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

<Part one                                                                                      Part Three>

outside the healthcare system: other provision for personality disordered offenders

33. Large numbers of offenders with personality disorders receive the bulk of their care and management from other agencies: social services, voluntary organisations, housing departments and probation. Many are in prison. Whilst none of theses agencies specialise in the management of personality disorder, examples can be found of approaches that have been adopted to meet the needs of this group.

34. The National Probation Services has developed two recent initiatives which will encompass offenders with personality disorder: community based sex offender treatment programmes (SOTP) and the Offender Assessment System (OASys). OASys provides a structured assessment tool to identify the risk of reconviction, and to identify and classify offending related needs, including basic personality characteristics.

35. Initiatives within the prison service include small scale DBT pilots in a limited number of women’s prisons, and the gradual introduction of prison inreach teams to all prisons in England. Inreach teams have been set up to provide better general mental health care throughout the prison, both on the wings and in the health centre, using a multi-disciplinary community team approach. Whilst this has been set up primarily to target prisoners with severe mental illness, inreach teams in 6 prisons will focus their attention on prisoners with personality disorder.

36. There are currently 2 prisons which have specialised therapeutic community regimes, geared to cater for offenders with a personality disorder: HMP Grendon Underwood, and HMP Dovegate. The experience in the prison estate is that the therapeutic community setting reduces self harm, assaults on staff, abuse of drugs, and provides a safe environment for treatment to take place.

37. HMP Grendon has 230 beds, and is a specialist prison for males, designed to run on the lines of a therapeutic community for those with a personality disorder. No one is transferred against their will; motivation to change and a willingness to participate in group work are important selection criteria.

38. The treatment model used in HMP Dovegate is similar, although with a slightly different focus. The population is not exclusively personality disordered, and there is a very strong emphasis on the development of skills that will be useful on release. It also differs from HMP Grendon in that psychologists, in contrast to psychotherapists, run the therapy.

Notable Practice Site : HMP Grendon – A Therapeutic Community

Grendon Prison is a specialist centre for the treatment of personality disorder particularly as it gives rise to serious offending. Five theraputic communities within the prison offer intensive group psychotherapy and social therapy. This core therapy is complemented by activities such as art therapy, psychodrama and cognitive behavioural groups.

There is a strong emphasis on multidisciplinary working and each team consists of forensic psychologist, prison officers, probation officer and psychodynamic psychotherapist.

The focus of much of the work is upon disordered relationships, which often arise from intolerable and uncontainable feelings, and the outcome of violence or other offending. Through exploring the past and present, clients can begin to make sense of their cycles of being abused and abusing and through forming reparative relationships with staff over a period of years the energy for violence can be ameliorated.

What do service users want?

The views of service users

39. Views of service users were captured by means of a service user focus group, as well as discussion with a number of organisations that represented service users and carers. The key thoughts and views gathered were as follows:

“A very sticky label”

40. No mental disorder carries a greater stigma than the diagnosis “Personality Disorder”, and those diagnosed can feel labelled by professionals as well as by society. There was a strong feeling that many professionals did not understand the diagnosis, and often equated it with untreatability.

41. Those with personality disorder have been described as “the patients psychiatrists dislike”, and many reported being called time-wasters, difficult, manipulative, bed-wasters or attention-seeking. Some felt that a more appropriate description would be “attachment-seeking”. They felt blamed for their condition and often sought basic acceptance and someone to listen to them. They sought to gain legitimacy rather than being told “you’re not mentally ill”. Some preferred terms
such as “emotional distress”.

42. ‘Antisocial personality disorder’ was felt to be even more stigmatising, and there was concern that the “dangerous and severe personality disorder” label would be wrongly applied, and lead to an inappropriate use of compulsory detention.

43. It was acknowledged that accurate diagnosis could be a useful process, but needed to be backed up with the provision of reliable information. Unlike other conditions there is little easily available printed information for patients. More is available on the internet, but its quality is variable, and much is American with little relevance for British service provision.

Experience of Services

44. There was strong agreement that there are not enough services available for people with personality disorder. In the main, experiences of general adult mental health services were negative. Unhelpful attitudes from staff were encountered, who would see “just the label”, and were often prejudiced about the condition, and belittling or patronising in manner. Although the benefits of CPA being required were acknowledged, the experience was that procedures were often not followed or not helpful.

45. The different attitudes in adolescent services, compared with adult ones, towards intervention and treatability were striking. Early intervention was highlighted as crucial to the prevention of major deterioration in personality disorder. The need for specific services covering an age range of about 15 -25 was suggested.

“Had I been helped when younger I would not have got this bad.”

46. Users felt that there needs to be acknowledgement by professionals that personality disorder is treatable: a negative experience on initial referral to a psychiatrist makes engagement less likely. There was also general agreement that endings of therapeutic relationships were often not addressed adequately. Also, once people show any improvement, services can be removed; this can discourage improvement.

“There is a link between hurting yourself and getting support and treatment. It is hard to resist self- harming behaviour when, you know if you do it, you will get treatment.”

Staffing issues

47. Users thought that staff need to be skilled to handle therapeutic relationships, particularly regarding attachment. They need to deal sensitively with issues of gender and sexual orientation in those who have a history of abuse. Staff with their own experiences of mental health difficulties were perceived as having much more insight into the difficulties of patients. It was recognised however that in clinical settings problems arise when boundaries break down, and staff begin to share their own problems with patients. However, it was felt to be therapeutically important for there to be a shared experience between patient and professional, and for professionals to be in touch with the patient’s distress but not overwhelmed by it.

48. A number of users thought that they should be engaged and paid to help train professionals in order to promote greater understanding, although it was recognised that this could be a challenging task.

|Public awareness and education

49. Users suggested teaching about mental health in schools as part of the life skills and citizenship curriculum. This could have a preventative function, educate adolescents about vulnerability, how to seek appropriate help, and reduce stigma.

50. Users thought that TV soap operas, discussions and documentaries could be effective ways of communicating information, whilst recognising that it is difficult to control how mental health is portrayed. Concerns about “putting ideas into people’s heads” in relation to self-harm, eating disorders or personality disorder were acknowledged. They thought that leaflets and posters in GP surgeries and other health settings would be help raise awareness. This could help turn the label of personality disorder into something that could be discussed between users and professionals, and “stop it being a dirty secret”.

Helpful/Unhelpful characteristics of services

51. One task of the focus groups was to identify characteristics of the service they have found helpful, and unhelpful:

Helpful features for personality disorder services

  • Early interventions, before crisis point
  • Specialist services, not part of general MH
  • Choice from a range of treatment options
  • Individually tailored care
  • Therapeutic optimism & high expectations
  • Develops patients’ skills
  • Fosters the use of creativity
  • Respects strengths and weaknesses
  • Good clear communication
  • Accepting, reliable, consistent
  • Clear and negotiated treatment contracts
  • Focus on education and personal development
  • Good assessment/treatment link
  • Conducive environment
  • Listens to feedback and has strong voice from service users
  • Supportive peer networks
  • Shared understanding of boundaries
  • Appropriate follow up and continuing care
  • Involves patients as experts
  • Attitude of acceptance and sympathy
  • Atmosphere of “truth and trust”
    …can make people feel respected, valued and hopeful

Unhelpful features for personality disorder services

  • Availability determined by postcode
  • Office hours only
  • Lack of continuity of staff
  • Staff without appropriate training
  • Treatment decided only by funding/availability/diagnosis
  • Inability to fulfil promises made
  • Critical of expressed needs (e.g. crisis or respite)
  • Staff only respond to behaviour
  • Staff not interested in causes of behaviour
  • Dismissive or pessimistic attitudes
  • Rigid adherence to a therapeutic model in cases where it becomes unhelpful
  • Passing on information without knowing a person
  • Long-term admissions
  • Use of physical restraint and obtrusive levels of observation
  • Inappropriate, automatic or forcible use of medication
  • Withdrawal of contact used as sanction
    …can make people into “career psychiatric patients”

For Further Information see Key Text on Website link: (as listed in Appendix 1) • Haigh, R. Services for People with Personality Disorder: The Thoughts of Service Users (2002)

Which treatments work?

Treatment in primary care and general mental health settings:

52. Many clinicians are sceptical about the effectiveness of treatment interventions for personality disorder, and hence often reluctant to accept people with a primary diagnosis of personality disorder for treatment. However, a range of treatment interventions are available for personality disorder, including psychological treatments and drug therapy, and there is a growing body of literature available on the efficacy of varying treatment approaches. In a study commissioned for this report, Bateman & Tyrer conclude that whilst more research is needed, there are real grounds for optimism that therapeutic interventions can work for personality disordered patients.

53. Bateman & Tyrer review the available evidence on treatment for personality disorder, but do not prescribe any one particular approach. They conclude that in general, a combination of psychological treatments reinforced by drug therapy at critical times is the consensus view of treatment in personality disorder.

54. They also identify the key guiding principles of effective therapy for personality disorder viz. that therapy should:

  • be well structured
  • devote effort to achieving adherence
  • have a clear focus
  • be theoretically coherent to both therapist and patient
  • be relatively long term
  • be well integrated with other services available to the patient
  • involve a clear treatment alliance between therapist and patient

55. Part of the benefit which severely personality disordered individuals derive from their treatment comes through their experience of being involved in a wellconstructed, well-structured and coherent interpersonal endeavour.

56. The psychological treatments available are as follows:

Dynamic psychotherapy

  • This is based on a developmental model of personality
  • Treatment is generally long term
  • The aim of therapy is to understand the way in which the past influences the present with the use of interpretation
  • Treatment focuses on the therapeutic alliance between patient and therapist, the  individual’s emotional life, and defences
  • Therapy uses the relationship between patient and therapist (transference) as a way to understand how the internal world of the individual affects relationships

Cognitive Analytical Therapy

  • Postulates that a set of partially dissociated ‘self-states’ account for the clinical  features of borderline personality disorder
  • Rapid switching between these self-states leads to dyscontrol of emotions including  intense expression and virtual absence (depersonalisation)
  • Therapy aims to formulate these processes collaboratively,examining them as they occur in treatment as well as in life experiences

Cognitive Therapy

  • This is a modification of standard cognitive and behaviour therapy that is goal directed and focused more on altering underlying belief structures rather than reduction of symptoms
  • It is likely to take up to 30 sessions of treatment of which the initial ones help to  define the areas of intervention by identifying what are the fundamental structures of past, present and future experiences
  • The therapist and patient maintain a collaborative therapeutic alliance throughout  treatment and include homework and testing of core beliefs and structures

Dialectic Behaviour Therapy (DBT)

  • This is a special adaptation of cognitive therapy, originally used for the treatment of women with borderline personality disorder who harmed themselves repeatedly
  • DBT is a manualised therapy including functional analysis of behaviour, skills training and support (empathy, validation of feelings, management of trauma)
  • Directed at reducing self-harm

Therapeutic Community Treatments

  • Therapeutic communities provide intensive psychosocial treatment which may include a variety of therapies but where the therapeutic environment itself is seen as the primary agent of change
  • They include democratic and concept types, the former including members of the community as decision makers
  • External control is kept to a minimum: members of the community take a significant role in decision making and the everyday running of the unit

The drug treatments available are as follows:

Antipsychotic drugs

  • These have shown variable results in controlled trials
  • Reduction in hostility and impulsivity are claimed but not always reliably achieved
  • Schizotypal’ features are helped most
  • Atypical neuroleptics may offer advantages but results are preliminary

Antidepressant drugs

  • Both tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) have been recommended in the treatment of borderline personality disorder
  • Improvement in borderline patients may be linked to depressive symptoms rather than personality pathology
  • Impulsiveness is particularly improved and SSRIs may offer advantages in this respect

Mood stabilisers

  • Lithium, carbamazepine and sodium valproate have all been used to treat symptoms of mood disorder in those with personality disorder
  • There is weak support for the notion that cluster B (antisocial, borderline, histrionic and impulsive) personality disorders may be helped by mood stabilisers

Treatment in forensic settings for personality disordered offenders

57. The range of treatments described above will form a key part of the therapeutic repertoire available to clinicians treating personality disordered offenders. However, in forensic settings, treatment interventions for personality disorder
are aimed not just at relieving the symptoms of mental distress, but also at preventing re-offending.

58. A number of interventions have been developed which are aimed specifically at addressing offending behaviour. In a study commissioned for this report, Craissati et al. describe the key treatments available and review the research
evidence. These are as follows:

Thinking Skills

  • programmes include Enhanced Thinking Skills (prison service), Think First (probation service) and Reasoning and Rehabilitation (multiple use)
  • group programmes comprise between 40 and 80 hours of treatment contact
  • treatment goals include being to enhance self-control, inter-personal problem solving skills, social perspective taking, critical reasoning skills, cognitive style, and an  understanding of the values which govern behaviour.
  • brief focussed training of multi-professional groups is emphasised, in order to ensure
    treatment integrity and consistent programme delivery.

Dialectical Behaviour Therapy

  • a modified version of DBT, for use with men with a diagnosis of antisocial personality disorder,is currently being adapted for use by high secure personality disorder services

Anger/violence management

  • recent evaluated programmes for personality disordered offenders in secure health settings include social problem solving, and a Violence Risk Programme
  • the RAID (“Reinforce Appropriate, Ignore Difficult and Disruptive”) approach for working with extreme behaviour is based on improving and strengthening  interpersonal relationships; it is being piloted in high secure personality disorder services

Sex Offender Treatment Programmes

  • accredited sex offender treatment programmes (SOTP) take place in prison and the
    community; additionally, multi-agency programmes have been developed to meet specialist needs, such as for adolescents or personality disordered sex offenders
  • programmes are based on a cognitive-behavioural model of treatment, which involves:
    • recognising the patterns of distorted thinking which allow the contemplation of illegal sexual acts,
    • understanding the impact which sexually abusive behaviour has on its victims
    • identifying key triggers to offending as an aid to relapse prevention
  • reducing recidivism has been shown to be contingent upon the level of deviancy
    demonstrated by the offender, and the duration of treatment (between 100-200 hours)

Forensic Psychoanalytic Psychotherapy

  • the stated aim of treatment is to help free patients from the more self-destructive ways of feeling, thinking, and behaving and so to enable them to live and function more easily in the community
  • staff are multi-disciplinary, but all have undertaken further training as psychoanalytic
    psychotherapists or psychoanalysts
  • the model emphasises consultation and support in forensic services

59. Individuals who score highly on the high scoring psychopaths – as measured by the Psychopathy Checklist (PCL-R, Hare, 1991) – have been thought to perform poorly in therapeutic programmes. However, eclectic long term approaches, such as group and individual therapy, psychoanalytic and the inclusion of family members in treatment programmes, have been found to be highly effective.

For Further Information see Key Text on Website link: (as listed in Appendix 1)
• Bateman, A. & Tyrer, P. Effective Management of Personality Disorder (2002)
• Craissati, J. Horne, L. & Taylor, R. Effective Treatment Models for Personality Disordered Offenders (2002)

The proposed mental health legislation

60. The proposed mental health legislation introduces a generic and inclusive definition of mental disorder, which will mean that in future people with all forms of personality disorder, including psychopathic disorder, can be subject to compulsion in the same way as those with other forms of mental illness, provided that they meet the conditions for compulsion.

61. 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 for people with personality disorder. This will place a new emphasis on the assessment and treatment of personality disorder as part of the legitimate business of mental health services.

62. The introduction of the proposed legislation is likely to have the an impact on clinical practice in the following ways:

  • Clinicians will need to develop skills in the identification, assessment and treatment of personality disorder, and appropriate training will need to be provided across all disciplines at pre-qualification, and post qualification stages , as well as becoming part of continuing professional development (CPD)
  • Offenders with personality disorders, including psychopathic disorder, will become the legitimate business of mental health services, and there will be an important role for Trusts to provide liaison and consultation to local criminal justice agencies via, the MAPPPs (multi-agency public protection panels).

63. The bulk of work with personality disordered offenders is likely to fall to forensic services both for consultation and advice to criminal justice agencies, and for the assessment, treatment and management of personality disordered offenders.
The section on forensic services (paras 88-115 ) recognises this development, and makes specific recommendations as to how this should be handled.

64. MAPPPs were established by the Criminal Justice and Court Services Act 2000 to make joint arrangements for the assessment and management of the risks posed by sexual and violent offenders. The Act placed a statutory duty on the police and probation to co-operate in this process, and invited the participation of other agencies, notably Social Services, Health and Local Authority Housing Departments.

65. MAPPPs function differently across the country: some discuss risks posed by the “critical few” i.e. those offenders who pose the highest level of risk, whilst others consider cases with a much lower threshold of risk . New Guidelines are being issued to bring a greater degree of uniformity in the way MAPPPs operate. The contribution of health is also variable: responses to a survey issued by DH in 2002 revealed that some Trusts are represented by senior managers at their local MAPPP, others by senior clinicians, and a few by more junior practitioners from the local CMHT (community mental health team).

66. However, MAPPPs are playing an increasingly important role in the multi agency management and supervision of offenders in the community, and are likely to become the key forum for local criminal justice agencies to seek psychiatric advice and consultation from their local Mental Health Trust on the management of mentally disordered offenders. Requests for the preliminary examination of mentally disordered offenders in the community under the proposed Mental Health legislation are likely to be channelled through MAPPPs. It is therefore important that Trusts should be represented by senior clinicians who can provide expert advice, both to divert inappropriate referrals and to ensure that ensure that psychiatric opinion is provided wherever necessary.

Guidance on the development of service models:

General adult mental health services

67. All Trusts delivering general adult 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.

Specialist Team

68. Trusts are currently developing a range of community teams to meet the requirements of the NHS Plan and NSF to provide appropriate care for those with severe mental illness. In the same way all Trusts may also wish to consider the development of a specialist personality disorder team to meet the needs of those with personality disorder who experience significant distress or difficulty.

69. Such a team would provide the hub within a hub and spoke approach to service delivery, and should target those with significant distress or difficulty who present with complex problems. This development need not be resource intensive, but is likely to require some dedicated funding in order to create several additional specialist posts from any recognised professional background to form a multi-disciplinary team.

70. The following guiding principles should underpin such a development:

  • Personality disordered patients will need multi-disciplinary input and a team approach
  • Treatment of personality disordered patients should be led by clinicians with appropriate expertise and dedicated resources
  • Triggers for referral and acceptance of patients by service hub, and coworking and/or consultation with service spokes will depend on the severity of the patient’s personality disorder and the capacity of less specialised services to provide appropriate treatment and containment

71. In a specialist team model, a group of specially trained practitioners work together and, whilst they may divide their roles, all are part of a specialist service. Patients with personality disorder need to feel that those responsible for their care communicate frequently and effectively, get on well together, and are clear about boundaries of treatment. One member may provide individual psychotherapy whilst another is primarily involved in working on behalf of the patient with courts, housing, or social aspects of care, and yet another may provide psychiatric care.

72. All work together as a treatment team and information is shared allowing interventions and management to be informed fully by biological, psychological, and social understanding. Good working relationships within the team and close collaboration are essential if treatment is to be consistent and implemented according to agreed protocols.

73. It is recommended that the specialist team would ideally sit within existing psychotherapy, psychological therapy or psychology departments. Although it may be appropriate for the service to operate from the psychotherapy department, the model of service delivery will be more flexible, multi-disciplinary and assertive than conventional psychotherapy.

74. It is important that there is clarity about the remit of this team and that it does not exclude those patients who most require a service. It is recommended that clear protocols drawn up at the outset, describing referral protocols, and setting out the relationship between this services and other teams, in–patient wards and specialisms within general adult mental health services.

75. The core functions of the specialist team would be as follows:

  • To take on patients for assessment and treatment in line with the principles of the Care Programme Approach (CPA)
  • To provide consultation and support, supervision and training
  • To develop a clear link with local district and regional forensic services
  • To develop a self help network
  • To set up out of hours/crisis arrangements

Notable Practice Site : Intensive Psychological Therapies Service (IPTS) – Dorset: An outpatient service

The IPTS is a specialist service for people with a personality disorder. Approximately 50% of patients meet DSM-IV criteria for borderline personality disorder and many engage in self-harming behaviours. The service aims to aim to provide evidence-based, cost-effective outpatient treatments, reduce self-harming behaviour, reduce the frequency and duration of hospital admissions, help patients become more skilled in managing their emotions and relationships, and improve the quality of their lives.

Taking on patients for assessment and treatment.

76. The primary responsibility of the specialist team would be to undertake the comprehensive assessment, treatment and co-ordination of care for patients with a personality disorder, using the mechanism of the CPA. Triggers for referral and acceptance of patients will depend on severity of the patient’s personality disorder. This is likely to be determined by:

  • The risk of harm to self or to others
  • The presence of co-morbid mental illness and/or addiction and the severity of these accompanying problems
  • The complexity of personal pathology, including the presence of one or more personality disorders from a single cluster, or diffuse personality disorder ( two personality disorders from more than one cluster)
  • The degree of burden/distress caused to family and other agencies
  • High consultation frequency within general practice

77. The specialist team would take on those patients who experience significant distress or difficulty as a result of their personality disorder, and who present with complex problems. Patients taken on for treatment should meet the criteria for enhanced CPA, and the team should deliver care according to its principles. The team would take responsibility for the management of risk including sharing relevant information where necessary with other staff, consistent with the law, and good practise regarding confidentiality

78. As discussed above, (para 52) the current state of research evidence on treatment discourages prescriptive statements about the type of treatments which patients should be offered by specialist services, but we can identify the key guiding principles of effective therapy to which all specialist personality disorder teams should adhere. (para 54).

Notable Practice Site : Paddington Outreach Rehabilitation Team (PORT) – An assertive outreach team

PORT is an assertive outreach team in Paddington that concentrates its work on the care of the most difficult patients in the area, North Westminster, all of whom have personality disorders. It has a maximum case load of 100 all of whom have had recurrent admissions to hospital, are very difficult to engage, cause significant disruption in the community and have an average of three different and largely independent diagnoses. All patients are referred as tertiary referrals from the existing services in Paddington and North Westminster and, after a course of treatment that can extend from 6 months to many years, may be referred back to the maonstream services once they reach a position of stability and are able to cooperate with standard aftercare arrangements.

Providing consultation and support, supervision and training

79. The specialist team would provide consultation and support for staff working in a range of settings in accordance with agreed protocols:

  • within the adult mental health service ( eg, in patient ward, community teams)
  • across the Trust (to CAMHS, A&E, and drug & alcohol teams etc)
  • to external agencies ( social services, probation, housing, primary care ).

80. The provision of consultancy and support should be seen as the core secondary function of the service, and one which should enable staff in a range of settings to manage personality disordered patients who experience significant distress or difficulty. It would take a variety of forms including one –off case discussion, regular case review, initial joint assessments, and shared care.

81. Similarly, the provision of regular case supervision and training would provide the necessary structure to enable staff in a range of settings to take on patients with less severe presentations onto their caseloads.

Developing a clear link with local and regional forensic services

82. The specialist team would develop close links with the local forensic service in order to share and develop expertise, and to pool resources (eg. for staff supervision). Clear protocols would need to be drawn up to set out the mechanics for the transfer of the care of patients between general mental health and forensic services.

Developing a user network

83. Informal mutual support networks operating outside normal working times (overnight and weekends) have been found to be helpful in containing personality disordered patients until services reopen, and in reducing the demands on emergency services. The specialist team would provide the necessary structure and support for service users to develop a self help network that provides mutual support, and links into professionally run out of hours service as needed.

Setting up out of hours/crisis arrangements

84. The Trust will need to ensure that out of hours arrangements are drawn up and linked to existing Trust infrastructure for out of hours services, but with an explicit personality disorder focus. This is to ensure that patients with personality disorder who experience significant distress or difficulty can access care when in crisis, and thence minimise inappropriate use of emergency services, primary care and A&E.

Day Units

85. The need to develop day units will depend on the population and demographics of the Trust catchment area, and it is advised that Trusts with high concentrations of morbidity should develop specialist day patient services, in addition to the specialist team outpatient service. This could involve the re-focusing or re-use of current services and facilities. Such units should be developed in tandem with an outpatient service, and would be expected to prioritise patients with severe personality disorder, including patients who pose a risk to self or others, and who place heavy demands on primary and secondary care.

Notable Practice Site : Halliwick Unit – London: A day unit and intensive outreach service

The Halliwick Psychotherapy Unit provides a treatment service tailored to the specific needs of patients with severe personality disorder. A package of group and individual treatment is therefore offered either within a day hospital over five days or within an intensive outpatient programme involving three sessions per week. Patients are also offered a self-booking psychiatric clinic to discuss medication and a rapid response in emergencies. Engagement of the patient is important and assertive outreach is included within the programme.

Inpatient and residential units

86. There is no expectation that Trusts should provide dedicated in patient provision for people with personality disorder. Patients with personality disorder do sometimes access in-patient beds, but the role of acute in-patient units in treating patients with personality disorder is largely confined to managing crises, including escalation in risk to self or others.

87. There are currently five specialist residential units run as therapeutic communities (para 20 ). There are no plans to extend this level of residential provision.

Notable Practice Site : Francis Dixon Lodge : A Monday to Friday residential theraputic community

Francis Dixon Lodge is a Monday to Friday residential theraputic community, part of the Leicestershire and Rutland Healthcare Trust. It has approximately 50 places per year and accepts referrals from CMHTs, probation, social services and self referrals. Residents play an active part in the day to day running and activities of the unit, whilst using the setting of large and small groups to talk about and try to understand the nature of their difficulties. The day to day experience of living and working together is felt to be as important as formal therapy and the structure is such that the two are closely integrated and inform each other.

Guidance Points: 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

For Further Information: see Key Text on Website link (as listed in Appendix 1)
• Fahy,T. General Adult Mental Health – Service Model (2002)

Forensic Services

88. The basic assumptions on which the delivery of services for personality disordered offenders are based are no different to those underpinning treatment within general mental health services. In other words, (cf paras 70-71) treatment should be led by clinicians with appropriate expertise and access to dedicated resources, and be delivered by a multi-disciplinary team in accordance with the principles of the Care Programme Approach (CPA)

89. However, forensic services are required not only to provide treatment interventions, but also to address offending behaviour, and the reduction of risk. In the case of offenders with personality disorder there is also a need to address issues of social functioning, in order to tackle antisocial behaviour, social exclusion and disorganisation. This underlines the need to develop effective working partnerships with criminal justice agencies, particularly through MAPPPs (multi- agency public protection panels).(cf paras 64-66 )

90. Services for personality disordered offenders would therefore combine four key elements: the treatment and/or management of :

  • social functioning
  • mental health issues
  • offending behaviour
  • risk

and they should operate in very close partnership with local criminal justice agencies.

91. Over time a range of service provision will need to be developed within forensic services. There needs to be a clear link between this provision and personality disorder services in high secure hospitals, so that there is a clear pathway and continuum of care for all personality disordered offenders across all levels of security. This is vital in order to ensure that patients do not get stuck at one level of security and are unable to move when they are ready to do so.

92. New services are required for offenders with personality disorder in order to:

  • fill the gap in current provision,
  • meet the new demands that are likely to arise as a result of the proposed mental health legislation, particularly in relation to the need to provide liaison, consultation and advice on the assessment and management of personality disordered offenders for criminal justice agencies via. the MAPPP
  • link in with prison mental health care services in order to provide treatment for some very disturbed and difficult individuals in prison for whom services do not currently exist

<Part one                                                                                      Part Three>

Please note this is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (, 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