from specialist
tertiary services. Even at the most severe end of the spectrum of difficulties, community
treatment is generally preferred to hospital treatment for the reasons outlined in the In-patient
Section.
General issues relating to care and treatment of personality disorder within Primary Care and
Community Mental Health Teams (CMHTs) are discussed in this section. Specific psychosocial
and pharmacological interventions are discussed in their respective sections.
10.2 Primary Care
People with personality disorder are heavy users of primary care services. Typically, around a
quarter of people in a general practice clinic fulfil the diagnostic criteria for personality disorder.
Although personality disorder may not be the given reason for attendance, the condition
appears to be associated with increased rates of other mental health and physical health
problems, substance use conditions, medically unexplained symptoms and frequent attendance
in primary care settings.
10.2.1 When to refer to mental health services
For patients already involved with mental health services, any existing care plan should be
followed except in exceptional circumstances. Care plans should be made easily available in
the casenotes or other patient information systems.
Patients who have no current involvement with mental health services and who are assessed as
needing the input of these services should be directed to the appropriate service according to
whether they represent an emergency or not.
Emergency referrals (those patients who require to be seen the same day for reasons of
significant risk) should generally be directed to the Mental Health Assessment Team (MHAT) at
New Craigs Hospital. MHAT can assess which treatment, including inpatient treatment is most
appropriate. GPs in the Inverness sector may also consider referring to Braeside Crisis and
Intensive Treatment Service. Braeside aims to provide an alternative to in-patient care for
patients with mental disorder who present a current significant risk to themselves or others.
Non-emergency referrals should be made to the sector Community Mental Health Team
(CMHT) via the single point of referral. Sometimes it can be difficult to establish if a
presentation is related to a mental state condition or a personality disorder (or both). In these
circumstances, referral to the CMHT for clarification of diagnosis is reasonable. Other
situations when referral to the CMHT might be considered include when the patient is unable
to be managed solely in primary care because of issues of severity, complexity, co-morbidity
or risk; or when the person’s personality appears to be acting as a vulnerability factor to
mental illness.
Just as it would be inappropriate for all people with depression to be referred to secondary
care mental health services, so it would also be inappropriate for all people with personality
disorder to be referred; matched care should be the aim. Regular communication and
discussion between primary care and community mental health services is likely to be of
benefit in maintaining the referral threshold at the most appropriate level.
Useful referral information includes:
• whether the general criteria for personality disorder are met, with some description of
severity
• an outline of the difficulties experienced by the patient in the four main domains:

cognitive-perceptual

affective

interpersonal

o
relationship with self including sense of self
o
interpersonal relationships
o
relationship with society
behavioural/impulse control (including self-harm and suicidal behaviour)
• concurrent physical and mental health conditions
• appropriate risk assessment, perhaps using a structured tool such as STORM
10.2.2 General Principles
Whether a person has mental health services involvment or not, they are likely to continue to
require the input of primary care to some degree. Every contact should be informed by the
concepts and principles outlined in the General Principles Section:
• Collaboration
This applies equally to collaboration with the patient and collaboration with the wider
team. Ensure that everyone is clear about their roles and responsibilities, and the
treatment frame. The importance of personal responsibility and self-management should
be emphasised. The Care Program Approach (CPA) can be very valuable in helping
clarify roles and promote consistency. CPA meetings provide a valuable opportunity for
professionals and the patient to assess needs and risk and develop an appropriate care
plan collaboratively. While it is recommended that patients at the more severe end of the
personality disorder spectrum who have multi-disciplinary or multi-agency involvement
should be managed under the CPA, any clear written care plan shared between all
relevant professionals and the patient is likely to improve care delivery.
• Consistency
Limiting the number of General Practitioners a patient sees to one or two in order to allow
a good working relationship to develop can be of value in promoting collaboration and
consistency.
If a Care Program Approach (CPA) care plan or other written care plan is in existence,
then it is important that clinicians (including out of hours staff) are aware and able to
easily access the information. Inconsistency, for whatever reason, can lead to significant
anxiety and dysregulation. A shared plan can make it less difficult to appropriately
maintain limits in the face of pressure. Consider placing any care plan in “special notes”
or similar.
Often GPs, working within tight clinic schedules or in out-of-hours settings, come under
significant pressure from patients in distress to “do something”. This can sometimes
result in unhelpful reactive prescribing. It is important to remember that standing by a
decision not to prescribe, while validating the patient’s desire for the situation to change
and explaining the rationale of the care plan, is in fact often “doing something”
therapeutic. If medication is felt to be appropriate, it is recommended that a written
prescribing agreement is used. See Medication Section for further details.
• Motivation
Some suggested strategies for increasing motivation to change can be found in General
Principles Section.
• Validation
Validation involves active listening and observation, accurate reflection of the patient’s
emotions, thoughts and behaviours, and direct validation (the explicit acknowledgement
of a thought, emotion or behaviour as valid and legitimate for that person, both
understandable in the current context and in the context of previous experiences). It is
important to recognise that validation does not necessarily imply approval.
• Promotion of self-management
Supporting self-management across health conditions is a key part of the role of primary
care. Further information on how the concept relates to personality disorder can be found
in the Self-management Section.
Promoting self-knowledge and self-reflection are a component of self-management which
is particularly important in personality disorder. This process may involve provision of
general information about the condition but should also comprise more individual-specific
knowledge gained by a process of self-reflection. Wherever possible, consider
highlighting the importance of attempting to understand the mental state of oneself and
others and how thoughts and emotions influence behaviour. For the clinician, a “not
knowing” or gently curious style which encourages the patient to reflect on the thoughts,
emotions and behaviours of themselves and others is usually more useful than simply
providing patients with “the answers”.
10.3 Community Mental Health Teams
People with personality disorder make up a significant component of the clinical load of CMHTs.
This will include people with a primary problem of personality disorder and people with other
mental disorders whose treatment may be made more challenging by coexisting personality
disorder or whose personality functions as a contributing factor to other mental disorders. Most
people with personality disorder in mental health services receive their treatment from generalist
rather than specialist services and this is likely always to be the case. The value of a
multidisciplinary team approach in treating personality disorder cannot be over-estimated and
increasing evidence is emerging which suggests that generalist multi-disciplinary care based
upon a shared psychologically-informed care plan can be as effective as specific psychological
treatments for personality disorder. In some instances it may be clinically indicated to limit the
number of professionals involved with a patient at any one time. In all cases, it is of real
importance that someone in the team functions as a caseholder, keyworker or point of contact,
and maintains an overview of the persons care and treatment, ideally for the duration of their
involvement with the team.
Over the past decade or so, documents such as the report “Personality Disorder in Scotland:
Demanding Patients or Deserving People” (Scottish Executive Mental Health Division and
Centre for Change and Innovation, 2004) have emphasised that no one should be excluded
from services solely on the basis of a diagnosis of personality disorder. While such exclusion did
unfortunately happen in the past, this practice is now regarded as absolutely unacceptable, not
least because of the ever-increasing evidence base of effective treatments for personality
disorder.
10.3.1 Role of the CMHT in the treatment of Personality Disorder
At a minimum, CMHTs should be able to provide assessment, diagnosis and formulation, offer a
variety of treatment strategies based upon the formulation, and signpost to other services as
appropriate.
10.3.1.1 Assessment, Diagnosis and Formulation
CMHTs should be able to provide an assessment, diagnosis and formulation function as
outlined in the Assessment, Diagnosis and Formulation Section of this ICP.
While most clinicians are well placed to describe and discuss personality traits and symptoms, a
formal diagnosis of personality disorder should usually only be made by a senior psychiatrist.
During the diagnosis process, is important that the patient receives balanced, honest feedback
in a form which they can understand. Personal strengths should be emphasised while
acknowledging difficulties and the importance of personal responsibility in the recovery process.
Explanation of treatment options and the relatively positive prognosis should be given. For
example, patients are often heartened to hear that studies suggest that around three quarters of
those meeting the diagnostic criteria for borderline personality disorder no longer do so after a
period of six years.
While many patients describe a sense of relief on receiving a diagnosis or formulation that
makes sense of their difficulties, many others find receiving a diagnosis of personality disorder
an upsetting experience. This is at least in part due to myths and misinformation perpetuated by
the media, and the associated stigma. Psychiatrists should consider giving verbal and written
information on personality disorder when discussing the diagnosis with the patient and asking
them to return with any questions once they have reflected on the information. It is also
reasonable to advise patients about the large amount of misleading information regarding
personality disorder on the internet, and recommend that they exercise caution in what they
read. Some useful information leaflets are available in the Appendix.
Occasionally, patients can have difficulty with the term “personality disorder”. If this is the case, it
may be helpful to explain that the term simply serves as short hand to describe sets of
symptoms and traits which typically occur together, and has the principle purpose of ensuring
delivery of the treatment that is best matched to the patient’s problems. Some patients with
borderline personality disorder find the reframing of their difficulties as “emotional intensity
disorder” (which is the terminology used in the STEPPS program) to be more acceptable. In any
case, the terminology is much less important than the clinician and patient agreeing on the
presenting features.
Assessment should aim to establish diagnosis and produce a formulation upon which an
individual’s treatment plan should be based. Particularly important components of the
assessment in guiding treatment planning include:
• phase of treatment
• symptoms
• personality traits
• needs assessment
• risk assessment
• environmental context
§1
Phase of treatment
Most commonly, patients will be referred to a CMHT needing input at phase 1 or 2. See the
General Principles Section for a more detailed description of phases of treatment.
§2 Symptoms
Symptoms occur as a result of maladaptation of the personality to the environment. It can be
helpful to think in terms of four broad headings:
• cognitive-perceptual (for example, excessive suspiciousness)
• affective (for example, emotional dysregulation and harmful anger)
• interpersonal
◦ relationship with self including sense of self
◦ interpersonal relationships
◦ relationship with society
• behavioural/impulse control (including self-harm and suicidal behaviour)
§3 Personality Traits
A personality trait or variable is a complex structure which represents a basic building block of
personality. In any given individual, genetic factors and environmental factors transact with each
other to form a complex biopsychological system which produces observable trait-based
behaviour. This biopsychological system can be described in terms of both biological processes
and psychological processes. Essentially, a personality trait represents a disposition to behave
in a particular way.
The term “trait” is also sometimes used to refer to individual features of specific personality
disorders, especially when the full diagnostic criteria are not met. For example, someone
meeting four of the five criteria needed for a diagnosis of borderline personality disorder may be
referred to as having “borderline traits”.
Some traits which are of particular importance in personality disorder are listed below with brief
descriptions of associated behaviours. Traits can be usefully organised into four main higher
order trait domains: dyregulated, detached, dissocial, and compulsive. There may be some
overlap between some traits and it is worth noting that some of the names used for particular
traits may have different meanings when used in other contexts. The traits below are drawn
from the Personality Assessment Schedule (Tyrer, 2000), and other sources may label
particular traits differently.
It is important to remember that no personality trait is inherently negative. Many traits can be
described by more than one term, some with negative connotations and some with positive
connotations. For example: impulsive versus spontaneous; stubborn versus determined; aloof
versus self-contained and so on. Problems arise when a person’s personality traits are
maladapted to their environment. With more extreme expressions of particular traits,
maladaption is likely in a greater number of environments leading to greater severity of
personality disturbance.
Dysregulated (Internalising) Domain
Pessimism — holds a pessimistic outlook on life.
Worthlessness — feelings of inferiority
Lability — mood instability
Anxiousness — anxiety-proneness
Shyness — shyness and lack of self-confidence
Sensitivity — personal sensitivity and tendency to self-reference
Vulnerability — experiences excessive emotional distress when faced with adversity
Childishness — excessive self-centeredness
Resourcelessness — tendency to give up when faced with adversity
Dependence — excessive reliance on others for advice and reassurance
Submissiveness — limited ability to express own views or stand up for
oneself
Hypochondriasis — over-concern about illness and health
Detached (Schizoid/inhibited) Domain
Suspiciousness — excessive mistrust of others
Introspection — prone to rumination and fantasy
Aloofness — detachment and lack of interest in other people
Eccentricity — oddness in behaviour and attitudes; unwilling or unable to
conform
Dissocial (Externalising) Domain
Optimism — unrealistically optimistic, over-confident, excessively self-important
Irritability — excessively irritable
Impulsiveness — excessive impulsiveness
Aggression — excessive levels of aggression
Callousness — indifferent to the feelings of others
Irresponsibility — indifferent to the consequences of one’s behaviour
Compulsive (Anankastic) Domain
Conscientiousness — overly fussy, perfectionistic
Rigidity — inflexibility and difficulty adjusting to new situations
§4 Needs Assessment
While it will certainly not be necessary to provide the CPA for every patient referred to the
CMHT, the Care Program Approach Needs Assessment Checklist provides a comprehensive
systematic guide to needs assessment. Common areas of need for people with personality
disorder, from which specific treatment goals can be identified, include:
• medication including:

polypharmacy

compliance issues
• concurrent mental health conditions including:

mood and anxiety disorders

substance misuse disorders
• physical health including:

not accessing appropriate care for medical conditions

reduced self-care including suboptimal management of chronic medical conditions
• emotional support including:

crisis resolution

containment strategies
• accommodation including:

difficulty maintaining a tenancy
• social/interpersonal situation including:

lack of interpersonal contacts

lack of leisure time activities
• employment, education or other meaningful, structured use of time
• financial including

debt problems

benefits issues

financial management difficulties
• dependent children/ other dependents including

difficulties managing childcare tasks
§5 Risk Assessment
Each individual risk should be specified in the care plan with indicators of an increase in risk
identified. Current level of risk of each specific situation occurring should be estimated as far as
possible. A clear risk management plan should be in place for each identified risk, with roles and
responsibilities made explicit. Consideration should be given to the use of a recognised tool such
as STORM in assessing the particular risk of suicide. The overall aim is to minimise the risk of
harm to the patient and those around them, while always promoting the personal responsibility
so vital for recovery.
The CPA documentation provides a useful structure for risk assessment and risk management.
§6 Environmental Context
This includes the interpersonal and social context which should become apparent during
assessment.
10.3.1.2 Treatment and Management
Evidence is emerging that structured multidisciplinary treatment based upon a sound
formulation can be of equal benefit to specific psychotherapies in the treatment of personality
disorder. CMHTs are well placed to enable the continuity of care which is so important in
maintaining consistency in the treatment of personality disorder, and to oversee the treatment
plan over the longer term. As well as this more general approach, all CMHTs should be
regularly delivering STEPPS groups for patients with borderline personality disorder and similar
difficulties (see Psychosocial Section). CMHTs can usefully deliver focused preparatory work for
STEPPS groups in the period between referral to the team and the start of the next STEPPS
group, for example anxiety management strategies for people who experience anxiety in group
settings.
Aside from treatment directed towards personality disorder itself, community teams play a vital
role in wider treatment and management including treatment of comorbidity, management and
monitoring of medication and environmental management. Any treatment offered by the team
should be focused and time-limited (although perhaps of long duration). At any given time, both
the clinician and the patient should be absolutely clear about the nature and purpose of the
work they are undertaking. Open-ended, unstructured contact should be avoided as this may
encourage unhelpful dependence. If a patient is unwilling to engage in their treatment plan,
motivation work may be indicated. However, sometimes, despite motivational strategies, a
patient may still decide that they do not wish to engage in treatment at that time. In these cases,
it may be less harmful to discharge a patient rather than engage in unfocused, unstructured,
dependence-inducing contact.
§1 What constitutes treatment of personality disorder within a CMHT?
For an intervention to be considered a treatment for personality disorder, the primary goal must
be to improve the difficulties associated with the patient’s personality disorder. A distinction can
be drawn between treatments aimed at a patient “overcoming” their personality difficulties by
seeking to initiate change in the patient, and treatment or interventions which “take account” of
the personality difficulties in order to minimise the impact of the personality disorder on the
patient and those around them. Examples of the former include psychological treatments like
DBT and STEPPS and any skills reinforcement or skills generalisation carried out by the CMHT.
Examples of the latter include environmental management (interventions aiming to improve
adaptive fit between the person and their environment), interventions aimed at changing the
social or interpersonal environment (family interventions etc) and adaptations to standard
interventions for another condition (changing the treatment approach for major depressive
disorder in someone with a concurrent personality disorder).
§2 Care planning
The following points are important to consider in collaboratively developing a care plan:
• The jointly developed care plan should be based on the individual formulation and cover
personality disorder and any co-occurring disorders.
• The patient should be supported to develop a crisis self-management plan as early as
possible in the treatment episode.
• A crisis care plan identifying how a team aims to respond to a crisis should be made
explicit
• The phase of treatment should be clearly identified.
• Risk management plans should be explicit.
• Care Program Approach may by useful in helping to manage complexity or severity. See
http://intranet.nhsh.scot.nhs.uk/org/dhs/mhandlearningdisabilities/cpa/Page/
Default.aspx.
• Quality assurance including appropriate supervision.
• Social network involvement where appropriate
§3 Co-occurring disorders
Personality disorder not only causes difficulties in its own right, but often functions as a
vulnerability factor for other mental health problems which can frequently be more challenging
to treat in the presence of personality disorder. Consequently, due attention should be paid to
any personality difficulties when there are co-occurring mental health problems. It is rarely
adequate to simply treat mental state disorders using standard approaches in such situations.
§4 Crisis planning
Crisis planning is of particular importance in personality disorder and should be a task
considered very early in any treatment process. When people with personality disorder
experience intense emotions, the ability to think clearly is reduced even more than it would be
for other people. Hence a crisis self-management plan, with options and contacts for dealing
with a crisis situation clearly listed, can be invaluable. Although a crisis may be produced in
collaboration with a clinician, it necessarily remains the patient’s document. However, clearly it
is likely to be beneficial for the patient to share copies with relevant people. Examples of
template crisis self-management plans can be found in the Appendix.
§5
Phase of treatment
Identification of the phase of treatment is a primary task. This section should be read in
conjunction with the General Principles Section.
1 Stabilisation (or MAKING STABLE). The focus here is on the present:
a Safety and
b Containment: The main aims of the first two parts of the stabilisation phase are
management of symptoms and crises. Interventions should be kept simple and
focused with the goal of returning the patient to the previous level of functioning as
soon as possible. It is important to avoid attempting to achieve too much during the
safety and containment phases
of treatment. See Crisis Management Section.
c Regulation and control: Once acute behavioural dysregulation has stabilised (even
temporarily), work can begin on the third part of the stabilisation phase. The main
aims are to promote self-management of impulsivity, self-harming behaviour and
emotions.
Useful strategies include behavioural analysis which can help the person to identify
the antecedents and reinforcing consequences of unhelpful behaviours. Distancing,
mindfulness, emotion regulation, distress tolerance and interpersonal effective skills
and strategies are likely to be of value in identifying solutions. These generic
approaches do not “belong” to any particular psychosocial intervention. However,
while it is entirely reasonable for these skills to be taught on an individual basis
outwith specific psychosocial approaches like STEPPS or DBT, it is important that
the clinician and patient are clear that what is being delivered in such a situation
does not constitute a DBT or STEPPS intervention.
A crisis self-management plan can prove very valuable in maintaining stabilisation
and preventing dysregulation by providing a clear set of helpful options when a
patient’s capacity to think clearly is reduced.
STEPPS and DBT are essentially stabilisation treatments which can be considered as
adjunctive to standard community psychiatric care (see Psychosocial Intervention Section). If
a patient in DBT or STEPPS treatment has contact with a CMHT clinician, reinforcement and
generalisation of skills represents a useful focus for therapeutic work. The responsibility
should rest with the patient to collaborate with the CMHT clinician in such a way that
reinforcement and generalisation occurs. This may include keeping the CMHT clinician up to
date on which skills are currently being taught and examples of how they are applying them
in their daily lives. While the concept of a reinforcer is built into STEPPS, this concept is not
a core concept of DBT. However, if a CMHT clinician has concerns that a patient in DBT is
not using their CMHT time to effectively reinforce and generalise skills, then it would be
reasonable to alert the DBT therapist, with the patient’s knowledge. Solutions could then be
found within DBT individual therapy.
DBT can be considered for patients with severe borderline personality disorder and recent,
potentially lethal parasuicidal behaviour or emergency hospitalisation who are also on the
Care Programme Approach.
STEPPS skills training groups run within each of the CMHTs and this intervention should be
considered for moderate borderline personality disorder or borderline traits (the terminology
used within the STEPPS program is “emotional intensity disorder”). Ideally, every participant
should have a reinforcement team. This is ideally composed of members of the social
network and a health professional (CPN, GP, support worker etc). The reinforcers need not
have in-depth knowledge of STEPPS but serve to help consolidation and generalisation of
skills. The health professional reinforcer can support the participant to complete the weekly
homework. Other ways of delivering reinforcement including by telephone or in small groups
have also proven effective. Borderline problems form a continuum of severity and while
benefit is likely to be greater if a patient has a full reinforcement team, service-based
evidence suggests that a health professional reinforcer is not an absolute requirement,
although it is certainly preferable.
2 Exploration and change (or MAKING SENSE). The focus here is on the past:
This phase can involve dealing with the effects of trauma and dissociation; treating self and
interpersonal problems; and treating maladaptive traits.
Post-traumatic stress disorder can be treated via specific psychosocial interventions such as
EMDR or trauma-focused CBT, (see Psychosocial Interventions Section).
However, for less severe presentations, psychoeducation and self-directed exposure may be
of value. Dissociation is likely to benefit from general improvement in emotion regulation but
the patient may also benefit from learning grounding strategies.
Intrapersonal (self) and interpersonal problems often relate to maladaptive schemas. These
can be addressed through formal psychological interventions or by within general clinical
contact by supporting self-reflection, identification of long-standing patterns of thinking and
behaviour, and introduction of more adaptive patterns. For example, it might be gently
brought to a patient’s attention that they have a pattern of negatively interpreting neutral
comments, becoming angry and breaking off relationships. Clearly, this kind of work can very
naturally take place within general clinical contact and does not need to be limited to specific
psychotherapy settings.
Behavioural strategies which may be useful include challenging behavioural avoidance, environmental management strategies (guided by needs assessment), behavioural rehearsal
and role play.
No personality trait is intrinsically maladaptive. Maladaptation occurs when the behaviours
through which the trait is expressed interact with the environment to prove unhelpful. Some
traits can be relatively plastic and amenable to some change but others are less so. In case
of less malleable traits, the task is to modulate the trait as far as possible but also to help
modify the social and environmental context so that adaptive fit is improved. In many
situations, it can be helpful to view traits as relatively stable characteristics which the patient
needs to learn to use constructively.
• Increase acceptance and tolerance of the trait
Many (but certainly not all) people with personality disorder can be intolerant of their own
basic traits in contrast to most non-personality disordered individuals who are usually
reasonably comfortable with their traits, even those which they would like to change.
Related negative self-judgements and self-invalidation can have markedly detrimental
effects in terms of self-view, emotional responses and unhelpful behaviours used to change
intolerable emotional states. Mindfulness-based approaches can be helpful in increasing
acceptance of traits.
Psycho-education may help reduce internal conflict and increase self-acceptance.
Explanation that traits are to a significant extent biologically determined can help people
assume ownership of their traits, whereas emphasising the role of environmental influence
on traits can help the patient understand that it is possible, within limits, to change the way
traits are expressed. Another useful strategy is to encourage patients to identify ways in
which their traits might be beneficial if the fit with the environment was more adaptive. A
good example is the trait of conscientiousness. . Clearly, moderate levels of
conscientiousness, attention to detail and orderliness would be regarded as desirable by
most people. The realisation that traits are only maladaptive when they are expressed in
unhelpful or inflexible ways can facilitate change by helping the person see that they do not
need to change a fundamental part of themselves but rather more specific aspects of
behaviour related to the trait.
• Reduce trait expression
For people at the extreme end of a trait distribution, the threshold for interpreting situations
as relevant to the trait is low. Cognitive and behavioural strategies can be of value here in
helping to restructure the way situations are perceived so that the tendency to see
situations as relevant to a given trait is reduced. For example, the core beliefs and
assumptions that are typical for people with high levels of anxiousness can be identified
and challenged cognitively and via behavioural experiment. This may modify a tendency to
over-estimate the risk associated with particular situations.
Increasing behavioural alternatives can also be a useful strategy. For example, someone
with high levels of submissiveness can modify trait expression by learning assertiveness
skills and putting new, more assertive behaviours into practice. Similarly, teaching effective
relaxation skills can provide incompatible behavioural alternatives to becoming anxious for
people with high anxiousness levels.
People with high levels of anxiousness and emotional lability traits could usefully attempt to
substitute the unhelpful, trait-amplifying behaviours of rumination and catastrophisation with
healthier, trait-reducing behaviours of problem solving, distraction and self-soothing.
• Promote more adaptive trait-based behaviour
The goal here is not to reduce trait expression but to replace the maladaptive behaviours
associated with the trait with more adaptive behaviours. For example someone with high
levels of stimulus-seeking may engage in risky sexual behaviour, become involved in
fights and misuse substances. More adaptive replacement behaviours could include, for
example, high-risk sports.
• Promote the selection and creation of environments compatible with the adaptive
expression of problematic traits
This strategy is about improving the goodness of fit between the person and the
environment by modifying the environment rather than the traits. For example, someone
with high levels of social avoidance may function poorly in a busy sales job, but may do
very well in a relatively solitary occupation such as a long distance lorry driver. Similarly, a
person with high levels of compulsivity may do very well in an administrative job which
requires methodical attention to detail but do less well in a less ordered work environment.
Similar considerations apply to accommodation, leisure time activities and the
interpersonal environment.
3 Integration and synthesis (or MAKING CONNECTIONS). The focus here is on the
future:
The key difference with this phase, with a primary focus on the future, is not so much
about changing existing psychological and interpersonal structures and processes as
putting new ones in place. The aim is to promote a more integrated sense of self and a
healthier interpersonal environment — this may include development of new leisure
activities, occupational or educational activities, together with new roles and
relationships. A wide range of activities can help with this process of developing more
stable and healthy representations of the self and others by promoting new roles,
relationships and responsibilities. The role of the CMHT more likely to be in supporting
this process rather than in providing the activities.
§6 Care Programme Approach Where there are issues of particular complexity or severity,
consideration should be given to using the Care Programme Approach or similar approach or
process which supports the aims listed below:
•
Clarity about roles and responsibilities
•
Improved communication and reduced “splitting”
•
Regular needs assessment and planning
•
Regular risk assessment and planning
•
Allowing for the care team, rather than one individual clinician to support the patient to
take positive, clinically-indicated risks. This helps avoid scenarios where one clinician is
overly risk-averse to the detriment of the patient by ensuring that clinical decisions are
taken in a well-reasoned way by a multidisciplinary team.
•
Enabling managed transition from one phase of treatment to another and ensuring that all
involved are aware of the current treatment phase
•
Influencing the interpersonal environment (including the CMHT) to minimise the impact of
personality disorder. For example, mental health services can sometimes represent most
or all of a patient’s interpersonal contacts. In these cases, the balance between providing
support without fostering dependency becomes very important.
•
Influencing nature and frequency of contact between patients and other services and
agencies with a view to gains in some of the areas described in the needs assessment.
This might include involving agencies such as housing in an attempt to help stabilise the
environment.
•
Highlighting which interventions are helpful at which times and, conversely, which are
not.
10.3.1.3 Risk management
Many patients with personality disorder carry significant risk issues and a degree of anxiety
can be experienced by patients, relatives and professionals as a result. However, elimination
of risk is impossible and working in a way which tries to eliminate all risk is often harmful.
Clinically indicated positive risk taking with the aim of increasing personal responsibility and
development of skills is a key part of the treatment of personality disorder. Unless there is a
compelling reason to do otherwise (for example, co-occurring severe mental state disorder), it
is important at all times to treat a patient with personality disorder as a competent adult, with
capacity to make their own choices and responsible for their own behaviour. Although the
clinician is responsible for carrying out clinical practice at a reasonable standard of care, the
patient is ultimately responsible for their own behaviour. This understanding is necessary to
enable the collaboration between the team and the patient which is necessary for recovery.
At times, patients may pose a risk to other people. Staff should remain aware of what
constitutes unacceptable behaviour, taking appropriate action as per NHS Highland policy if
such behaviour occurs. If the unacceptable behaviour constitutes criminal behaviour such as
displays of aggression or the obstruction of health care workers in the legimate course of their
duties, consideration should be given to involving the police rather than treating law-breaking
as a health issue in the first instance. The importance of maintaining a safe treatment frame is
paramount. Clinical experience suggests that if external behavioural modifiers such as the
ability to access police and criminal justice services are inappropriately removed, then clinical,
behavioural and functional deterioration is likely. An individual is unlikely to be harmed by
appropriately maintaining a limit whereas they are unlikely to be helped by inappropriately
ignoring a limit.
Multidisciplinary care planning means that the team jointly accepts any risk associated with a
patient, rather than a single clinician. The Care Program Approach can help formalise risk
assessment and management plans and identify roles and responsibilities clearly. At times it
may be helpful to document if a person has a chronically raised risk of completed suicide (for
example in situations where a history of parasuicidal behaviour is present), which treatments
have been offered and what has been helpful, unhelpful or harmful.
It is important to distinguish between chronic and acute risk of suicide. Acute risk increase often
occurs in the presence of increased impulsivity or intent.
Important factors to consider in reviewing an adverse event are:
• Was there a foreseeable risk? Appropriate assessment and documentation of risk is
crucial.
•
Was there a reasonable response? Any decision should be well reasoned, come from a
caring, therapeutic position and have a documented cost-benefit analysis. This allows for
clinically indicated (but sometimes superficially counterintuitive) responses. For example,
not admitting someone with potentially lethal self-harming behaviour to hospital.
•
Was there a reasonable standard of practice? Quality of practice should be assured
with regular supervision and communication with the rest of the team. Relevant guidance
should be followed and reasons documented if it is not. Documentation should be of a
reasonable standard.
10.3.1.4 Supervision
Appropriate supervision is important for clinicians providing treatment for individuals with
personality disorder. Peer supervision, discussion within multidisciplinary team meetings, time
within usual clinical supervision and specific supervision may all be valuable according to the
nature, severity and complexity of the situation. The Personality Disorder Service is available for
consultation as appropriate.
10.3.1.5 Social Network Involvement
The issue of carer involvement in the treatment of personality disorder is a contentious one.
There is even some controversy over the term carer itself inasmuch as it is deemed by some to
be an invalidating term which moves the focus from self-management. Bearing that in mind, the
term “social network” is used here.
It is recommended that consideration of individual circumstances is given in relation to social
network involvement. Some patients will be very keen to avoid such involvement for a variety of
reasons and this should always be respected. However, involvement of social supports can
sometimes be helpful in modifying the interpersonal environment. If the decision is made to
involve social supports, education about personality disorder and how it can present can be
helpful to all concerned.
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