Personality disorder: no longer a diagnosis of exclusion (Part One) |

Part Two>

Please note this is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. You can download a PDF copy here: Personality disorder – no longer a diagnosis of exclusion.

Policy implementation guidance for the development of services for people with personality disorder

This guide is aimed at medical professionals, providing guidance on the identification, assessment and treatment of personality disorders within general mental health and forensic services. It aims to ensure that people with personality disorders who experience significant distress or difficulty as a result of their disorder are seen as being part of the legitimate business of mental health services.

Foreword
Introduction
Executive Summary
Backgound
- How common is personality disorder and what are it’s chief characteristics?
- What services currently exist?
- What do service users want?
- Which treatments work?
- The proposed mental health legislation
Recommended Service Models
- General adult mental health services
- Forensic services
Staff Selection, Supervision, Education and Training
Appendix 1: Key Texts
Appendix 2: Strategy Development Process
- Membership of expert groups
- Membership of user groups

Foreword

The National Service Framework for adult mental health sets out our responsibilities to provide evidence based, effective services for all those with severe mental illness, including people with personality disorder who experience significant distress or
difficulty. The guidance aims to builds on standards four and five in the national service framework and sets out specific guidance on development of services for people with personality disorder. It brings this often neglected and isolated area of mental health
into focus for the first time.

There is some excellent work happening now in general and forensic mental health to provide services and support in this important area of work, examples of which are included in the guidance. I hope that these guidelines will build on the improvements
that have already been achieved and set a clear direction for all services for the future.

But writing policy alone isn’t enough. We must value time for development at all levels in order to implement lasting, manageable change. With this goal in mind, The Department of Health is working closely with the National Institute for Mental Health
in England (NIMHE). NIMHE’s role will include working with local teams to help people put this guidance into practice.

Through eight development centres, which are in the process of being established now, and our web site www.nimhe.org.uk, NIMHE will provide a gateway to learning and development, with real opportunities to share experiences, challenges and what
works on the ground. Do get in touch if you want to get involved or share your work with others. You can email ask@nimhe.org.uk or write to us at NIMHE, Blenheim House, Duncombe Street, Leeds LS1 4PL.

We look forward to hearing from you.
Antony Sheehan
Chief Executive NIMHE

Introduction

Personality disorders are common and often disabling conditions. Many people with personality disorder are able to negotiate the tasks of daily living without too much distress or difficulty, but there are others who, because of the severity of their condition, suffer a great deal of distress, and can place a heavy burden on family, friends and those who provide care for them.

As with all forms of mental disorder, the majority of people with a personality disorder who require treatment will be cared for within primary care. Only those who suffer the most significant distress or difficulty will be referred to secondary services. This guidance is designed to ensure that once referred, they receive access to appropriate care.

As things stand today, people with a primary diagnosis of personality disorder are frequently unable to access the care they need from secondary mental health services. A few Trusts have dedicated personality disorder services but these are the exception
rather than the rule. In many services people with personality disorder are treated at the margins – through A&E, through inappropriate admissions to inpatient psychiatric wards, on the caseloads of community team staff who are likely to prioritise the needs
of other clients and may lack the skills to work with them. Within forensic services a number of regional secure units actively exclude patients with a primary diagnosis of personality disorder, because they do not consider this to be their core business. Many
clinicians and mental health practitioners are reluctant to work with people with personality disorder because they believe that they have neither the skills, training or resources to provide an adequate service, and because many believe there is nothing
that mental health services can offer.

In addition the changes proposed in the draft Mental Health Bill – the broad definition of mental disorder, the abolition of the so-called “treatability test” in relation to psychopathic disorder and the provisions enabling compulsory treatment in the community – will highlight the need for new community and in-patient services. This also places an emphasis on the need to provide new training in the assessment and diagnosis of personality disorder, in order to ensure clinicians and practitioners are
equipped with adequate information about treatment options and service models.

This Guidance has been produced to facilitate the implementation of the National Service Framework for Mental Health as it applies to people with a personality disorder.

The Purpose of the Guidance is:

To assist people with personality disorder who experience significant distress or difficulty to access appropriate clinical care and management from specialist mental health services.
To ensure that offenders with a personality disorder receive appropriate care from forensic services and interventions designed both to provide treatment and to address their offending behaviour
To establish the necessary education and training to equip mental health practitioners to provide effective assessment and management

Executive Summary

This document provides information for Trusts about the Government’s intentions for the delivery of personality disorder services within general mental health and forensic settings. All Trusts delivering mental health services need to consider how to meet
the needs of patients with a personality disorder who experience significant distress or difficulty as a result of their disorder. Funding will be available to enable Trusts to develop personality disorder services over the next three-year period from 2003-2006.

Key Points to note are as follows:

General Adult Mental Health Services

1. Good practice indicates that service provision for personality disorder can most appropriately be provided by means of:

the development of a specialist multi-disciplinary personality disorder team to target those with significant distress or difficulty who present with complex problems.
the development of specialist day patient services in areas with high concentrations of morbidity

Forensic Services

2. In future forensic services will need to consider how to develop expertise in the identification and assessment of personality disordered offenders in order to
provide effective liaison to MAPPPs.

3. The DH expects to pump prime the development of a small number of personality disorder centres nationally within regional forensic services to provide dedicated infrastructure for the assessment, treatment and management of
personality disordered offenders.

Staff Selection, Supervision, Education and Training

4. The DH will engage in dialogue with the Royal Colleges, regulatory bodies and curriculum setting bodies

to address the gap in training provided at pre-registration and prequalification for key disciplines
to influence the content of undergraduate syllabuses
to influence the mechanisms determining selection of CPD educational opportunities

5. The DH expects to pump prime the development of new training opportunities, inviting tenders from recognised sites of good practice and from training providers to offer a range of inputs to Trusts delivering personality disorder services, and to expand the pool and range of personality disorder courses available nationally. Training providers will need to consider how best to involve service users in training professionals.

Background

How common is personality disorder?

Health professionals have not always agreed how best to identify personality disorders, but over recent years the World Health Organisation and the American Psychiatric Association have produced useful definitions.

1. The International Classification of Mental and Behavioural Disorders (ICD-10) (World Health Organisation 1992), defines a personality disorder as: ‘a severe disturbance in the characterological condition and behavioural tendencies of the
individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’.

2. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994) defines a personality disorder as: ‘an enduring pattern of inner experience and behaviour that deviates markedly
from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”.

3. There are nine categories of ICD-10 personality disorder and ten categories of DSM-IV personality disorder. The classification scheme is unwieldy as personalitydisordered patients rarely belong to just one category of personality disorder. However, the DSM clustering system provides a useful solution to this problem by grouping the subcategories of DSM-IV personality disorder into three broad ‘clusters’: Cluster A, B and C. These are as follows:

Cluster A (the ‘odd or eccentric’ types): paranoid, schizoid and schizotypal personality disorder

Example of a Cluster A patient

AA was referred by his GP to psychiatric outpatients, following the death of his father with whom he had lived. Father had been a ‘distant’ figure who had suffered a nervous breakdown in early life and, according to A, had ‘heard voices’. A had deluged the GP with numerous ways in which the health service had let down his father but had few complaints on his own behalf. However, history-taking revealed a longstanding fascination with the occult and, since his father’s death, a preoccupation with euthanasia. This had concerned the GP and occasioned the referral.

A had been a shy child and later a ‘poor mixer’, with no contacts outside the family. He had no academic qualifications. He had only worked intermittently and for brief periods in solitary situations, for example as a warehouseman. He had been involved in occasional ‘scuffles’ in the street but had no convictions for violence. He had no sexual experience. He lived with his elderly mother who had chronic arthritis and who, since the death of her husband, depended on him for shopping and the collection of regular drug prescriptions.

At interview, A was hard to engage. He seemed to be lost in his own thoughts and found responding to the interviewing psychiatrist’s questions difficult. However, there were no symptoms or signs to suggest a major mood disorder or psychosis. His mother who was also interviewed indicated that her main concern was that A was spending increasing amounts of time at the library or on the internet ‘researching’ euthanasia and that ‘this was not healthy’.

Having gathered sufficient information to make a diagnosis of a Cluster A PD, the psychiatrist recommended attendance at a local Day Hospital to carry out both an assessment of A’s social functioning, and the extent to which he might be able to widen his options and activities, and also of his level of risk in relation to his ideas of euthanasia and the safety of his mother. Early observation confirmed his social awkwardness and revealed him to be self-obsessed and easily raised to anger if challenged to engage more socially. His risk assessment continues.

Cluster B (the ‘dramatic, emotional or erratic’ types): histrionic, narcissistic, antisocial and borderline personality disorders

Example of a Cluster B patient

BB is a 22 year old unemployed single woman whose two children were adopted shortly after birth.In the early hours of Saturday morning, B (who was well known to the psychiatric service as someone suffering from a Cluster B PD) had been admitted to the local acute psychiatric ward from the Accident and Emergency Department.

She had slashed both her wrists following a row with her ex-boyfriend. This was the latest in a long series of violent relationships with men. None lasted more than a few months. B had become pregnant on five occasions but only two of these had gone to term. On both occasions the infant had been removed into care to be adopted shortly afterwards, as B was not considered to be a fit mother.

B herself had been the product of a short-lived relationship. Her mother had many partners subsequently, some of whom had sexually abused B. It was not clear whether mother had been aware of this as B was growing up. The latter had been noted to be intelligent when assessed at primary school but had played truant from an early age and been expelled for violence to a teacher when at secondary school. By this time she was already abusing both alcohol and ‘soft’ drugs. This behaviour escalated after leaving school to include heroin addiction. To feed this habit B had prostituted herself on a number of occasions.

At interview on the psychiatric ward, B was noted to have multiple scars on both arms and some on her abdomen. She described herself as feeling ‘empty and dead inside’- feelings that were relieved in the short-term by her self-harming. She intermittently heard ’a male voice’ inside her head but there was no evidence of a major mood disorder or of psychosis. On the ward she quickly settled into the routine not appearing unduly depressed. She made friends with the younger patients there and was continually asking favours of the younger staff members, sometimes being intrusive and sexually inappropriate. She left the ward on her third day and returned with cannabis, which she encouraged other patients to share. She was discharged on account of this after it was discovered since there were no reasons to consider compulsory detention. She has been referred for an outpatient assessment for psychotherapy

Cluster C (the ‘anxious and fearful’ types): obsessive-compulsive, avoidant
and dependent

Example of a Cluster C patient

CC is 42 a mother of four and recently separated from her husband of twenty years. C was referred by the GP to the liaison psychiatrist visiting his clinic. The GP described C as a kind woman, devoted to her family but who had been a frequent attender over the years for many minor physical ailments. Mostly it was possible to reassure her and yet she would return as before, albeit with a ‘new’ complaint. Now C had presented tearful and in a dishevelled state accompanied by her eldest daughter who was also upset. It quickly materialised that husband had left the family and it was this that had brought about the current presentation.

What also emerged, however, from talking to the daughter, was a long history of agoraphobia, previously unreported due to C’s feelings of shame. C had been an only child of elderly parents. She had always been under-confident and had found it hard going to school and moving to secondary school, where she was also bullied on account of being seen as ‘teacher’s pet’ She was, however, successful academically. After leaving school at 16, she met an older, confident man, a friend of the family, and married him, quickly falling pregnant.

He ran his own business from home and C made herself invaluable in taking care of the accounts as well as running the home. She had always been excessively neat and tidy and ‘kept the books’ and the house in such a state of regimentation that both husband and the children felt uncomfortable. The business proved so successful over the year, however, that it was taken over, enabling husband (and B) in effect to retire early.

This change of routine affected C badly. Her husband wished to travel to take advantage of their new freedom only to find that C ‘refused’ to join him. Eventually he struck up a relationship with a younger woman and suddenly left the marital home. The psychiatrist diagnosed a Cluster C PD in addition to the longstanding phobic disorder. Both aspects are being addressed via a cognitive-behavioural approach from a clinical psychologist. Her depressive symptoms have improved as progress has been made with her ability to leave the housed unaccompanied.

She feels freer, although still ashamed of having a psychological problem in the first place. There are no plans for a reconciliation with husband but the relationship with her children is improved, being mutually supportive. Previously, C now realises, she was somewhat infantilising of her teenage brood.

5. Personality disorders are common conditions, although there is considerable variation in severity, and in the degree of distress and dysfunction caused. Epidemiological data needs to be interpreted with some caution, as studies use
varying diagnostic standards.

6. Studies indicate prevalence of 10-13% of the adult population in the community, and show that personality disorders are more common in younger age groups (25-44 yrs) and equally distributed between males and females. However, the sex
ratio for specific types of personality disorder is variable e.g. antisocial personality disorder is commoner among males, and borderline personality disorder commoner amongst females. Compared with white people, black people
attract a diagnosis of personality disorder relatively infrequently. It is still unclear whether this reflects a true difference in prevalence or errors of diagnostic
practice.

7. Personality disordered individuals are more likely to suffer from alcohol and drug problems and are also more likely to experience adverse life events, such as relationship difficulties, housing problems and long-term unemployment.

8. Antisocial personality disorder has a prevalence of between 2 – 3%, and is commoner in men, younger people, those of low socio-economic status, single individuals, and in those who have been poorly educated. There is a very high
prevalence of personality disorder in the prison population – one recent study indicated this was as high as 78%, with antisocial personality disorder being the most common presentation.

9. Personality disorder in adults has its origins in childhood disturbance. Adults who present with antisocial personality disorder have often been subjected to severe neglect and abuse and are likely to have a parent or caregiver who has a psychiatric
disorder and has difficulties in parenting. Key factors in the development of antisocial personality disorder include the early onset of conduct problems, persistent antisocial behaviour, and the presence of attention-deficit/hyperactivity
disorder. There is currently no reliable method of identifying adolescents who are a high risk for developing antisocial personality disorder in adult life.

10. Estimates of the prevalence of personality disorders in psychiatric hospital populations vary, but range between 36% – 67%. In psychiatric settings, people with Cluster B personality disorders attract the most attention. They have poor impulse control and often present when in crisis, threatening deliberate self- harm, or aggression to others. Personality disorders are particularly prevalent amongst inpatients with drug, alcohol, and eating disorders. People with personality disorders are more vulnerable to other psychiatric conditions, and in particular, they are more likely to suffer from depression. The existence of a co-morbid personality disorder can complicate recovery in severe mental illness (e.g. schizophrenia.)

11. What is clear is that people with personality disorders make heavy demands on local services, which are often ill equipped to deal with these. One of the characteristics of this group is that they often evoke high levels of anxiety in carers, relatives and professionals. They tend to have relatively frequent, often escalating, contact across a spectrum of services including mental health, social services, A&E, GPs and the criminal justice system. They may present to mental health services with recurrent deliberate self harm, substance abuse, interpersonal problems that may include violence, various symptoms of anxiety and depression, brief psychotic episodes, and eating disturbances.

12. Providing appropriate treatment for people with personality disorder requires clinicians to develop particular skills. Access to good systems for support and supervision is essential: without this staff may experience burn out and exhaustion.

What services currently exist?

General Adult Mental Health Services:

What are Trusts providing ?

13. Many general mental health services struggle to provide an adequate service for people with personality disorder. In many services people with personality disorder are treated at the margins – through A&E, through inappropriate admissions to inpatient wards, on caseloads of community team staff who are likely to prioritise the needs of other clients and may lack the skills to work with them. They have become the new revolving door patients, with multiple admissions, inadequate care planning and infrequent follow-up.

14. Many clinicians are reluctant to work with people with personality disorder because they believe that they have neither the skills, training, or resources to provide an adequate service. Clinicians may find the nature of interactions with personality disordered patients so difficult that they are reluctant to get involved.

15. There is significant disparity in the availability of services for people with personality disorder. A questionnaire issued to all Trusts in England providing general adult mental health services in 2002 found that 17% of trusts provide a dedicated personality disorder service, 40% provide some level of service, and 28% provide no identified service. No Response was obtained from the remainder.

16. These results present a confusing picture that requires some interpretation. We know that all dual diagnosis/drug & alcohol and eating disorder services are treating significant numbers of people with personality disorder. Similarly, clinicians and practitioners in every Trust will assess and provide some kind of intervention for people with personality disorder, if only to exclude them from active treatment. For the 28% of Trusts indicating that they provide no service, this should be taken to mean that the treatment of personality disorder is not seen as the focus of intervention, and that these Trusts do not see the provision of services for personality disorder as being part of their core business.

17. Amongst those Trusts providing services for personality disorder, there was a disparity of therapeutic approach and mode of service delivery. Trusts providing services used the full range of recognised therapeutic models. The most common therapies used being psychodynamic psychotherapy, cognitive behaviour therapy (CBT), dialectical behaviour therapy (DBT), or cognitive analytic therapy (CAT). Services were being delivered both on an out patient and day patient basis by the full range of disciplines, with the lead being taken variously by psychology departments, psychotherapy departments, community mental health teams, and specialised PD teams. The only dedicated in patient provision currently provided is in specialist therapeutic communities, although several respondents noted that people with a primary diagnosis of personality disorder are admitted to general inpatient psychiatric wards, often inappropriately, because of a lack of other service options.

18. There was no agreement as to the need to cater for this group. A number of Trusts recognised the inadequate nature of their provision, and several were in the process of reviewing the organisation of their general mental health services with a
view to trying to establish an agreed approach to the management of individuals with a personality disorder. However, a minority of respondents did not accept the need to provide a service for people with personality disorder, raising the issue of the “medicalising” of personality disorder as a cause for concern.

19. There are a limited number of gold standard services. Detailed additional information was provided by those Trusts with dedicated personality disorder services, and some examples of these services are cited in this document. No common patterns could be discerned as to costs, numbers of referrals, or numbers in treatment, although it was clear that several services were being delivered at a low cost, involving a handful of clinicians. Many of these services had grown up because of the enthusiasm and commitment of a single individual, who had successfully championed the cause of personality disorder services in the locality, attracting other clinicians over time to join, and persuading local commissioners to fund.

Notable Practice Site : Winterbourne House – Reading: A therapeutic community as an intensive treatment programme.

The district psychotherapy service is part of the adult mental health services for Berkshire Healthcare Trust, with an intensive treatment programme run as a therapeutic community for the most disturbed patients. The therapeutic community serves a population of about 800,000. The service takes 400-500 referrals per annum, mainly from local GPs, psychiatrists and CMHTs.

About 10% of all referrals are routed to the therapeutic community, where the assessment programme is one afternoon per week for between 2 and 12 months, followed by a daily programme of up to 18 months. In the outpatient programmes, individual work takes 12 weeks to 2 years, and group therapy 6 months to 3 years. Inpatients from local psychiatric hospitals can start to attend the assessment programme for the therapeutic community, and some outpatient therapy. A new “inreach” service runs inpatient groups, undertakes joint assessments and offers staff teams ‘difficult patient’ supervision and general consultancy work with inpatient wards.

What about residential provision ?

20. Patients with severe personality disorder can benefit from intensive residential treatment, and there are currently five specialist residential units which are run as therapeutic communities, and take referrals from across the country. Three of these units, the Henderson Hospital (Sutton, Surrey), Webb House (Crewe) and Main House (Birmingham) currently receive central funding from NSCAG. The Cassell Hospital (Richmond, Surrey) provides separate residential accommodation for adults, adolescents and families, and is part of West London Mental Health Trust. Francis Dixon Lodge (Leicester) is a Monday to Friday residential unit with 15 beds, 10 day places and an outreach programme.

Notable Practice Site : The Cassel Hospital – Richmond : A therapeutic community

The Cassel Hospital has developed the concept of treating personality disordered patients in a therapeutic community and offers this service to patients who have proved largely resistant to other forms of psychiatric treatment.

The Cassel Hospital is recognised internationally as a leading treatment, research and training centre. It has pioneered a psychosocial model for assessment and treatment, integrating psychoanalytical and social systems theory. Treatment consists of a combination of psychosocial practice and psychoanalytical psychotherapy within a structured therapeutic community. The hospital, part of West London Mental Health Trust, is widely considered to be a centre of excellence in the treatment of severe emotional and behavioural disturbances in both families and individuals.

There are Inpatient Services for Adults, Families and Adolescents, and a Children’s Centre, as well as an Outpatient Psychotherapy Service and Outreach Psychosocial Nursing Service.

Forensic Services:

high security

21. Services for the treatment of patients with psychopathic disorder are provided at all 3 high secure hospitals – Ashworth, Rampton and Broadmoor, and these services provide a real repository of expertise in the treatment of personality disorder.
Ashworth and Rampton have personality disorder units, whilst at Broadmoor, patients are treated across a number of units, the greatest concentration being on Woodstock ward. A range of therapeutic models are used.

22. Regional commissioners have estimated that around a third of patients with a primary diagnosis of personality disorder in high security could be appropriately cared for in a less secure environment. But because of the lack of service infrastructure for personality disorder many wait long periods of time – years in some cases- for an appropriate placement to be found, either in medium security or in a community setting.

23. It is however acknowledged and recognised that there will be an ongoing need to provide services within high security for patients with a primary diagnosis of personality disorder. Although small specialist units for DSPD are being built (cf
para 24), these will cater for the needs of a small group only, and will not replace existing personality disorder provision in high security.

24. 140 new places are being purpose built in new units at Rampton and Broadmoor for those people who are assessed as dangerous as a result of a severe personality disorder (DSPD). It is planned that these units will be operational from 2003/4. These services will be designed to treat only those offenders who demonstrate a clear functional link between their personality disorder and their offending behaviour, and who pose a very high risk indeed to the public. It is estimated that as few as 10% of the current patients in personality disorder beds in the 3 high secure hospitals would meet the criteria to transfer to these units.

25. Parallel developments are taking place within the prison estate. 160 places will be provided at HMP Whitemoor and HMP Frankland by 2003/4. local and regional forensic services

26. Local and regional forensic services treat many patients with co-morbidity – where aspects of personality disorder present alongside symptoms of major mental illness. However, there is very little in the way of dedicated infrastructure for the assessment or treatment of personality disorder. Arnold Lodge in Leicester is currently the only NHS unit with designated forensic personality disorder beds in the country. There is also some expertise within the independent sector, notably at Kneesworth House.

27. Almost all patients in forensic settings are held under sections of the Mental Health Act, and the current 1983 Act is often interpreted as excluding those with personality disorder from compulsory detention because of the requirement that the mental disorder be “treatable”. (i.e. treatment is likely to alleviate or prevent a deterioration in the patient’s condition). Many clinicians have not seen personality disorder as a mental disorder that is treatable. This will change with the new mental health legislation (cf paras 60-63) which removes the treatability clause, and provides a generic description of mental disorder.

Notable Practice Site : Arnold Lodge – Leicester : A forensic residential personality disorder unit within a medium secure unit

The personality disorder Unit at Arnold Lodge aims to reduce the likelihood of further offending by offering treatment to men who have both an offending history and a personality disorder. It is a 12 bedded facility within a medium secure unit dedicated to the treatment of male offenders with a personality disorder. It offers a service to residents of Trent , with the majority of referrals coming from prison, and is funded by health authorities within the region.

Individuals first undergo a detailed pre-admission assessment to determine if they are suitable for the unit. If deemed to be suitable, they are then admitted for a maximum period of two years. This is sub-divided into a three-month assessment, a 15-month treatment and a six-month pre discharge phase.

The total duration of admission and its various phases are rigidly adhered to, thereby giving the programme a sharply defined focus. Treatment is offered in both group and individual formats. All treatments are integrated so that there is an expectation that gains in any area are generalised to the wider community in which the individuals live.

28. A questionnaire issued to all Trusts providing medium secure forensic services and to independent sector providers of forensic services in 2002 provided evidence of the very limited services for patients with PD within forensic settings.

29. Although medium secure units (MSUs) are experienced in the treatment of patients with co-morbidity, the majority only treat one or two patients as inpatients at any time who have a primary diagnosis of personality disorder. Generally this is because they find it very difficult to manage patients with personality disorder in the same wards as those with major mental illness, and also believe they lack the expertise to provide an effective service for this group. A few units actively exclude patients with a primary diagnosis of personality disorder because they believe that they have neither the skills, training or resources to provide an adequate service.

30. The most common word used by units to describe the therapeutic models and interventions was “eclectic”. Units describe a mix of cognitive behaviour approaches, psychodynamic psychotherapy and some therapeutic community elements in the treatment model. CBT was the most commonly mentioned therapeutic provision.

31. There were wide differences in staff training and support, with many units committed to the support and supervision of their staff, but less focussed on their training. The training of staff seemed to be on an “ad hoc “ basis, with a great variety in training methods between units. Many reported not having any specific training for work with pd patients. Others reported staff attending courses “when these are arranged “ or trained “on the job”.

other specialist NHS services:

32. The Portman Clinic in London is the centre for the assessment, treatment, consultation and training for forensic psychotherapy for the UK. It provides an outpatient NHS psychotherapy clinic for people who suffer with problems from criminal or violent behaviour or from disturbing sexual experiences, and accepts referrals from anywhere in the UK. The expansion of specialist training in forensic psychotherapy is a recent development, with training now available in Oxford, Birmingham, Trent, Yorkshire and the North West, as well as in London.