Personality Disorder Service Research Articles

Reasons Why Patients Are Turned Down From Treatment at a Personality Disorder Service: Implications for Referrers and Personality Disorder Services

Reasons Why Patients Are Turned Down From Treatment at a Personality Disorder Service: Implications for Referrers and Personality Disorder Services

‘Challenging’ doesn’t sum it up: Exploring probation practitioners’ experiences managing high-risk individuals during the COVID-19 pandemic

The COVID-19 pandemic has been, and still is, a worldwide health crisis. Despite the surge of literature on this phenomenon, little research has been conducted with the Probation Service during this time. The aim of this research was to explore Probation Practitioners’ (PPs’) experiences of the COVID-19 restrictions with a specific focus on those who access the Psychologically Informed Consultation Service (PICS). Further, to explore the experiences of key aspects of the COVID-19 pandemic through the lens of the Community Offender Personality Disorder Service. Semi-structured interviews were conducted with 9 PPs who represented a broad cross-section in terms of age and years of experience in the role. Interpretative Phenomenological Analysis was used to explore the experiences of PPs and revealed 5 main themes: unmet support needs, problematic working environments, an emotionally distressing time, the use of PICS, and a silver lining. These findings are discussed with implications for further research.

Leaving it at the gate: A phenomenological exploration of resilience in mental health nursing staff in a high-secure personality disorder unit.

This study reports a qualitative phenomenological investigation of resilience in nursing staff working in a high-secure personality disorder service. Interviews were carried out with six nursing staff, and these captured the richness and complexity of the lived experience of nursing staff. Four superordinate themes emerged from the analysis: Management of emotions: participants showed an awareness that their job is about giving care to patients who may present with very challenging behaviours. The care that they offered was conceptualized as something that needed to be provided in a measured way, with boundaries. A clear distinction was drawn between 'caring personally' for patients, and 'providing care'. Teamwork: teamwork was cited as a major influencing factor by all participants. This was seen as directly impacting the smooth running of the ward, and therefore on the well-being of nursing staff, but also of patients. Understanding: nursing staff were acutely aware that they were working in an environment where everyday interactions would be open to intense scrutiny and possible misinterpretation by patients. Work-life balance: All the participants spoke of making a conscious effort to have a separate work and home life, which was influenced by a number of factors. The article has discussed the themes of managing emotion, team understanding and work-life balance, illustrating how each contributes to the resilience of nursing staff in this challenging environment. New insights - applicable in both national and international contexts - have been produced. In secure environments, mental health nursing staff need organizational support and assistance to develop ways of managing difficult experiences with patients, systems that promote recovery, and educational and supervisory support to help understand and process the effects on them. This article provides evidence to support the work of managers and clinicians in these environments. No Patient or Public Contribution.

Co-Occurring Autism Spectrum and Borderline Personality Disorder: An Emerging Clinical Challenge Seeking Informed Interventions.

Co-Occurring Autism Spectrum and Borderline Personality Disorder: An Emerging Clinical Challenge Seeking Informed Interventions.

Delivering remote therapy during the COVID-19 pandemic: a qualitative study with service users accessing a community personality disorder service

PurposeThe purpose of this study is to qualitatively explore the views and opinions of service users accessing remote therapy through a community forensic personality disorder service during the COVID-19 pandemic.Design/methodology/approachA qualitative exploratory approach was adopted. Nine community forensic service users accessing virtual/telephone therapy through a community forensic mental health service were interviewed using semi-structed interviews. Data was analysed using Braun and Clarke (2006) thematic analysis techniques.FindingsAnalysis resulted in three overall themes: experience of communication in the therapeutic relationship; impacts of the change to remote working and making the best of what we have. A further seven subthemes were developed. A range of advantages and disadvantages to remote therapy were highlighted.Research limitations/implicationsThis study was based on a small sample of service users accessing one community forensic service in England, and therefore caution should be taken when generalising the findings. All interviews were conducted remotely and thus may have only supported those who are able to engage in this way.Practical implicationsThis paper has the potential to inform future remote therapy guidelines. Health services should consider keeping some elements of remote working and offering this as a choice to all service users.Originality/valueThis study is, to the best of the authors’ knowledge, the first study that attempts to explore the experiences of individuals accessing remote therapy within a forensic population who have personality disorders or traits.

Enhancing member engagement in a Tier 3 personality disorder service during COVID-19: evaluation of a virtual group programme.

Drop-out rates from evidence-based interventions for people with a diagnosis of personality disorder (PD) are high. The COVID-19 pandemic has likely exacerbated barriers to engagement with the introduction of virtual working. Virtual therapy has a good evidence-base for Axis I disorders, but limited research for Axis II disorders. To investigate facilitators and barriers to engagement in a Tier 3 PD service virtual group programme. A virtual group programme was developed in collaboration with service members, and analysed members' attendance rates over a 5-month period pre- and post-COVID-19. Thematic analysis of semi-structured telephone interviews with 38 members is reported, describing their experience of the virtual group programme. Attendance rates were significantly higher pre-COVID (72%) than post-COVID (50%). Thematic analysis highlighted key barriers to attendance were: practical issues, low motivation, challenges of working in a group online and feeling triggered at home. Main promoters of engagement were: feeling valued, continued sense of connection and maintaining focus on recovery. The results suggest that the pandemic has exacerbated relational and practical barriers to engagement in a Tier 3 PD service. Ways of enhancing engagement are discussed, as well as preliminary recommendation for services offering virtual therapy to people with a diagnosis of PD.

You hear me: The power of a brief intervention service in an Offender Personality Disorder (OPD) community pathway setting

The Lightbulb Service, a brief intervention, provided the opportunity for people who screened into the Offender Personality Disorder (OPD) pathway to access a therapeutic service to increase insight and experience a positive change in their wellbeing. The Service Evaluation used qualitative methods to explore the benefits of this intervention whilst recognising its limitations. Specificall, themes around being listened to; someone interested in them and their story, and improved connection to other professionals were just some of the discoveries made. It provided us with hope that brief interventions within a personality disorder service can make real and positive change for someone, who otherwise would not have accessed help.

Exploring the Effects of Early Trauma in a Forensic High Secure Population: Evaluating Associations Between Adverse Childhood Experiences (ACEs) and Diagnosis of Antisocial Personality Disorder (ASPD)

AimsTo examine links between Adverse Childhood Experiences (ACE) categories and diagnosis of antisocial personality disorder (ASPD) in this population; it is predicted that there will be a positive association between number of ACEs and ASPD. The effectiveness of high secure hospital admission and treatment in reducing number of risk incidents was also examined. ACEs are known to impact significantly on the development of the personality and future psychiatric risk. Currently, research into links between distinct ACE categories and the diagnosis of ASPD in the high-secure inpatient population is limited.MethodsData were collected from a sample (n = 221) including all patients in the Mental Health, Personality Disorder and Women's Services at a high-secure hospital. Records were examined for evidence of abuse/neglect during childhood, and a number of markers of household dysfunction. The statistical relationship between each ACE category and subsequent diagnosis of ASPD was examined through paired t-tests. Frequency of incident reports (IR1s) involving violence was compared in the first, third and fifth years post-admission.ResultsSignificant associations with adult diagnosis of ASPD were seen in categories of childhood physical abuse, sexual abuse, divorced/separated parents, Looked After Child (LAC) status and parental substance misuse, and total number of ACE categories present overall. Significant reductions in frequency of IR1s were seen in all services between first- and fifth- year post admission.ConclusionA significant association between ACEs in specific domains and ASPD in adulthood was found. The importance of detailed exploration of childhood circumstances in this group is highlighted, as well as the need for further investigation of the psychological and social mechanisms underlying.

An evaluation of a pilot multi-professional offender personality disorder (OPD) higher education programme

PurposeWorkforce development is crucial to the offender personality disorder (OPD) service to provide contemporary, evidenced care and treatment. This study aims to provide an overview and the research evaluation results of a regional higher education programme delivered to a range of criminal justice workers used on the OPD pathway.Design/methodology/approachThree modules were developed and delivered; these are (1) enhancing understanding (20 students), (2) formulation and therapeutic intervention (20 students) and (3) relationships, teams and environments (17 students). A mixed-methods study evaluated participant confidence and compassion. Pre, post and six-month follow-up questionnaires were completed. Additionally, a series of focus groups were conducted to gain in-depth qualitative feedback with a cross-section of students across the modules (N = 7). Quantitative data was collected and analysed separately due to the three modules all having different content. Qualitative data was analysed, and a synthesis of qualitative findings was reported from data taken across the three modules.FindingsA total of 52 students participated, drawn from three modules: Module 1 (N = 19); Module 2 (N = 18); Module 3 (N = 15). Confidence in working with people with a personality disorder or associated difficulties improved significantly following completion of any of the modules, whereas compassion did not. Results have been synthesised and have assisted in the future shaping of modules to meet the learning needs of students.Research limitations/implicationsFurther evaluation of the effectiveness of educational programmes requires attention, as does the longer-term durability of effect. Further research is required to explore the post-training impact upon practice, and further exploration is required and larger sample sizes to draw definitive conclusions related to compassion.Practical implicationsThis unique model of co-production that draws upon the expertise of people with lived experience, occupational frontline and academics is achievable and well received by students and can be reproduced elsewhere.Social implicationsThe positive uptake and results of this study indicate a need for expansion of accessible OPD workforce training opportunities across the UK. Further research is required to explore student feedback and comparisons of effectiveness comparing different modes of training delivery, especially in light of the pandemic, which has forced organisations and higher education institutions to develop more digital and distance learning approaches to their portfolios.Originality/valueThis novel research provides an evaluation of the only higher education credit-bearing modules in the UK focussed solely upon the OPD workforce and aligned with the national drive for non-credit bearing awareness level training “knowledge and understanding framework” (KUF).

Administrators within personality disorder services: their role and contribution in maintaining the overall structure and treatment approach

PurposePeople with personality disorders often present with interpersonal difficulties which affect their relationship with significant others but also with staff involved in their care. Administrators work in “frontline positions” where they are required to face challenging situations yet their role has not been studied. This study aims to describe the role and contribution of an administrator in a personality disorder service.Design/methodology/approachA mixed-methods design was used. All incoming calls to a specialist personality disorder service over three months were documented. A semi-structured focus group (n = 7) with clinicians working in the service was conducted. The data was analysed using thematic analysis. Clinical vignettes are presented to highlight typical interactions.FindingsThe qualitative results highlighted that the administrator is key in psychological preparations, managing pressure and maintaining clinical boundaries. Traits identified as useful in an administrator working in a personality disorder service are flexibility, consistency and assertiveness. Tensions between administrators and clinicians were related to the role definition of the administrator, boundaries, countertransference and process interaction. The majority of incoming calls were from patients scheduling and cancelling appointments. Only 3% of calls evoked negative feelings in the administrator such as feeling “annoyed” or “drained”.Practical implicationsResults highlight a need for careful selection, training and supervision of staff. A key recommendation is the need for integration and close coordination of the administrator within the clinical team.Originality/valueThis study represents one of the first efforts to explore the contribution of administrators within personality disorder services. It explores the impact of the administrator on the team.

The impact of COVID-19 lockdown on the well-being of clients of a specialist personality disorder service.

ObjectiveThe aim of this study was to investigate the well-being of people with severe borderline personality disorder (BPD) during the first wave of COVID-19 social restrictions.MethodClients of an outpatient specialist personality disorder clinic (n = 77) were invited to the study. An online survey was conducted including a range of open-ended questions exploring well-being and the Coronavirus Anxiety Scale (CAS) which assesses ‘coronaphobia’. Qualitative data were analysed using inductive content analysis with NVivo software. CAS data were analysed descriptively using SPSS version 25.ResultsThirty-six surveys were completed (48% response rate). Many participants experienced significant challenges to their overall well-being during lockdown although some reported improvements in psychosocial functioning. Three participants (8.3%) experienced clinically significant ‘coronaphobia’.ConclusionThe self-reported physical and mental health of participants with BPD demonstrated resilience, suggesting that the capacity to maintain treatment via telehealth helped to mitigate many of the adverse aspects of social restrictions. This study was conducted during the first wave of social restrictions; subsequent studies will reveal longer-term effects of extended community lockdowns.

Poem written by a resident on Primrose (Personality Disorder Service) about her experience of the service

Poem written by a resident on Primrose (Personality Disorder Service) about her experience of the service

A service evaluation of short-term mentalisation based treatment for personality disorder.

People with personality disorder experience long waiting times for access to psychological treatments, resulting from a limited availability of long-term psychotherapies and a paucity of evidence-based brief interventions. Mentalisation-based treatment (MBT) is an efficacious therapeutic modality for personality disorder, but little is known about its viability as a short-term treatment. We aimed to evaluate mental health, client satisfaction and psychological functioning outcomes before and after a 10-week group MBT programme as part of a stepped-care out-patient personality disorder service. We examined routinely collected pre-post treatment outcomes from 176 individuals (73% female) aged 20-63 years, attending a dedicated out-patient personality disorder service, who completed MBT treatment. Participants completed assessments examining mentalising capacity, client satisfaction, emotional reactivity, psychiatric symptom distress and social functioning. Post-MBT outcomes suggested increased mentalising capacity (mean difference 5.1, 95% CI 3.4-6.8, P < 0.001) and increased client satisfaction with care (mean difference 4.3, 95% CI 3.3-5.2, P < 0.001). Post-MBT emotional reactivity (mean difference -6.3, 95% CI -8.4 to -4.3, P < 0.001), psychiatric symptom distress (mean difference -5.2, 95% CI -6.8 to -3.7, P < 0.001) and impaired social functioning (mean difference -0.7, 95% CI -1.2 to -0.3, P = 0.002) were significantly lower than pre-treatment. Improved mentalising capacity predicted improvements in emotional reactivity (β = -0.56, P < 0.001) and social functioning (β = -0.35, P < 0.001). Short-term MBT as a low-intensity treatment for personality disorder was associated with positive pre-post treatment changes in social and psychological functioning. MBT as deployed in this out-patient service expands access to personality disorder treatment.

The Mental Health Act 1983 (as amended in 2007) reform – How proposed changes potentially impact personality disorder services

At the beginning of this year, the UK government released a White Paper on Reforms of the 1983 Mental Health Act (MHA) aiming to achieve higher quality, accessible mental health care, as well as empowering people detained under MHA during the process and continuation of detention. In this piece, we focus on the potential impact of the proposal around appropriate care, management and detention of people with Personality Disorder (PD) within the criminal justice system (CJS), psychiatric service provision and community routes. We briefly review the historical context of reforms of PD services in the UK and discuss the proposed changes and issues in relation to the criteria of least restriction, detention and therapeutic benefit. We highlight the complexity around referral routes and logistics barriers for secure PD services that might hamper speeded referral routes and raise concerns around responsibility for authorisation of transfers in the context of risk of serious harm to the public. We emphasise the complex treatment needs of individuals with PDs and how these are potentially not met. We also discuss the shift of focus from reactive care to preventative measures and early intervention in the community for individuals with mild-to-moderate levels of PD. We highlight the need for appropriate integrative services in the community to facilitate assessment across services, identification of complex needs and support options including earlier routine screening and potential digital interventions to optimise specialised care for PD. • Discusses potential impact of the Mental Health Act reform on management of individuals with Personality Disorders (PD). • Discusses criteria of least restriction, detention and therapeutic benefit for management of severe PD in PD services. • Raises concerns around complexity of referral routes, logistic barriers and responsibility for authorisation of transfers. • Discusses the shift of focus from reactive care to preventative measures and early intervention in the community. • Highlight a need for appropriate integrative services in the community for assessment of complex needs and support options.

Beyond the walls of Camden & Islington personality disorder service: a qualitative study of clinical consultation to external services

The Camden and Islington Personality Disorder Service (PDS) increasingly provides clinical consultation to external services. There is a dearth of research on the experience of clinicians delivering such consultation. Interviews were conducted with clinicians from the PDS, and a semantic Thematic Analysis was conducted on transcripts to answer the question, ‘What is the experience of Personality Disorder Service staff providing input to staff in external services?’ 13 sub-themes under four overarching themes were identified (these latter were: Anxiety, Fragmented Co-working, Task Difficulty, and Positive Outcome). These themes provide an overview of the experience of consulting clinicians. Themes are explored through Kleinian psychoanalytic theory, with reference to Bion’s work on containment and groups. Findings suggest that staff need to retain thinking space to work effectively, to feel safe and recover a sense of competence when it is attacked, highlighting the need for access to structures such as supervision. The responsibility for trying to reduce distress, risk (to self, to and from others) and functional disability of people with a diagnosis of personality disorder cannot belong to one person or service but services need to be able to think together to gain a better understanding and have an agreed cross-service response.

What happens to frequent attenders when they attend psychiatric liaison services? a clinical and demographic profile

AimsWe aimed to describe the demographic and clinical profile, and management of frequent attenders to a psychiatric liaison service.BackgroundFrequent Attenders to emergency departments contribute significantly to the burden on health services and by definition are subjectively highly stressed. It is therefore important that mental health services develop effective responses to this group of patients. A systematic literature search indicated a paucity of information on this group of patients.MethodWe conducted a case series of 49 frequently attending patients to the Psychiatric Liaison service in Tower Hamlets, East London NHS Foundation Trust.We defined frequent attenders as seeing the Psychiatric Liaison Service 5 or more times in 2018. We excluded 4 patients aged &lt;18 years or &gt;65 years.For each patient we collected data regarding their demographics; the details of each attendance to the Psychiatric Liaison Service; and their use of other psychiatric services.We then conducted a multivariate analysis, including stratification of patients based on number of attendances to identify correlation between frequency of attendance and the other information.ResultDemographic: The 45 patients reviewed had a mean age of 37 and a mean of 7 attendances during the study period.Clinical: 89% had a history of emotional trauma, 71% of substance misuse, and 49% of any personality disorder. Only 9% of the patients were under the care of the locality Personality Disorder Service.73% of the patients were under the care of any other psychiatric service. There was no correlation between being under other services and the frequency of attendance.Only 31% had contact with the locality Frequent Attenders Service during the study period, as this was established recently.ConclusionPsychiatric Frequent Attenders have complex needs, which do not fit neatly into existing psychiatric diagnoses and services.The high frequency of emotional trauma, substance misuse and personality disorder indicates a need for training of clinicians in these services to manage these patients, as well as planning for referral pathways for this group of patients who provide services with major challenges in appropriate pathways to care and follow-up

Evidence-based psychological interventions for borderline personality disorder in the United Kingdom—who falls through the gaps?

Over the past fifteen years, access to evidence-based psychological interventions (EBPIs) for borderline personality disorder has dramatically increased in the United Kingdom. However, some patients continue to fall through the gaps. This article presents a novel analysis of evidence on patients who are currently unable to benefit from EBPIs and explores possible solutions, with particular reference to dialectical behaviour therapy and mentalization-based therapy. At one end of the spectrum, patients with less severe difficulties often do not meet the threshold for receiving EBPIs in dedicated personality disorder services. The nascent evidence base for a possible solution—implementation of streamlined versions of EBPIs in generic mental health or even primary care services—is reviewed. At the other end, a sizeable minority of patients receiving long-term EBPIs discontinue treatment prematurely and/or experience poor outcomes. This is a highly distressing experience with potential for iatrogenesis—yet the evidence base for what to do next is non-existent and follow-on treatment pathways in services are unclear. Difficulties in the therapeutic alliance, a failure to overcome epistemic hypervigilance, and therapist non-adherence to the model are reviewed as possible contributing factors. The importance of understanding the patient perspective on what happened, considering the role of both patient and therapist in contributing to difficulties, and offering patients a choice in specifying their onward treatment, is discussed. Finally, increasing access to trauma-focused EBPIs for post-traumatic stress disorder is recommended as an avenue for the future.

Prescribing in personality disorder: patients’ perspectives on their encounters with GPs and psychiatrists

ObjectiveThe purpose of this study was to explore the views of patients with personality disorder on their experiences of prescribing practices by general practitioners (GPs) and psychiatrists, and their expectations...

Offender personality disorder pathway screening tools evaluation

PurposeThe offender personality disorder (OPD) pathway faces the difficult task of identifying individuals who are eligible for their service from the entire probation caseload. The offender assessment system personality disorder (OASys PD) screen is a national screening tool used by the pathway to help with this task. This paper aims to describe an evaluation of the effectiveness of this plus an additional screening tool currently used to identify eligible individuals for the OPD service in the South of England. Recommendations for improvements were made as necessary.Design/methodology/approachA mixed methods design used a quantitative analysis of data on the effectiveness of the OASys PD for correctly identifying individuals and a thematic analysis of a focus-group conducted with clinicians within the service.FindingsThe analysis revealed a positive predictive value of the OASys PD screen of 72% and a negative predictive value of 91%. Key themes from the focus-group revealed what worked well about the screening process, what was difficult and what needed to be improved.Practical implicationsThe OASys PD performed better than the clinicians had expected. It was recommended that the service continued to use the combination of the screening tool and the interviews with minor adjustments.Originality/valueThis is the first research study of its kind on the effectiveness of the OASys Personality Disorder Screening tool. Using such a tool with some caution (the addition of consultation) creates a useful and effective process for tackling the very difficult task of identifying people for the community component of the Offender Personality Disorder Service. This research provides some evidence for the validity of such a process that is currently used throughout the National Probation Service in England and Wales.

Security needs among patients referred for high secure care in Broadmoor Hospital England.

Security needs among patients referred to forensic mental health services have rarely been systematically studied. To ascertain security needs among patients referred to a high secure hospital, Broadmoor High Secure Hospital, England. We also aimed to compare the security needs for those referred to mental illness services with those referred to personality disorder services in the hospital. A retrospective complete cohort study of all referrals to Broadmoor Hospital over a 2-year period was conducted. All referred patients (n = 204) were assessed for need for high secure care by two Broadmoor clinicians. The final decision on need for admission was taken by a multidisciplinary admission panel. Independent of the panel, researchers rated need for security using the DUNDRUM-1 triage security scale. Those admitted to Broadmoor Hospital had higher triage security scores than those declined (F = 4.209, d.f. = 1, P = 0.042). Referrals to the personality disorder pathway had higher security needs than those referred to the mental illness pathway high secure service (F = 6.9835, d.f. = 1, P = 0.0089). Overall security needs among referrals to Broadmoor were extremely high, both by comparison with previous needs identified in UK medium secure services and international medium and high secure services. High secure patient cohorts represent a uniquely vulnerable group within mental health services, with extremely high security needs identified in this study. This has significant implications for services given the high levels of resources needed to provide therapeutically safe and secure care and treatment to this group.