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

<Part two                                                                                     

Development of Expertise

93. All Trusts delivering forensic services will need to consider how to develop expertise in the identification and assessment of offenders with personality disorder. This may involve the provision of specialist training for a number of existing staff, and/or the creation of a small specialist multi-disciplinary team.

94. This team would work in close partnership with criminal justice agencies, and would provide:

  • consultation, liaison and case management advice
  • advice to courts, including court reports
  • preliminary examination under the proposed mental health legislation
  • links with prison mental health care services

95. Where appropriate the team would also take on the treatment and management of personality disordered offenders, and would provide an assertive outreach service to those individuals who are unwilling to engage with services, and who, because of their offending history, and the nature of the risks they pose, will need assertive management in the community.

96. Close links will be need to be made between this team, and the specialist personality disorder teams being developed within general mental health services in order to share and develop expertise, and to pool resources (eg. for staff supervision). Clear  protocols will be required for the transfer of the care of personality disordered patients between general mental health and forensic services.

Personality Disorder Centres

97. 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. We anticipate that these centres will provide for the treatment of male offenders most of whom will have a primary diagnosis of antisocial personality disorder.

98. Work is currently in hand to develop three early pilots: two in London and one in the North East, which between them will pilot the main components of a personality disorder centre. The pilots will initially provide services for their local catchment area.

99. In time these personality disorder centres will provide:

  • new service infrastructure for the treatment of personality disordered offenders
  • in-patient assessment and treatment services for a broad geographical catchment area
  • a focus for research into effective interventions
  • training and consultation for forensic services in local Trusts to assist them to develop their own expertise with personality disordered offenders

100. These centres should provide a range of services including in patient facilities , a multi-disciplinary specialist team, and specialist psychiatric support for community hostels and other forms of supervised accommodation. They will need to work closely with local police, probation and prisons, and to link in with local prison mental health inreach services.

101. The core clinical function of these centres will be to provide:

  • Assessment under the proposed mental health legislation
  • Short term treatment
  • Longer term rehabilitation

102. They will take referrals from the courts, from prisons, from local criminal justice agencies, from high secure hospitals, from local general mental health services and from the forensic services in other Trusts.

103. Triggers for referral and acceptance of offenders to these centres should include the following:

  • Presence of one or more personality disorders
  • History of persistent or very severe antisocial behaviour
  • Considered by experienced workers to be at risk of harm to others

104. The philosophy of care provided by these centres will be in accordance with the principles of the Care Programme Approach ( CPA), and a key function will be to ensure that risk assessment is carried out on all offenders referred to the service. There are a range of risk assessment tools available, and it is anticipated that clinicians will use a combination of actuarial tools and clinical judgement to assess risk.

Assessment under the proposed mental health legislation

105. Under the proposed mental health legislation, Trusts will be required to respond to any “reasonable request” for preliminary examination. In the case of personality disordered offenders, such requests are likely to be made by local criminal justice agencies, often via the MAPPP, and every Trust should consider how to develop the necessary expertise to respond to such requests. (cf para 62)

106. As part of the process of preliminary examination a decision will be made as to whether someone meets the criteria for detention under the Mental Health Act of up to a 28 day period of assessment. Such assessment should wherever possible take place within one of the designated personality disorder centres, rather than in a standard medium secure unit (MSU) or in a general acute mental health ward. These centres will therefore take patients for assessment from a wide geographic catchment area.

107. Specialist DSPD assessment units will be provided at Rampton and Broadmoor for those offenders who are thought to pose a very high risk and to exhibit severe personality disorder.

Short term treatment

108. This would include:

  • treatment under the Mental Health Act following assessment, where a tribunal decides that detention for a period of treatment is warranted
  • treatment of patients taken in from prison for specific interventions aimed to address their offending behaviour and their personality disorder
  • treatment of patients under the Mental Health Act, who have been assessed for the DSPD units at Broadmoor or Rampton, do not meet the threshold of dangerousness for continued treatment in a maximum secure DSPD unit, but where a tribunal decides they require further compulsion and intervention
  • crisis management of patients requiring short term interventions from

community placements and community hostels

109. The current state of research evidence on treatment discourages prescriptive statements about which type of interventions should be offered, but interventions should be targeted both at relieving the symptoms of mental distress, and at preventing re-offending.

Longer term rehabilitation.

110. Longer term beds are needed for some patients leaving high secure hospitals. There are clearly patients with psychopathic disorder within the current system who could move directly from high secure hospitals to supervised accommodation in the community, with the right level of support. Research indicates that direct transition to a supported community setting may be associated with a better eventual outcome for those whose risk has been assessed to be low, than a move to an interim setting of a medium secure unit.

111. However, there will also be a need for a limited number of longer term rehabilitative beds for those requiring the level of containment that a medium secure unit offers.

112. In time these facilities will also provide rehabilitation for those offenders who are assessed as ready to leave DSPD high secure units, but who require stepdown care in a medium secure setting, prior to discharge into the community.

113. Community hostel and supported accommodation will be needed to provide step-down care from medium secure provision, as well as having the facility to take directly from high secure hospitals, from the community and from prison. Community hostels can work effectively with different agencies taking responsibility for different aspects of care; the housing stock provided and administered by a housing association, day to day care delivered by a specialist care provider, and psychiatric care provided by clinicians from the personality disorder centre.

114. All Trusts hosting a personality disorder centre will be required to develop community hostel places in conjunction with local suppliers, and to provide the specialist psychiatric input to the residents living there.

115. There will need to be an overarching service model that sets out the relationship between multidisciplinary specialist team, the inpatient facility and the community hostel, to ensure continuity of care, and clarity of responsibility.

Guidance Points: 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.

For Further Information: see Key Text on Website link (as listed in Appendix 1)
• Thomas-Peter, B. Forensic Service Models (2002)

Staff Selection, Supervision, Education and Training

Key Issues:

116. The need to provide appropriate training opportunities for staff at all levels of experience- from the newly qualified practitioner to the experienced clinical leader – is a central requirement of this Guidance. Practitioners will need to develop skills in the identification, assessment and treatment of personality disorder both within existing services, and in particular in existing forensic services, and in new personality disorder teams and services as these become established.

117. It is important that training is team focused, supported and valued by the organisation, and tailored to meet the specific requirements of the service. It should also be recognised that the provision of training is not solely the province of professionals. Service users who contributed to the development of this strategy were keen to stress the value of user involvement in training, and some current training providers, including the Henderson Hospital actively involve users in their training programme. The active involvement of service users in training is an area that requires further thought and development.

118. But training alone is not sufficient. Pre-registration and pre-qualification education across all disciplines needs to offer sufficient grounding to provide practitioners with an understanding of the basic issues involved in the treatment of personality disorder. Continuing professional development (CPD) needs to be appropriately targeted to ensure that clinicians who may be experienced mental health professionals, but who have had little exposure to working with people with a primary diagnosis of personality  disorder, can develop new skills.

119. It is also important that the right staff are selected to work in this field, and that they are supported by their organisation through the provision of access to adequate support and supervision. A scoping study commissioned for this report by Maria Duggan identified existing training capacity in personality disorder and also explored the competencies and attributes ideally required by staff to work effectively with people with personality disorder.

The Selection of Staff:

120. Working in the field of personality disorder is not easy. Staff need a high degree of personal resilience and particular personal qualities that allow them to maintain good boundaries, survive hostility and manage conflict. They need to appreciate the value of team working, be effective team players and feel comfortable working as part of a multi-disciplinary team.

121. The scoping study suggests that in some important respects, the competencies required to work effectively with people with personality disorder are similar to those required for work with other groups of people with mental disorders, although there are also some key differences. These include emotional resilience, particular clarity about personal and interpersonal boundaries, and the ability to tolerate and withstand the particular emotional impact that working with personality disordered patients can have on relationships within a team and service.

122. Further work needs to be done to build on existing competency/capability frameworks in order to identify more clearly the particular attributes needed for effective work with personality disordered patients. The DH will collaborate with the lead Workforce Development Confederation to provide an indicative list of competencies at various levels, taking account of the differing skills needed by newly qualified practitioners, experienced clinicians and clinical leaders across all disciplines.

123. The development of these competencies will assist Trusts in deploying and recruiting staff for personality disorder services, and will provide the framework to ensure that selection procedures are appropriately targeted to facilitate the appointment of staff with the appropriate personal characteristics and skills.

Supervision:

124. As well as having the appropriate personal characteristics to work effectively in this field, practitioners also need access to regular supervision. Without this there is likely to be a high degree of staff burn out, absenteeism, sickness and disillusion, and services may fail.

125. All personality disorder teams and services should set out robust structures for supervision that support reflective practise, and assist staff to manage anxiety and deal with conflict. There will be a need both for individual supervision, and for team based supervision and case discussion. This is particularly important in forensic services where staff are likely to be working with offenders who have no wish to engage in treatment, and who may be very resistant and hostile.

Education:

126. The scoping study found that pre-registration/pre-qualification education across all mental health disciplines generally provides little specific content that would enable trainees to understand and feel confident to assess or manage personality disorder, although those with an interest could seek out training attachments that would address this gap.

127. The importance of continuing professional development (CPD) is recognised across all disciplines, but the choice of course or educational event attended may well be determined again by the individual practitioner’s interests, rather than changing service need.

128. In order to promote greater generic understanding of personality disorder 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

Training: Characteristics of Training

129. Training should be team focused, supported and valued by the organisation, appropriately targeted and context specific.

130. Team focused. The management and treatment of patients with personality disorder requires the expertise of a multi-disciplinary team (paras 68-71). 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. Training in team building and team working should be provided as an essential part of the training requirements of a personality disorder service. Team focused training will need to assist practitioners to work effectively in teams by addressing issues around hierarchy, rivalry, conflict resolution and collaboration.

131. Supported and valued by the organisation. It is essential that the Trust recognises and supports the need for training in personality disorder both for existing staff and where new services or teams are being established, by identifying the necessary resource and by providing cover where necessary to free up staff to attend training.

132. Appropriately targeted. The training needs of newly qualified staff will be different to those of experienced practitioners and to those of clinical leaders, and training should be targeted to meet recognise different needs. The role of clinical leader is crucial, and particular attention should be given to ensure that leaders are adequately trained, with the requisite skills as individual therapist, as team leaders, and as political players within their organisation.

133. Responsive to local need. Training must be tailored to meet the specific requirements of the service. Staff working in forensic services, for example, are likely to need specific training in the identification and assessment of personality disorder, so that they can provide appropriate liaison and consultation to MAPPPs. If a service is dealing with a number of very aggressive individuals with behavioural dyscontrol, it makes sense to have several staff trained in skills based approaches. Conversely, if other  problems pre-dominate (e.g. self-harming behaviour because of childhood sexual abuse) it may be appropriate to call on DBT or psychodynamic psychotherapy.

Training: Availability

134. It is not always easy for Trusts to access the right training for their staff. The scoping study commissioned for this report found that there is a paucity of training available at all levels of demand.

135. The study found that access to training in specialist therapeutic techniques is limited, with a small number of courses being delivered by an equally small number of training providers. Such training as is available is often driven by local needs and interests and by the energy and commitment of local “product champions”. The current level of training provision is not adequate to support any major service expansion at any level.

136. In addition, less formal opportunities for learning from acknowledged experts in the field are reducing. The Personality Disorder Beacon scheme, set up as part of the NHS Beacon initiative, funded 5 beacon sites to provide advice and consultation to Trusts wishing to develop personality disorder services, through educational visit and day events. The NHS Beacon initiative came to an end in 2002. The Personality Disorder Beacon scheme provided a very useful opportunity, particularly in personality disorder, for Trusts to learn from the experience of established services, and the withdrawal of funding leaves a significant gap.

137. In order to stimulate training initiatives, DH will pump prime the development of new training opportunities. DH will invite tenders from recognised sites of good practice and from training providers to enable them to develop or to expand their training arm to:

  • provide a range of inputs to Trusts delivering personality disorder services.
  • expand the pool and range of personality disorder courses available nationally

138. Tenders will be invited for the provision of a range of training opportunities which could include:

  • educational visits
  • on-going advice and consultancy
  • basic introductory training in working with personality disordered patients
  • team management and team building
  • training in specialist techniques

139. DH will work with the lead Workforce Development Confederation, and with the National Institute of Mental Health (NIMHE) to work up a tendering exercise, and to examine a range of options to develop appropriate training opportunities. It will be important to ensure that new training opportunities set up as a result of the tendering exercise do not themselves become fragmented and ad hoc in their delivery.

Guidance Points: 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 the 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.

For Further Information: see Key Text on Website link (as listed in Appendix 1)
• Duggan, M. Developing Services for people with Personality Disorder: The
Training Needs of Staff and Services (2002)

Appendix 1: Key Texts

All were written in 2002, and will be posted on the following websites:
www.nimhe.org.uk and at www.doh.gov.uk

  • Effective Management of Personality Disorder – Dr Anthony Bateman &
    Professor Peter Tyrer
  • Effective Treatment Models for Personality Disordered Offenders -Jackie Craissati, Louise Horne, & Ricky Taylor
  • Pathways in and out of secure care for personality disordered offenders – Professor Conor Duggan
  • Developing Services forPeople With Personality Disorder: The Training Needs of Staff and Services – Maria Duggan
  • General Adult Mental Health: Service Model – Professor Thomas Fahy
  • Services for People with Personality Disorder: The Thoughts of Service Users  – Dr Rex Haigh
  • The Epidemiology of Personality Disorders – Dr Paul Moran
  • Personality Disorder in African and African-Caribbean People in the U.K – Dr David Ndegwa
  • Forensic Service Models – Professor Brian Thomas-Peter
  • Personality Disorder and Substance Abuse – Dr Sarah Welch

Appendix 2: Strategy Development Process

Membership of expert groups

  • Dr Anthony Bateman Consultant Psychotherapist, Halliwick Day Unit, London
  • Dr Jed Boardman Consultant Psychiatrist, General Mental Health Services, South London & Maudsley
  • Ms Jackie Craissati Head of Forensic Clinical Psychology Services, The Bracton Centre
  • Professor Conor Duggan Consultant Forensic Psychiatrist, Arnold Lodge, Leicester
  • Ms Maria Duggan Independent Policy Analyst, London
  • Professor Tom Fahy Consultant Forensic Psychiatrist, Institute of Psychiatry

Chair of GMH Sub Group

  • Dr Brian Ferguson Consultant Psychiatrist, General Mental Health Services, Stonebridge Centre, Nottingham
  • Mr Paul Gantley Social Work Manager, Three Bridges MSU, Enfield and Broadmoor Hospital
  • Acting Superintendent West Mercia Police Ray Groves
  • Professor John Gunn Consultant Forensic Psychiatrist, Institute of Psychiatry
  • Dr Rex Haigh Consultant Psychiatrist in Psychotherapy, Winterbourne House, Reading
  • Ms Louise Horne Chartered Clinical Psychologist, Ashworth
  • Dr Jeremy Holmes Senior Lecturer In Psychotherapy, Barnstaple, North Devon
  • Dr Gill McGauley Senior Lecturer, Consultant Forensic Psychotherapist, Broadmoor
  • Ms Fiona McGruer Nurse Consultant, Webb House Theraputic Community
  • Dr Sarah Marriott Consultant Psychiatrist, General Mental Health Services
  • Ms Elizabeth Moody Joint Programme Head, DSPD Programme and Mental Health Unit, Home Office
  • Dr Paul Moran Honorary Specialist Registrar, Institute of Psychiatry
  • Mr Andrew Morley DSPD Programme, Home Office
  • Dr Kingsley Norton Director of Henderson Hospital, Sutton

Chair of Training Sub group

  • Mr Adam Penwarden Business and Policy Development Manager, Stonham Housing Association
  • Mr Simon Rippon Nurse Consultant, Miranda House, Hull
  • Dr Tony Roth Joint Course Director, and Chartered Clinical Psychologist, UCL
  • Ms Ethel Samkange Director of Link Worker Schemes, The Revolving Door Agency, London
  • Mr Chris Scanlon Psychotherapist, Henderson Outreach Service
  • Ms Sara Scott Deputy Director, The Revolving Door Agency, London
  • Ms Fiona Spencer Joint Programme Head, DSPD Programme and Mental Health Unit, Home Office
  • Dr Pete Snowden Chair of Steering Group Consultant Forensic Psychiatrist, Ashworth
  • Mr Les Storey University of Central Lancashire
  • Mr Ricky Taylor R&D Project Manager, DSPD Programme, Home Office
  • Professor Brian Thomas-Peter Director of Psychological Services, The Reaside Clinic, Chair of Forensic Sub Group Birmingham
  • Ms Louise Tuhill Acting Assistant Chief Probation Officer, Mitre House, London
  • Professor Peter Tyrer Consultant Psychiatrist, Imperial College
  • Ms Georgina Wilcocks PD Services Directorate Manager, Rampton
  • Dr Heather Wood Clinical Psychologist, Halliwick Day Unit, London
  • Dr Tony Zigmond Consultant Psychiatrist, General Mental Health Services, Leeds

Membership of Service User Focus groups

  • Lesley Allen Northants
  • Mary-Ann Ambrose Colchester
  • Yolandé Hadden Berkshire
  • Cameron Jordan Colchester
  • Liz Main London
  • Sheena Money Berkshire
  • A. Mills London
  • Peter Oates London
  • Paul Priami Coventry
  • Ms S. Mulholland London
  • Hannah Stein London
  • Jayne Treby Jersey
  • Kati Turner London

Focus Group Facilitators

  • Dr Rex Haigh Consultant Psychiatrist in Psychotherapy, Winterbourne House
  • Dr Kevin Healy Clinical Director, The Cassell Hospital, Richmond, Surrey
  • Ms Fiona McGruer Nurse Consultant, Theraputic Community Service
  • Dr Gary Winship Adult Psychotherapist, Winterbourne
    House

Advice from User Groups

  • Jean Haldane – Breakthrough
  • Dale Ashman – Borderline UK
  • Vicky Cox – Borderline UK
  • Debbie Tallis – Borderline UK
  • Heather Castillo – Colchester Mind
  • Maggi Harrison-  District Alliance
  • Julie Bayley – First Steps to Freedom, and BPD Carers
  • Michael Connar – First Steps to Freedom
  • Sue Johnson – James Naylor Foundation

Input from North East

  • Anthony Nemo – Service User
  • Dr Peter Whewell – Consultant Psychotherapist, Newcastle
  • Representatives from the BPD Service at Claremont House

Further Input from

Amanda Bosley A1 Elite

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

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