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Working effectively to support people with personality disorder in the community. MeetingTheChallengeCOVER.qxd 20/6/14 12:12 Page 2

THIS HANDBOOK HAS BEEN WRITTEN AND COMPILED BY: Winifred Bolton, Camden and Islington NHS Foundation Trust Kath Lovell, Emergence Lou Morgan, Emergence Heather Wood, Tavistock and Portman NHS Foundation Trust

ADDITIONAL CONTRIBUTIONS FROM: Jina Barrett, Tavistock and Portman NHS Foundation Trust Heather Castillo, The Haven Project, Colchester Rex Haigh, Berkshire Healthcare NHS Foundation Trust Sheena Money, Thames Valley Initiative Sue Pauley, Thames Valley Initiative Barbara Riddell, Emergence And other members of Emergence, STARS and Thames Valley Initiative.

We are grateful to all those service users whose quotes have been included, and the experts by training and by experience who provided useful comments. With thanks also to the authors of ‘Working with personality disordered offenders in the community’ (2011, Department of Health and Ministry of Justice), from which we have drawn ideas and some sections of text. Contents

Foreword ...... 2

Executive summary ...... 3

Introduction...... 4

BACKGROUND 1 What do we mean when we talk about ‘personality disorder’? ...... 8 How do I recognise when someone has a personality disorder? ...... 10 What do you do if you identify that someone has personality difficulties? ...... 12 How do we describe and understand these problems? ...... 15 Thinking about the individual and arriving at a formulation of their difficulties...... 18

2 Why is the diagnosis of personality disorder so controversial?...... 22 Stigma ...... 23 The notion of treatability...... 25 It matters how a diagnosis is given ...... 26 It’s not the label that matters but what happens afterwards...... 27 Supporting someone through the process of receiving the diagnosis...... 28

3 How does personality disorder develop? ...... 30 What is biological sensitivity?...... 31 Early experiences with important others ...... 32 How does failure to meet core needs contribute to personality disorder? ...... 34 Broader social and environmental factors...... 35 Life course of personality disorder ...... 36

PRACTICAL GUIDANCE 4 What can I do to make a difference? ...... 38 How can personal agency be developed and supported? ...... 39 What might get in the way of achieving a boundaried relationship?...... 41 How can we deal with challenging behaviour?...... 42 Self harm...... 42

5 What help might be available?...... 48 What do the NICE guidelines advise? ...... 54

6 Service user involvement...... 58 What are the types of service user involvement? ...... 59 What are the principles of good service user involvement? ...... 62 What are the challenges associated with service user involvement? ...... 64 What are the benefits associated with service user involvement? ...... 64

7 Surviving or thriving at work? What helps staff?...... 66 Wellbeing and burnout...... 68 What do you need in order to do this work?...... 69 Developing your capacity to work with people with personality disorders...... 70 Working in teams ...... 71

Appendix 1: Specific psychological therapies which may be available for people with personality disorders...... 76

Appendix 2: References and resources ...... 79

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Foreword

The last ten years have seen major changes in the way health and social care services work with people with the complex psycho-social difficulties known as personality disorder. Great strides have been made in developing new treatment interventions to support people in leading more fulfilling lives

At the same time, the government has Health Nottingham, Emergence provided additional funding for (formerly Borderline UK), the Tavistock specialist and innovative services and and Portman NHS Trust and the Open the publication of guidance documents University established the Knowledge about workforce development and and Understanding Framework (KUF) commissioning of services for people which now offers a comprehensive with personality disorder. education and training programme for staff working with people with In 2003 the Department of Health personality disorder. published No Longer a Diagnosis of Exclusion, a guidance document which These initiatives, supported by NICE highlighted the failure of mainstream Guidance on Borderline and Antisocial mental health services to identify and PD in 2009, have opened the door to provide appropriate treatment for those service development and most with personality disorder or other complex importantly, workforce training psycho- social disorders. A programme initiatives to ensure that services can to develop 11 community personality better provide for those with complex disorder services was established in psychological difficulties. 2005 with the aim of testing new Meeting the Challenge – making a service models and evaluating their difference serves as a companion guide effectiveness.The majority of these to Working with Personality Disordered pilot services have since transferred Offenders, published in 2011.This present into mainstream local provision and Guide is intended for community have led to steady growth in personality practitioners, and aims to bring disorder services across the UK. up-to-date thinking about personality Breaking the Cycle of Rejection:The disorder into the daily work of Personality Disorder Capabilities thousands of staff working across Framework, published in 2004, health and social care services.Their launched a major education and committed work deserves support. training initiative to improve the awareness, capability and competence Nick Benefield, of workforces across health, social care Programme Director, Department and criminal justice. A partnership of Health Personality Disorder between the Institute for Mental Programme, 2004-2014

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Executive summary

It’s not personality disorder unless someone’s difficulties are persistent, pervasive and problematic. Personality difficulties affect the way an individual characteristically feels about themselves and others, and may be evident in recurring problems in their relationship with others.

Personality disorder may be apparent Symptoms such as self harm in the person’s account of their require workers to deal in an effective problems, their history, difficulties in way with risk and injury, while also engaging with services, or the way in remaining concerned about what has which staff or services led the person to harm themselves. characteristically respond to them. Service users with personality While there are sometimes disorders who may have experienced benefits to establishing a formal neglect, rejection or maltreatment, diagnosis, this can be stigmatising. both within their families growing up For most workers in the field, it is and later when they have sought more helpful to work with the service help, may be wary of accessing help. user to arrive at a formulation of Becoming involved in services – their difficulties. planning, evaluation, and delivery There is no single pathway to – are all ways that service users developing personality difficulties or can make a highly valuable disorders. Difficult experiences in contribution and may discover new childhood can combine with biological skills and talents. vulnerability and social disadvantage Engaging with a person with to create a life course that leads to serious personality difficulties personality disorder. can impact on staff emotionally. Even though personality difficulties Look after yourself. Seek may be longstanding, there is a psychologically informed supervision great deal that can be done to and support, take time out to help people. reflect, be realistic about change, and celebrate real progress. A helpful stance towards someone with personality disorder is to be curious and compassionate, trying to understand what the person is experiencing, and what is affecting their present feelings and behaviour.

3 Introduction All frontline workers will encounter people who might be seen to have a personality disorder. Someone’s personality is their characteristic patterns of thinking, feeling and behaving that remain fairly consistent across situations and over time. ‘Personality disorder’is the term used within mental health services to describe longstanding difficulties in how an individual thinks and feels about themselves and others, and consequently how they behave in relation to other people. INTRODUCTION

THE PURPOSE OF THIS GUIDE IS: • To help people to know more and to understand more about personality disorder, and how this impacts on individuals who may attract this diagnosis, and the staff, teams and organisations that work with them. • To invite people to think about their own attitudes to working with people with personality disorder. • To provide some information about services that might be available, how to access help for people with personality disorders, and what can be expected from services. • To offer guidance on helpful and unhelpful ways of responding to people with personality disorders.

Sometimes it is our own There are many different ways and will not forgive and forget, reaction to a service user1 in which someone can have so over the years he has lost that alerts us to the fact that personality difficulties, or a friends and become this person struggles with personality disorder.These are increasingly isolated. three examples of people who relationships. We may find Kelly manages to hold down a have personality difficulties ourselves feeling job as a nursery nurse, but she which interfere with their uncharacteristically struggles with mood swings, everyday life:2 frustrated with someone, sometimes feeling OK, but or eager to help and ‘rescue’ Jack often reads hidden often overwhelmed by anger them from their difficulties, meanings into harmless or feeling depressed and or feeling we have to tip toe remarks and is quick to feel worthless. Her relationships around them for fear of injured or slighted and then with partners start well but provoking them. Sometimes reacts in an angry way. His seem to ‘crash’ within a few these reactions are to do with family feel they have to tread weeks; she is very sensitive to our own issues, but carefully around him. His feeling rejected or abandoned sometimes it signals that this partner experiences him as and partners can experience service user has personality suspicious and inclined to be her as too demanding.When difficulties and will need the jealous; he has accused her of she feels hurt or rejected she worker to be particularly having affairs. If he feels he can get in a rage and she careful and thoughtful in has been got at or betrayed by sometimes lashes out at their approach. friends he harbours grudges others, but she is more likely

1 Throughout this guide the term ‘service user’ will be used to refer to people who might be given this diagnosis and who have accessed help from services.We have chosen to use this in preference to other terms in use to denote people in receipt of services, such as ‘patient’,‘client’ or ‘customer’.We recognise that the term ‘service user’ is not ideal as some people feel it devalues the many aspects of individuals’ lives beyond their engagement with services.We use it here for ease of understanding but hold in mind these reservations. 2 When examples are given, these are not real people, but are fictitious examples based on people we have known.

5 THE TERM ‘PERSONALITY DISORDER’ HAS BEEN CRITICISED FOR THE FOLLOWING: • There is no clear cut-off between someone who has an unusual or troublesome personality, and someone with a ‘disorder’. • Individuals labelled as having a ‘personality disorder’ might feel that this marks them out in a way that is stigmatising or unhelpful.

to harm herself. Kelly finds it because she has been staying difficulties or people with these very difficult to be alone; at home to care for her mother. kinds of difficulties, including: when alone she feels empty Do you recognize anyone with • ‘Complex and severe and frighteningly unsure of similar, longstanding difficulties psychological difficulties’. who she is.When feeling amongst the people that you desperate she sometimes • ‘Complex needs’ (this is work with? If so, reading this cuts herself, and she took two sometimes also used to guide may help you in your work. overdoses in the last 2 years. refer to people with severe When working with people who mental illness). Susan has been suffering from have personality problems, we anxiety and panic for over 20 • ‘People diagnosable with do not want them to feel years. She relies heavily on her personality disorder’. labelled, put down, or squeezed teenage children, expecting into diagnostic boxes.They are • ‘People who identify with them to accompany her fellow human beings, many of the problems associated whenever she leaves the whom have suffered greatly as with the diagnosis of house, and calling them on they were growing up, and personality disorder’. their mobile phones if she now struggle in adult life. panics when alone. She also In this guide we are going often calls the emergency We want to help people on the to stick to using the phrases services, imagining that she is road to recovery by working ‘personality disorder’ or having a heart attack when alongside them in a respectful ‘personality difficulties’ she has anxiety symptoms. way, working together, helping though we will describe to build their sense of trust some of the problems with She has been repeatedly and confidence.The language these terms. referred to mental health, IAPT that we use is therefore very and psychology services for We all have personalities, important. Service users treatment of her anxiety and and we all have aspects of sometimes say that they do agoraphobia, but has difficulty our personalities that are not like the abbreviation getting to appointments and troublesome at times. People ‘PD’, or to be seen as nothing has never stuck with any with personality disorder are but a disorder. treatment programme. Her not fundamentally different older daughter has recently A number of different phrases from anyone else, but might, been missing a lot of school have been used to describe these at times, need extra help.

6 WORKING TOGETHER

Professionals have come to recognise that working alongside service users with diagnosable personality disorder to plan, design and deliver services has led to better services and a better experience for everyone. Service users’ views are taken seriously, service users have the opportunity to hold valued roles and influence, and professionals get a much better idea of what is really needed and what really helps.This guide has been produced through service users (‘experts by experience’) working with professionals (‘experts by training’) in a collaborative and equal way.

7 1 What do we mean when we talk about ‘personality disorder’? We all have personalities – the collection of qualities and personal characteristics that make us distinctive as people.We all also make assessments of other people’s personalities: we might describe one person as an extrovert, or another as shy. BACKGROUND

Each person’s personality • For someone to be given a potential sources of help. has a number of different diagnosis of personality They are present in most if qualities or ‘traits’; these may disorder, the individual’s not all aspects of the sometimes seem contrasting personality characteristics person’s life. In other words, or contradictory: a person need to be outside the norm they are pervasive. can be cautious with respect for the society in which they Diagnosing ‘personality to money, but impulsive live, to be a source of disorder’ is a task for a skilled when it comes to making unhappiness to that person and trained professional. relationships; they might and/or to others, and/or to Labelling someone as having a be very serious and dutiful severely limit them in their personality disorder may have at work, but humourous lives.Those characteristics serious implications for them, and warm with friends. are problematic. and some people may be very We all have parts of our • Personality disorders are upset by or disagree with the personalities that cause us chronic conditions, meaning diagnosis. If someone is problems in some situations. that the problematic formally diagnosed as having For example, someone who characteristics continue over a personality disorder, this generally copes well in life a long period of time, they diagnosis should be discussed might be inclined to be irritable usually emerge in adolescence with them in a careful and and suspicious when they or early adulthood, they are sensitive way. (For helpful tips meet someone new, or feel relatively stable and can see Chapter 2,Why is the anxious when alone. continue into later life.The diagnosis so controversial?). What is the difference characteristics are persistent. between having aspects • These problematic Because of the dangers of your personality which characteristics result in of casual or careless can sometimes cause distress or difficulties in a labelling, we would problems, and having number of different aspects discourage you from a personality disorder? of someone’s life, such as labelling your clients intimate, family and social as having a personality relationships, how someone disorder unless you are The three ‘P’s’ experiences the world professionally trained around them, their to do so. It is much relationship to themselves more useful to think For someone’s personality (that is, their inner world), about them as having difficulties to be considered and in any employment or complex needs, or a ‘disorder’, those difficulties occupation that the person personality difficulties, must be Problematic, takes part in .They can also and to think about what Persistent and Pervasive. affect the way in which the those are, and how they Think about ‘the three Ps’: individual relates to affect the person.

9 How common is it? How do I recognise when someone has personality disorder? ‘Complex needs’ or ‘complex emotional needs’ are quite Different types of information may alert you to the fact that new terms, and we do not yet someone has a personality disorder. You will never find that all have any figures about the of these factors are present in one person, and some of these proportion of people in factors may be associated with other types of difficulties such different contexts who have as long term illnesses, but if a number of the items listed are complex needs. At present, the apparent you might start to think about whether the person statistics we have tell us how has enduring personality difficulties or complex needs. commonly people meet the criteria for personality disorder. 1) HOW THE PERSON PRESENTS AND DESCRIBES THEMSELVES TO YOU Different research studies come up with different results, The person may describe one or more of the following: but in general in the UK • A long-standing pattern of emotional or relationship between 5% and 12% of the difficulties, like always finding themselves being let down, population would meet the abused or abandoned by others. criteria for a diagnosis of • Feeling caught up in a whirl-wind of rapidly changing feelings, personality disorder.This often overwhelmed, or overwhelming others, in the intensity means that it is quite common. of what they are feeling. In comparison, only about 1% of people will have at least one • A history of turbulent or unstable relationships. episode of psychosis at some • Feeling wary or suspicious, reluctant to disclose information point in their lives; at any one despite your intention to help them. time, about 2% of people • Long-standing personality characteristics which have always suffer from major depression. been a problem, like “I’ve never had any friends”, or “I’ve always Some of the people who would been painfully shy”, or “I’ve never been able to bear being on my meet the criteria for own”,or “I’ve always wanted everything to be ‘just so’”. personality disorder have relatively mild difficulties and • A difficult relationship to ‘self’ such as difficulties with identity, may only need treatment at self-esteem, feeling ‘different’ to others, or a sense that they times of stress, but there are are failing in the world. many people living with disabling problems which 2) THE PERSON’S HISTORY impact on their wellbeing, their • Does the person have recurring patterns of impulsive or self- relationships, and their destructive behaviour, like self-harm, drug misuse, repeatedly everyday lives. provoking fights, repeated criminal offences, or an eating disorder? • Is there evidence of patterns in relationships which keep repeating, like repeatedly getting sacked from jobs, repeatedly getting involved with abusive partners, or seeming to be exceptionally dependent on friends, family and services?

10 BACKGROUND

• People with personality disorder commonly report having QUICK QUESTIONS: experienced a range of traumatic or unhappy experiences in If you only have a few childhood such as physical, sexual or emotional abuse, being minutes, and want to bullied, or witnessing violence within the family. Experiencing assess whether someone a single traumatic event is not usually enough on its own to might have a personality cause someone to have personality disorder in adulthood, but disorder, Paul Moran and his negative factors in childhood can add up to make the person’s colleagues have developed start in life very difficult. 8 simple questions which • Have they had a number of hospital admissions for mental you can ask (Moran et al health problems, which do not appear to have resolved their 2003). If the person answers problems? Or a history of seeking help from doctors for a range yes to several of these of physical symptoms which have been fully investigated but questions, and thinks that for which there seems to be no explanation? the description applies most of the time and in most • Are there frequent emotional crises perhaps evident in situations, it may alert you repeated trips to A&E, or GPs? to the possibility that they • Is there a history of previous suicide attempts or self-harm? have personality difficulties and indicate the need for a 3) DIFFICULTIES IN ENGAGING WITH SERVICES fuller assessment. • Is there evidence of previous difficulties in relation to 1) In general, do you have accessing services? They might have dropped out of treatment, difficulty making and not kept appointments, become aggressive and been excluded keeping friends? from services, or have a history of making complaints.This may 2) Would you normally have been a response to inadequacies in the service, or reflect describe yourself as the individual’s difficulties with engagement. a loner? • Have they had a number of previous treatments for psychological 3) In general, do you trust problems which seem to have failed or not worked? other people?

4) SOMETHING UNUSUAL IN HOW YOU OR THE SERVICE 4) Do you normally lose RESPONDS TO THIS INDIVIDUAL your temper easily? Sometimes it is our own reactions, or the response of our 5) Are you normally an colleagues or our agency to an individual, which alert us to the impulsive sort of person? fact that this individual brings out an unusual reaction in people. 6) Are you normally We find ourselves reacting to someone in a way which seems a worrier? uncharacteristic or hard to explain. 7) In general, do you Sometimes these reactions reflect our own shortcomings; with depend on others a lot? greater training or experience, or support from colleagues, we can overcome or manage such feelings. But sometimes it does seem as 8) In general, are you though these strong reactions are a response to the particular a perfectionist? individual and how they see themselves and others.

11 What do you do DO YOU FIND YOURSELF RESPONDING TO THE PERSON if you identify IN A WAY THAT YOU FEEL IS UNUSUAL FOR YOU?: • Forgetting about them or feeling reluctant to engage that someone with them has personality • Making an exception and offering them special treatment difficulties? • Hotly disagreeing with colleagues about how the person should be treated If you recognise that someone • Feeling useless and as though you have nothing to offer has personality difficulties, • Feeling overwhelmed by the person’s needs think about: • Finding yourself responding less sympathetically than usual • How severe are the person’s personality problems and what level of help might they need? (see following). • Are there unaddressed risks, Sometimes this indicates • What is your agency’s role and if so, what needs to that the person is trying to and what is it appropriate happen to address these? communicate their need for for your agency to do? (In help with increasing • Is there a need for a crisis plan, desperation, but sometimes Chapter 4 we look at what and if so, can you or your you might be able to do to it signals that there has agency offer this, or should been a shift from the person make a difference, whatever another agency be involved? your particular role). self-harming to actively Even if it is not your agency’s trying to take their own life. • Are you comfortable to role to provide psychological It may also be the case that work with the person with treatment or counselling, there the behaviour threatens your current level of training may be a great deal that you their life, without them and support? can do to help the person. necessarily intending to • Would you be able to work commit suicide. For example, with the person yourself if a person who overdoses on you had some extra support When to worry medication as a method of (training, supervision, team self-harm, may, over time, support, peer support)? (In increase the amount they It is impossible to write an Chapter 7 we explore what are taking to the point exhaustive list of situations support staff need in order where it poses a risk to life that should ring alarm bells, to do this kind of work). even though their intention but here are some examples: was to harm themselves • What other resources are 1) Escalation in risk associated rather than commit suicide. available locally? (In Chapter with episodes of self harm or 5 we describe the range of 2) Evidence that someone challenging behaviour. resources that may be available who has previously within your local area).

12 BACKGROUND

taken overdoses is HOW SEVERE ARE THE PERSON’S PERSONALITY PROBLEMS? stockpiling tablets. All of us have within our personalities areas where we function 3) If the person is unable well, and areas where we function less well. to control emotional and angry outbursts and is FUNCTIONING WELL NOT FUNCTIONING WELL living with children or vulnerable adults. Able to be flexible, to adapt Stuck in a particular way of to different situations, able viewing or relating to others, 4) If someone who struggles to respond effectively most repeatedly feeling bad about with relationships of the time. how we are in social situations, becomes very withdrawn, responding to others in a way barely leaves the house that is not helpful and often causes distress to them and/ or their computer, and is or ourselves. at risk of neglecting self- care and eating. 5) If personality difficulties are contributing to the breakdown of housing, It is important to be alert, not just to more ‘dramatic’ symptoms employment and like self harm or aggressive outbursts, but also ‘quieter’ symptoms, relationships and there is like someone becoming very withdrawn, isolated, and starting to a risk of homelessness. neglect themselves. In Chapter 4 we think about what you can do to make a difference, and in Chapter 5, what 6) When someone with a other help might be available. history of violence to strangers starts to be violent to a partner. A CONTINUUM OF PERSONALITY FUNCTIONING Some of these situations may It is helpful to think of personality difficulties as existing along require other agencies to be a continuum, with adaptive personality functioning at one end involved, such as mental and personality disorder or complex needs at the other end, as health services, the police or illustrated below: social services. In other situations, it may be enough to ask the person what help they need and to think with them PERSONALITY about how they might get it. HEALTHY SOME MANY DISORDER PERSONALITY PROBLEMATIC PROBLEMATIC If you remain worried, seek OR COMPLEX FUNCTIONING TRAITS TRAITS advice from within your own NEEDS organization, and think about whether the person needs a specialist assessment or input.

13 THE RANGE OF SEVERITY OF PERSONALITY PROBLEMS AND THE DIFFERENT INTERVENTIONS THAT MIGHT BE HELPFUL

HEALTHY PERSONALITY Anna is a teacher who regularly puts on school plays. She takes great FUNCTIONING pleasure in the children’s delight, and in the response of the audience. She enjoys the applause and the appreciation for her hard work, but is happy to step back and let the children be the stars of the show. • Anna is unlikely to need or want help with this aspect of her life

SOME PROBLEMATIC TRAITS Angela is a music teacher at another school, where she has a reputation for organizing outstanding concerts.The quality of the children’s work is very high, but some parents feel that she drives the children too hard to excel, often losing her temper with them if she thinks they are not working hard enough. Her friends know that if she thinks the performance is less than perfect she will be miserable for days • Angela might benefit from some short-term counselling or self-help information to help her see that her very high standards are problematic and can make her unhappy

MANY PROBLEMATIC TRAITS Annabel is a teacher at a third school. She is known for demanding very high standards from herself and everyone she comes into contact with, and for losing her temper very easily if she feels criticised or slighted in any way. Annabel works extremely long hours and sleeps very badly, feels very stressed and has repeatedly sought help from her GP.Her colleagues and acquaintances feel they have to tread very carefully around her so as not to spark off an outburst. Annabel feels anxious, unappreciated, and wonders why she does not have more friends. • Annabel’s problems are pervasive and she might benefit from some psychological therapy to explore the range of situations that cause her difficulty

POSSIBLE PERSONALITY Anne-Marie has not worked for several years. She started out as an art DISORDER teacher but left teaching after a number of uncontrolled outbursts at work led to her being disciplined. She could not stand having to fit in with the strict timetable and demands of the job. She tries to paint, but swings between feeling that she is an exceptional artist and that people should recognise her talent, and feeling that her work is worthless rubbish. She has had a number of intimate relationships, but she is quick to feel that she is being let down or misunderstood, and relationships tend to deteriorate into jealous arguments and physical fights. She has always cut herself when very stressed, but recently this has been getting more frequent and more severe. Her life feels empty and depressing and she holds onto the thought that, if things got desperate, she could always kill herself. • Anne-Marie’s difficulties are persistent, pervasive and problematic. She may need longer term or specialist help from a personality disorder service or team.

14 BACKGROUND

How do we describe and understand Different types of these problems? personality disorder: Although the term ‘personality disorder’ is in everyday use, in There are three main approaches to thinking about these kinds practice there is much of problems: disagreement between people 1) Medical-type diagnosis, identifying whether people have who work in and study this problems that fit certain defined diagnostic categories of area of human life, about how personality disorder. to think about, describe, categorise and label difficulties 2) Looking at how personality varies for each person along a continuum, of personality functioning. sometimes known as the ‘dimensional’ approach to personality. Different classification systems 3) A formulation based approach using psychological theory to are used for diagnosis.The help us to understand what anxieties or dilemmas lie beneath American Psychiatric Association the surface behaviours, how these difficulties have developed, has a system known as DSM what maintains them and how are they triggered. (Diagnostic and Statistical Each of these approaches has something valuable to contribute to Manual) which has been revised building a full, clear and informative picture of someone’s difficulties. a number of times.The fifth revision (DSM 5) was published in 2013. Both DSM 5 and 1) THE CATEGORICAL APPROACH TO DIAGNOSIS DSM IV which preceded it, In mental health as with physical health, diagnoses are made so define 10 personality disorders that we can make a summary statement which should communicate in terms of the traits,attitudes to other people what problems an individual has, and which may or behaviours which are provide some pointers about which treatments are likely to be helpful. characteristic of each.The disorders are also grouped into three clusters according to their primary presenting features.

CLUSTER A ‘Odd and eccentric’ personality types Includes: paranoid, CLUSTER B schizoid, and schizotypal ‘Dramatic, CLUSTER C personality disorder emotional and erratic’ ‘Anxious and fearful’ personality types personality types Includes: antisocial, Includes: dependent, histrionic, narcissistic avoidant and obsessive- and borderline compulsive personality personality disorder disorders

15 To meet the threshold for being diagnosed with a personality 2) THE ‘TRAIT’ APPROACH OR disorder, DSM specifies that a person must have a certain number DIMENSIONAL APPROACH of the possible characteristics for that disorder (often 4 or 5 out of TO PERSONALITY 8 or 9 possible characteristics). A diagnosis of personality disorder Most people working in this field cannot be made on the basis of just one or two features. now accept that personality Many people equate personality disorder with borderline does not fit neatly into personality disorder, which is characterized by someone having categories or ‘disease entities’. unstable relationships, self image and emotions, as well as Instead, it is now recognised impulsivity.Within the Criminal Justice field, people often equate that personality traits and personality disorder with antisocial disorder, which is often (but difficulties vary in how much not always) associated with an offending history. It is important, they impact on someone’s life when we talk about ‘personality disorder’, to be aware of the (severity) and in the specific range and variety of personality difficulties that can cause aspects of their personality that severe problems for people. are affected (different dimensions). In recognition of However, there are many problems with this ‘categorical’ this, proposals for ICD 11 include system of diagnosis: reference to the severity of • Many people have more than one diagnosis of personality impairment in personality disorder. functioning, and the nature of • People given the same diagnosis may have markedly problematic personality traits. different problems. Psychologists have attempted • Clinicians often disagree about which type of personality to identify the key dimensions disorder an individual has. that make up ‘personality’. • With many illnesses there is a clear distinction between a Although not everyone agrees person with the illness, and someone who does not have the about the structure of illness, but there is no hard and fast cut-off between a normal personality, most modern personality, and one that is considered ‘pathological’. theories of personality suggest that it consists of a number of As a sign of how confusing this area is, clinicians and researchers broad qualities or ‘domains’ tried to propose major changes in how personality disorder was with each of these domains diagnosed for DSM 5, but could not agree how this should be having a number of done, and so ended up sticking with the existing system. component aspects, or ‘traits’. DSM is developed in the USA. An alternative model, widely used in One of the most widely the UK, is the International Classification of Diseases (ICD) accepted models is the ‘Five developed by the World Health Organisation.The system in current Factor Model’ of personality. use, ICD 10, describes 9 types of personality disorder, The Five Factor Model The advantages and disadvantages of being diagnosed with a suggests that personality can personality disorder will be discussed further in Chapter 2, be summed up by thinking ‘Why is the diagnosis so controversial’. where someone falls along the following five dimensions:

16 BACKGROUND

1) Openness (seeking out new experience , being curious, versus 3) PSYCHOLOGICAL being more consistent and cautious) FORMULATION BASED 2) Conscientiousness (the extent to which someone shows self- APPROACH discipline and is dutiful, organized and plans in advance, versus Clinicians who provide therapy someone being more carefree or careless) to people with personality 3) Extraversion (whether someone is outgoing and sociable and difficulties and disorders seeks stimulation in the company of others, or whether they are (this includes psychiatrists, more solitary and reserved) psychologists, psychotherapists and counsellors) may use 4) Agreeableness (whether someone is friendly and shows concern for diagnosis as a starting point, others,or whether they are more suspicious or antagonistic to others) but usually they also attempt 5) Neuroticism (whether someone tends to experience a range of to develop a psychological unpleasant emotions easily, such as anger, anxiety and formulation that will guide the depression, or whether they are secure and confident). psychological treatment. An international group of experts have been working on a revision A psychological formulation is of ICD10 that will lead to an up-dated system, ICD 11.They question an attempt to describe and the usefulness and validity of ‘categories’ of personality disorder, explain a person’s problems in and propose a more dimensional model. In ICD11, personality terms of the range of factors disorder is likely to be diagnosed by the severity of personality which contribute to the problems, rather than whether they match a defined ‘category’ development and maintenance such as borderline or avoidant personality disorder. Apart from of the problems. Its purpose is normal personality, there are likely to be four graded levels, to guide interventions and risk ‘personality difficulty’ which will not be coded as a mental health management strategies. Unlike disorder,‘mild personality disorder’,‘moderate personality disorder’, psychiatric diagnosis, it aims to 3 and ‘severe personality disorder’. In addition to establishing capture what is individual and degrees of severity, personality will be assessed in four domains: unique about the person. There are a range of Internalising/ Anxious, poor self-esteem, shyness, emotional/neurotic dependence on others psychological theories that can be used to structure a Externalising/ Irresponsible, lack of regard for the needs formulation, including learning antagonistic/ of others, aggressive, deceitful sociopathic theory, information processing theory, psychoanalytic theory Detached/schizoid Aloof, indifferent, reduced expression of and attachment theory. Each emotion, suspicious of these theories provides a Anankastic Over-conscientious, excessive orderliness, framework for organizing and perfectionism, inflexibility, cautiousness linking the information that we have collected about a person This dimensional model fits with the idea that we all have during the assessment process. personalities that vary on roughly similar dimensions.

3 The exact names of these degrees of severity and domains may differ in the final document.

17 The aim is to identify patterns PROBLEMS It is always important to work to develop a shared which connect childhood view with the service user of what the problems are development and adult that they need help with.Their experience of their difficulties won’t always tally with yours. You might personality, so that we have think that they need to stop using drugs and alcohol an understanding of the but they may feel they need help with their relationships person’s history, and how they first of all. In order to engage them effectively it is come to have these problems. necessary to take seriously their point of view. For We can then design an example, their alcohol and drug use may be a way intervention to help them to of coping with relationship difficulties, so working with them on the relationship issues may open the overcome their difficulties. door to addressing their drug and alcohol use. PREDISPOSING These are early childhood experiences, such as FACTORS trauma, neglect and deprivation that increase Thinking about vulnerability in adult life. An understanding of how these affect the person’s adult personality will the individual, inform you of how they are likely to respond to your and arriving at a efforts to help them.This hopefully will help you to be prepared for the kind of difficulties in the ‘formulation’ of relationship that may arise. their difficulties PRECIPITATING These are factors currently present in the person’s FACTORS life that trigger the problems.These can be triggers in the mind or in the external environment, such as A formulation is like a recent loss of a relationship, or substance misuse. thumbnail sketch of a person, Identifying these triggers, in partnership with our best understanding at that service users, can be of great practical help as it is point in time of how the person something concrete that you might be able to help the person to change or reduce. developed these problems, how they affect them now, PERPETUATING These are factors which maintain the problem, that what triggers them and what FACTORS is, make it more likely that the problem will continue to recur, for example lack of support, or implications this has for how only being cared for when you are in crisis. Again, it we should treat them. It’s very is important to do this in collaboration with the helpful to write it down but person experiencing the problems as different people always with a willingness to experience the same circumstances in different ways modify it as new information PROTECTIVE These are factors which contribute to the person’s becomes available or on the FACTORS resilience and capacity to cope with adversity. basis of the service user’s Relationships, employment, housing, and a support response to our intervention. network can sometimes increase stress, but very often they work to promote resilience. If you can A useful model of formulation harness them in your work to overcome problems is called the ‘Five P’ model: you are more likely to be successful. Again, it is important to identify these collaboratively with the individual, as they may well draw on resources which are not obvious to others.

18 BACKGROUND

“Music has got me Cultural “When I first saw a through some of the differences and psychiatrist I was a young most difficult times of value judgments gay woman, embedded in my life, I don’t have gay culture – that was my any family and find ‘normal’ so when I saw The judgments we make friendships complicated, about desirable and in my notes that my short but sometimes when undesirable personality hair and boyish clothes I have hit a crisis, traits are sometimes very were written about as a I find solace and subjective, and reflect our sign of something weird, understanding in music. own cultural context. In one I flipped out. The culture, young people This ‘connection’ that breaking away from their psychiatrist was an old, I find in music has been families and showing straight, white man – ‘there’ for me in a way independence may be seen what the hell did he know no actual person has.” as mature and impressive; in of my culture? If he’d ever another culture, continuing been to a gay club he dependence on and close These five P’s are different from involvement with the family would have known that the three P’s described earlier, may be praised and seen as I looked like most of the for identifying personality a mark of health.This is one other women there. To problems (persistent, pervasive reason why staff in mental his credit, once I calmed and problematic). If you can health services and other work with the individual in your agencies who work with down and explained this, service to identify these ‘five people with personality he did remove that section P’s’, it will provide a sound disorder need to engage in from my notes. But it initial framework for thinking ‘reflective practice’ with made me wonder what about the person, what might others.They need the other assumptions had be affecting them, and where opportunity to check out there might be scope to help their judgments with a range been made about me...” them to make changes. It is of others to guard against usually difficult to change the the possibility of their own The definition of personality predisposing factors because cultural attitudes negatively disorder given in DSM IV states these are part of someone’s influencing their perceptions that there must be an history, but you may be able to of service users. “enduring pattern of inner help the person to avoid or experience and behavior that challenge the precipitating deviates markedly from the and perpetuating factors, or expectations of an individual’s to strengthen the protective given culture”, but in today’s factors in their lives. complex world we often engage with more than one culture.

19 Is the culture of a second Distinguishing personality disorder generation immigrant that of the family he or she grew up in, and mental illness or the culture of the wider community in which he or she Within a psychiatric framework for understanding mental health went to school? problems a clear distinction is made between personality difficulties and This is why the phrase in the ‘mental illness’such as severe depression,psychotic disorder and bipolar DSM IV definition is very disorder.However,this distinction rarely reflects individual experience;it is important: that the common for people to have a range of difficulties,which this model would problematic pattern of see as mental illness and personality problems;health professionals call behaviour ‘leads to distress or this ‘co-morbidity’.Some people are now questioning whether it is helpful impairment’. Sometimes being to see someone as having two or more disorders,rather than viewing extreme or unusual within a them as a person whose problems have different aspects.For example, particular culture is adaptive many people with personality disorders use drugs and alcohol to help and functional: it enables them manage their feelings.If they become dependent on substances people to challenge the status some people would regard it as an additional disorder (a ‘co-morbid’ quo, and to achieve extreme or disorder) rather than part of the same underlying problem.Service users exceptional things like the generally want to be treated as individuals,seeking supportive,empathic early feminists or civil rights staff to help them navigate through the difficulties they experience in activists.When this is the case, life,rather than being seen to have a number of disorders. if they do not harm others or As discussed earlier, there is controversy about using a psychiatric feel distress themselves in the approach to understanding emotional distress. However, it is process, we may think of them widely used, and a distinction is often made between ‘mental as eccentric maybe, but ‘high illness’ and ‘personality disorder’ based on the following: functioning’ and not suffering • Unlike personality disorders, mental illnesses are thought to from a mental disorder. have an identifiable onset, in which a period of ‘illness’ interferes with the individual’s usual way of functioning. In contrast, personality disorder is more developmental, so there is no identifiable point in time when someone becomes unwell. • Severe mental illnesses are traditionally treated with medication with the aim of returning someone to a state of wellness,although fluctuations can occur.In contrast,the difficulties associated with personality disorder form part of the personality system;medication may have a part to play but will not be the main component of the help required.People with personality disorder have long term problems,and do not have a healthy self to return to,but rather need to build one. • Despite these distinctions, some people diagnosed with personality disorders also meet the criteria for ‘mental illnesses’ such as depression, psychotic disorder or bipolar disorder. It is also suggested that having a personality disorder may increase one’s risk for developing mental illness.

20 LEARNING POINTS FROM CHAPTER 1

Personality difficulties or personality disorder mean that people have difficulties in lots of different areas of their life; you are likely to see this reflected in the range of problems that a person needs help with and in the ways that you and your organisation feel about and respond to them. — We need people who are extreme and unusual as well as people who are more ‘ordinary’ to function well as a society. It is usually helpful to focus on personality characteristics that cause problems, rather than those we might consider unusual. — For someone’s personality difficulties to be considered a disorder, they must be pervasive, persistent and problematic. — Criteria exist to determine whether someone has a personality disorder; unless you have been trained to make diagnoses, it is usually more helpful to arrive at a personalized formulation about how someone’s problems seem to have come about, what triggers and perpetuates them, and also what might enable them to change.

21 2 Why is the diagnosis of personality disorder so controversial? The term ‘personality disorder’ is a psychiatric one, drawing on a medical framework for understanding behaviour, emotions and psychological distress. BACKGROUND

There is no underlying ‘disease’ in personality disorder. There are no biological markers or signs that someone has a personality disorder. The term is a form of shorthand to describe a range of psychological characteristics that give rise to patterns of emotion, behaviour, relationships and thinking. The label ‘personality disorder’ cannot be used as an explanation and it can only be judged by its usefulness.

Personality disorder problems – for example, the “A lot of people see you is a familiar term to staff reason they struggle to as untreatable. You’re maintain their tenancy is working in mental health not offered the help services. Many other agencies because they have a also work with people who personality disorder. In fact, and support. You’re not have problems associated this explains very little because seen as a human being with the diagnosis, such as it tells us almost nothing about but as a diagnosis. social services, housing and the nature of the person’s Everything you do is particular difficulties. voluntary organizations, and seen in that light.” they may not use this term. The diagnosis of personality They will recognize and disorder is controversial.This is “With panic disorder and encounter the difficulties because of the qualities often experienced by their service associated with such a depression I received help. users, but are likely to describe diagnosis in many people’s With personality disorder them in terms more relevant minds, and because of mental I was treated differently, to the task of their agency. health services’ history of I had no help.” For example, housing support marginalizing and excluding agencies may describe a such people because they service user as having were not seen to have a Stigma difficulties maintaining a treatable ‘illness’.We now tenancy, rather than as know that personality disorder having a personality disorder. is treatable; the vast majority Many service users, carers They may neither understand, of people can benefit from the and mental health nor feel they need to know, right support at the right time. professionals strongly dislike why the problem arises. One of However the idea that the term ‘personality disorder’ the difficulties with the term personality disorder is because it is seen as ‘personality disorder’ is that it untreatable still lingers and invalidating to their whole may give a mistaken has contributed to many identity and sense of self. It impression that we now have service users not wanting to be implies a criticism or judgment, an explanation for the person’s associated with the diagnosis. rather than a description.

23 Personality disorder is also linked in the public mind with “I was treated less criminality and dangerousness; in fact, the majority of sympathetically because people with difficulties associated with personality disorder of personality disorder. are not violent or criminal. They believe it’s not mental illness but REFLECTING ON EXPERIENCES OF STIGMA AND DISCRIMINATION: something you’ve Many of us understand what it is like to be stigmatised brought on yourself.” from our own experience in society. “I think the diagnosis is Are you... - Black or from a minority ethnic group? saying ‘trouble maker’. You’re ignored. People - Lesbian, gay or bisexual? can be hostile. You’re - Transgendered? not taken seriously. - Female? People don’t believe - Disabled? there’s anything wrong - Religious? with you if you’ve got - Ever been unemployed/needed benefits? personality disorder.”

It takes considerable emotional resilience to deal with Personality disorder has been people making judgements and assumptions about you. called ‘a very sticky label’.When For someone who already feels vulnerable and like an it comes to personality, people outsider who does not ‘fit’, as many people with personality often assume that we cannot disorder do, then it can be very difficult to face stigma. change,‘the leopard can’t change its spots’. Actually, we know that people can change very considerably, sometimes “I became a ‘services leper’. I was told by the through professional help, but psychiatrist I had been blacklisted. After the also through forming helpful relationships, having good diagnosis was made I felt excluded. There was experiences, and through the a general unwillingness to help and I was passage of time. But, once refused treatment.” someone has that label, it can be difficult to persuade others that they have changed.

24 BACKGROUND

The notion of treatability Why give a diagnosis of For many years, people given the diagnosis of personality disorder personality were regarded as ‘untreatable’ and were either excluded from services or severely marginalized within them. On the edges of disorder? services, psychotherapists and psychologists had been providing treatment to people who had problems associated with the While many people believe the diagnosis for many years. By the 1990s, evidence was beginning to diagnosis is not useful or valid, emerge from a number of research trials that some of these others feel a sense of relief on psychological treatments were effective. But generic mental receiving it.The label can be health services continued to regard the problems associated with stigmatizing but the diagnosis personality disorder as untreatable.This seems to be because the also helps some people to notion of treatability was largely defined medically within the 1983 make sense of their experience Mental Health Act. It meant treatable by medication. No one and enables them to put a thinks the psychological and emotional difficulties of personality name to things they grapple disorder can be cured by medication (though some aspects, like with but are difficult to symptoms of depression or anxiety, can be helped by medication). explain. Being given a So people with personality disorder were dealt a double blow: they diagnosis also enables people were stigmatized by a diagnosis that many experienced as to become more informed attacking of personal identity, and without access to any form of about different treatment help or treatment. options, what other people Over the last 10 years, this has changed to a degree. A have found helpful and about combination of government policy and some investment in the issues themselves. It can innovative specialist personality disorder services has increased also help people feel less the range of provision and gone some way towards improving alone, and more part of a accessibility (see Appendix 2 for links to policy documents that community of likeminded were important in bringing about change, such as ‘Personality others. It enables people to Disorder: No longer a diagnosis of exclusion’). However, provision seek out peer support and and accessibility remain extremely patchy.Where a person lives still connect with others who have determines whether they can get treatment and support from a shared experience, which can statutory services. be extremely powerful.Where there is local specialist service provision, a diagnosis is also the key to unlocking this.

25 Specialist personality disorder It matters how a diagnosis is given treatment services almost always have entry criteria which include a formal Research carried out by Emergence in partnership with St. diagnosis. For these reasons, George’s University (Turner et al, 2011) shows that how individuals the diagnosis can be helpful receive and understand their diagnosis has a direct bearing on and useful for some people. their aspirations and expectations of recovery, often limiting their hopes. Some of the quotations in this section were taken from two “I was pleased and research studies interviewing service users carried out in North relieved to have the East Essex in 1999 and 2009.When asked how they discovered diagnosis of PD. I had they had been given a diagnosis of personality disorder, many read about it and it was people had made this discovery indirectly from records, reports, like I was reading about or at social services meetings. Others appeared to have been told about the diagnosis after many years; yet others were told me. It always felt as if by professionals only after they asked. I had more than Reactions to finding out about the diagnosis included anger, depression, and when feeling insulted, feeling blamed, depressed, anxious, daft, I found out about PD abnormal, numb, bewildered, mystified, helpless, shocked I knew that I was not and excluded. the only one who had these wacky moods and “At the review nobody took time to explain the weird things going on in diagnosis to me and all the discussions took place my head. I have joined a about me, but not involving me. I remember feeling support group and know numb and bewildered, as if everyone knew except that I am not mad ‘cos me. I felt as if there was little or no hope for me.” there are others just like me and they are okay, “After I was discharged I opened a letter from my so I might be as well.” psychiatrist to the GP. It said it there. I was a bit stumped, shocked. I’d heard about people that had been diagnosed with personality disorder being the black sheep of the community. It made me feel I didn’t belong anywhere.”

26 BACKGROUND

For many years, because of It’s not the label that matters but what the controversy about the diagnosis, some practitioners happens afterwards. have chosen not to share the diagnosis with the service user. ‘‘They have given me the label Borderline Personality Although there are challenges Disorder. I don’t seem to be getting a referral to any to giving people this diagnosis, if someone has been formally kind of service, or any help that I need. After years of diagnosed with personality desperation, of suicide attempts, hospital admissions disorder, we recommend and a body pumped full of medication they have sharing this information with given me this label and walked away.” the individual themselves. Many of the benefits of having a diagnosis are only “My brother is now in his 50’s and has suffered all his available if it is shared with adult life with OCD and PD. Good PD services are not the service user, such as available in the area in which he lives so he has had feeling less alone, being able to ‘make do’ with a weekly general mental health to find out more about the group which keeps him ‘well enough to work’ but difficulties and how others have survived similar does not address underlying issues. I am sure that, experiences. One of the should good services have been available, he would key elements of working now be living a much more worthwhile and fulfilled effectively with people with life, rather than just existing from day to day.” these difficulties is an emphasis on the relationship between staff and service There is now a view that if the label has some advantages, it can user. Service users cannot be tolerated, as long as the person is informed of the diagnosis make informed choices or in a way that feels supportive and informative.When giving the work in partnership with diagnosis or discussing it with a service user, it is helpful to refer staff to develop support to the controversy surrounding it, and the discomfort many plans/formulations and so people feel in using it. Explaining that it is actually shorthand on, if their diagnosis is hidden for ‘complex and long term emotional and psychological from them. difficulties’ and does not imply any judgment or blame, is likely to be reassuring, especially if accompanied by an offer of appropriate treatment and support.

27 “Being in a place where • Give people time to ask I thought my only questions and talk through option was death, I was what the diagnosis means. so grateful when I was • Provide information that people told (a) I possible have can take away with them and read over later (Emergence Personality Disorder (PD) and Mind both have leaflets and (b) that Complex for service users about what Needs exists and they the diagnosis means). could help me. I cannot • People might not be able to stress enough that take in information if they being told that gave are upset about the me such hope.” diagnosis, so try to offer opportunities for further discussion at a later date. Supporting • Acknowledge that not everyone agrees with someone through the diagnosis and it is just the process of one way to understand receiving the their difficulties. • Remind people that they are diagnosis no different now they have the diagnosis than they were Whether or not the person before – being given a understands the meaning of diagnosis doesn’t change the diagnosis they have been who you are. given, they are probably aware • Provide information about of its stigmatising effect and service user groups and will likely need support to organisations where they process being given the can meet other people diagnosis. Regardless of your with the same diagnosis role, individuals may well want if they want to (e.g. to talk this through with you Emergence, STARS, online so here are some ideas to forums). For a list of support the process: resources see Appendix 2.

28 Learning points from Chapter 2

Personality disorder does not mean that someone cannot be treated, nor that they should be excluded from mental health services — The way in which a person finds out about their diagnosis has an impact on their view of their future, but many people are not told about it and instead find out ‘accidentally’. — How a person is given a diagnosis, and what happens afterwards, can make all the difference between someone feeling recognised and helped, or labelled and stigmatised. — A diagnosis can be the key to unlocking a range of help and support, but it has also been used as a key to lock doors to keep people out of services. — Whatever your role, you may be able to help a person to talk through how they feel about their diagnosis, and to access appropriate support and help.

29 3 How does personality disorder develop? We have difficulty in agreeing what a personality disorder is, so it is even more difficult to be sure about its causes. In fact, rather than thinking in terms of causes, it makes more sense to think in terms of factors that make it more likely that a person will develop a personality disorder. BACKGROUND

Most professionals agree that the most helpful approach to understanding the development of personality disorder is the biopsychosocial model. This is based on the idea that three types of factors interact to give rise to personality disorder: • Biological sensitivities (‘bio’). • Early childhood experiences with important others (‘psycho’). • Broader social and environmental factors, including school, neighbourhood and culture (‘social’).

It is often thought that What is biological This is part of what we mean by trauma and different types sensitivity? differences in temperament, or of abuse ‘cause’ personality basic personality predispositions. disorder because these It is thought that about half experiences figure This refers to characteristics of of the variation between prominently in the histories the individual’s nervous system people in basic temperamental and narratives of people that are present at birth, and or personality characteristics is receiving help for personality are usually genetically due to genetic differences. So disorder. However, it has inherited.The human nervous that equivalent adverse life events become clearer from the system is not a machine that can be experienced quite results of community studies passively responds to inputs differently by different people. that some people suffer from the environment.The For example, two twelve year old abuse and trauma and do not brain actively organizes boys, Liam and Danny, both live go on to develop personality incoming information in a way alone with their mothers who disorder. It is also true that that substantially affects have developed serious problems some people with personality whether and how an event is with alcohol. Liam who has an disorder have not experienced experienced. Individuals vary in outgoing, easy temperament, significant abuse and trauma their brain’s sensitivity and may notices when his mother is during childhood. Negative attend to, select and register starting to drink to excess and or adverse early experiences the same events very keeps out of her way, staying may be much more likely to differently. For example, one late at school, and inviting give rise to negative person might feel devastated himself to friends for consequences in a person and rejected if they arrived for sleepovers. Danny, who is much who is biologically sensitive. a doctor’s appointment and more shy, withdraws into himself, found that the doctor had left hides out in his bedroom playing already; for another, this might computer games, and dreads be experienced as a small seeing his mother out-of-control irritation and a nuisance. when she neglects herself and is verbally abusive to him.

31 Liam makes use of whatever Person-environment interactions good support he can find; Danny may be more likely to suffer long term harm from Understanding that babies and children have personality this difficult situation. predispositions right from the start, we can see that the responses of caregivers will, at least partly, be determined by the behaviour of You may have observed the the infant. An infant who cries continuously, is difficult to soothe enormous temperamental and sleeps irregularly will evoke a different parental response than variations that can occur in a placid, cheerful baby who eats and sleeps predictably.The baby babies and young children that is difficult to soothe may bring out more irritability or feelings from the same family.This is of helplessness and unhappiness in the caregiver, than a baby who sometimes particularly evident is easier to care for.There is then an element of an individual child in non-identical twins, who influencing and shaping the environment, contributing to the creation are likely to have had similar of an environment that matches their personality, accentuating early experiences, but may be biological tendencies. However, this effect should not be overstated. very different temperamentally. Extreme environments can override any influence which the baby Research which follows might have on shaping the caregiver’s response. A caregiver who has children’s development for serious problems and is abusive or neglectful towards a baby or child several years has confirmed may behave in this way whatever the child is like.The main point is that children differ consistently that personality does not develop from birth in a straight, predictable in features such as their path, but is the outcome of interacting influences. People used to talk activity levels, their emotional about what proportion of our make-up is determined by ‘nature’and reactivity, their alertness what proportion by ‘nurture’.We now know that this is an over- and their adaptability to simplification and that ‘nature’and ‘nurture’interact in complex ways. change.These variations are almost certainly underpinned by biological differences in Early experiences with important others the brain.

Nearly everyone agrees that early experiences in childhood play a large part in determining personality development and, therefore, personality disorder.The earlier the experience, the stronger the impact. For example, a child of ten who is regularly left unattended for several hours, may suffer less long-term harm than a small baby that is regularly left unattended for long periods. Early experience can either accentuate or moderate biological predispositions. An infant with a tendency for high emotional reactivity can develop into a more or less reactive adult depending on the number and type of adverse events to which she is exposed and the type of caregiving provided; if she has a

32 BACKGROUND

soothing, responsive caregiver, Children who are repeatedly treated in an abusive way may develop a and does not experience any dismissive attitude, making out that it does not harm them; we can unusual trauma in childhood, think of this as their way of coping with something they cannot control. she may become a relatively They,like any other child,will be hurt and harmed by abusive treatment. calm child and adult; if she The care that a child receives can also be a positive factor, helping experiences neglect or abusive them to learn to deal with emotional situations and to solve problems. care, and/or a number of Caregiving that is loving, reliable, consistent and attuned to the needs disturbing traumatic events, she of the child will contribute to a personality type that can flexibly adapt may be prone to feel over- to new situations, can effectively regulate emotion and is strong whelmed by extreme emotions. and resilient in the face of life’s challenges. Caregiving that is Experiences that have a negative unpredictable, inconsistent, hostile, neglectful and exploitative can impact on personality can take engender a personality style that is anxious, avoidant, dependent and the form of either isolated,‘one- prone to reacting to problems in a way that can make them worse. off’ events or long-term and pervasive experiences. For example, one person may be Core childhood needs extremely traumatized and suffer long-term consequences from having witnessed one Much of our understanding of the link between early experience parent seriously injuring the and adult personality derives from clinical observation of children other parent. For another and adults for whom psychological and emotional difficulties have person, it may be the effect of arisen. On this basis, clinicians have suggested that children have being repeatedly criticized and a number of basic emotional needs. If these needs are not met, undermined by a parent that has personality difficulties are likely to follow.The psychologist Jeffrey a long-term impact on their Young suggests that the core needs of the child are: personality; being repeatedly undermined over a long period may add up to have a major impact on someone’s personality. Severely adverse events and experiences strongly affect SECURE ATTACHMENT TO OTHERS personality development (for safety, stability, because they provoke extreme nurturance and acceptance) anxiety which the child is not AUTONOMY (for competence and yet able to cope with. All types sense of identity) of emotional, physical and SPONTANEITY AND PLAY sexual abuse will have a strong REALISTIC LIMITS AND impact on a child, and count SELF-CONTROL as severely adverse events.

33 How does failure Therapists of different So infant behaviours such as persuasions have attempted crying or smiling are built-in to to meet core to provide explanations mainly the way our brains work, and needs contribute of the difficulties associated serve to keep the carer close to personality with the diagnosis of at hand and to make the borderline personality disorder. infant feel secure.This enables the child to learn through disorder? All explanations of the exploring the environment, development of personality confident that with the It may seem common sense to disorder take as their starting caregiver nearby, no harm will us in our psychologically- point the importance of the occur.When there is a threat oriented culture that a failure relationship between an infant of harm, the attachment to meet the emotional needs and a primary caregiver, usually system is activated and the of the child will lead to a parent, which is often called infant communicates to the problems in adulthood. But the ‘attachment relationship’. caregiver through crying or human societies have not seeking closeness. always seen it this way, historically or cross-culturally. Attachment theory A responsive carer will protect For example, some groups of the child by coming close people think that strictness and seeing what is wrong. and physical punishment will Attachment theory proposes An unavailable or insensitive produce well-behaved and that human babies come into care giver can leave the child obedient children; others think the world all ready to form a feeling frightened, or that this will produce angry strong attachment to a confused. For example, the and traumatised children. primary care giver during the caregiver who responds to first year of life. It is thought the child’s anxious calls by If we are attempting to that becoming emotionally becoming irritable with the provide treatment and attached to the caregiver child, may leave the child support to those with adult helps humans to survive and feeling that calling for a personality disorder, we need gives them an advantage.The caregiver at times of stress to understand more precisely closer the infant remains to the only makes things worse, so what people have experienced caregiver, the less likely he or that child may grow up that has shaped their she is to be vulnerable to threat avoiding close contact with personalities, and so leads or predation and the more others, particularly when they to outwardly difficult-to- likely the infant is to survive. feel at their most vulnerable. understand behaviour.

34 BACKGROUND

THE THEORY OF MENTALIZATION Broader social Anthony Bateman and Peter Fonagy have extended and environmental attachment theory to try to explain the problems associated with borderline personality disorder: emotional, relationship and factors identity instability.They have coined the term ‘mentalization’ to refer to an individual’s capacity to think about and reflect There are a range of factors on their own mental state (thoughts, emotions, action urges) that will contribute to the and the mental states of others.They believe that this is development of personality vulnerable to disruption in people with borderline personality disorder and these factors also disorder, leading them to quickly become over-aroused, when interact with each other, so they misinterpret the thoughts and feelings of others, and that there can be a circular therefore experience extreme ups and downs in relationships. quality to the process. A child Poorly established capacity for mentalization occurs when the who has been disturbed by attachment relationship has been inadequate to the child’s traumatic experiences or poor needs. A carer who bursts into tears when they see the baby care, may have difficulty crying will offer no comfort; the carer who expresses concern controlling his own behaviour through her eyes and her tone of voice, shows that she knows or emotions, and then be seen the baby is upset, but is not so upset herself that she is as ‘difficult’ or ‘demanding’, overwhelmed.The child takes this experience of a responsive and so evoke a negative carer into him or herself and can later in life become a good reaction from some teachers or ‘carer’ to him or herself.This gradually enables the child to family members.The social and manage their own emotions and to experience inner stability. cultural environment of the extended family, schools, peer Where the caregiver is unavailable, preoccupied or incapable of group, and community or responding sensitively and accurately, the child will internalize a religious groups, also play a response which does not match his feeling. For example, if the part, either for better or for carer laughs mockingly when the child cries, the child will worse.We know that one internalize a sense of an uncaring or dismissive ‘carer’. If there is good relationship with no internalized ‘in tune’carer, the infant will continue to feel someone like a grandparent anxious or upset, and, because the carer has not been able to or teacher can do a great deal soothe his anxiety, the anxiety may have a quality of being to offset the bad effects of impossible to think about or moderate. It feels like something a difficult home life. in the mind which does not quite belong to the self.This can lead to an urge to get rid of the experience. People who act Inequality, whether this be in impulsively or who self harm, often describe these behaviours terms of poverty, access to as a way of trying to get rid of an internal feeling of tension good schools and housing or that they cannot understand, can’t change, and can’t bear. social prejudice, can have a The child and the adult may then lack resilience in the face of major impact on people’s lives. life stress, and can be vulnerable to emotional collapse when, as often happens, further trauma occurs.

35 Our society values the Life course of personality disorder acquisition of wealth, and those who do not achieve this may feel that they have failed. It was once thought that people with personality disorder were unlikely We are also a competitive to recover. More recent research,following up people with borderline society. During childhood, the and antisocial personality disorder,suggests that there is a substantial testing and grading of children amount of positive change over time.The change occurs particularly in at school creates winners and the area of impulsive behaviour and emotional instability.It is likely that losers.We are also status this change is due to maturation. Over time,people become more able conscious. Social prejudice, on to predict the consequences of their actions,learn how to regulate the grounds of race, gender, their emotions and become more accepting of themselves. sexual orientation, religion However, it is still worth trying to help people with personality (and other characteristics), disorders.Without help, people can suffer for years and even despite our best efforts, decades, and their problems are likely to impact on the lives of those continues to be a powerful around them. Even though someone’s personality may mature, their force. For some unfortunate core dispositions appear to remain the same and may continue to individuals, biological create difficulties for them. Difficulties in relationships and a sensitivity, adverse early subjective sense of distress and dissatisfaction are likely to continue experience and social even if the person is less impulsive and emotionally unstable. marginalization line up to create a life course that leads to personality disorder. Recovery, or discovery?

In mental health services, the idea of ‘recovery’ has become very fashionable, with ‘recovery programmes’and ‘recovery teams’in some places.The recovery model is intended to counter pessimism about whether people can change, and to stress the possibility of someone being able to return to normal functioning and re-engagement with society.This idea has been developed with people with major mental illnesses. However, in the field of personality disorder, people have questioned the usefulness of this model. If someone has very longstanding problems they may never have experienced a level of ‘wellness’that they want to return to.Members of Emergence,a user led organisation for personality disorder, (Turner et al 2011) argue that the recovery model stresses people fitting in with society and engaging with the outside world,playing by its rules – that is,achieving ‘social inclusion’. For some people, this has been so traumatic in the past that this is not a path they want to follow. For example, they may prefer instead to turn to their inner world,perhaps pursuing creativity rather than fitting in.Turner et al suggest that the journey of someone with a personality disorder be thought of as ‘self discovery’ rather than ‘recovery’.

36 Learning points from Chapter 3

The child or baby will be affected by poor quality or abusive care, but the child’s temperament may also affect the way they are treated by others. — Experiences in childhood which are harmful may take the form of extreme and traumatic events, or more apparently low-key negative experiences repeated regularly over a long period of time. — Different cultures and at different times in history people have had different ideas about the best way to treat children. From observing the lives of people with personality disorder, we now have a clearer idea of the kinds of experiences that can be harmful, and the kinds of things that help children to develop flexible, resilient personalities. — Having a caregiver in childhood who attended to and thought about what we were feeling and experiencing, helps us to develop a reliable ability to think about our own emotions and those of others. — For some people, biological vulnerability, experiences in relation to caregivers, trauma and social disadvantage, add up to create a path towards personality disorder. — Good experiences in childhood in relation to key figures – teachers, parents, grandparents – can do a lot to build good attachment patterns and resilience. — Someone who has had lifelong problems may not be looking to ‘recover’ their previous functioning, but will be wanting to explore new ways of being,‘discovery’ not ‘ recovery’.

37 4 What can I do to make a difference? Providing therapy or counselling may not be part of your role, but every interaction with a service user that you have may be therapeutic. Social care, or personal care, or housing support, which is provided in a curious and compassionate way, may help a service user to feel cared for, hopeful and empowered rather than feeling frustrated, misunderstood and despairing. PRACTICAL GUIDANCE

RECEIVING GOOD CARE, IN WHATEVER SITUATION, CAN BE A TURNING POINT IN A PERSON’S LIFE.

It is very important, when working with a person with How can personal personality disorder, to be clear about what your ‘primary agency be task’ is. The primary task is what you are being employed to achieve by your organisation. If you are a housing support developed and worker, your primary task may be to help the service user to supported? obtain and maintain a housing tenancy. If you are a social worker in a children’s social care team, your primary task is to reduce the risk of harm to children in the family. If you are The most effective forms of a worker in a community mental health team your primary therapy for people with task may be to help the service user to reduce their personality disorder all tackle vulnerability to crises. this issue of personal agency, so we can learn from them how Whatever your primary task, it can be more difficult to achieve to develop and support it. when the service user has a personality disorder.Their anxieties about relationships may make it difficult to engage them with It helps to be explicit about the the primary task.Their problems in managing their behaviour primary task and clearly define are likely to affect the professional relationship. how you will both know when this has been achieved.This A worker needs additional capabilities, above and beyond the prevents a ‘drift’ in the direction core capabilities required for the primary task.These additional of general support (although capabilities centre on the relationship between service user and occasionally providing general worker.This needs to be one in which both parties recognise, support may actually be the openly acknowledge and support the development of personal primary task, particularly during agency for the service user. Personal agency means that the transitions or life-events). service user takes responsibility for their actions but in a context which is non-blaming, non-judgmental, and compassionate It is also very important to try towards the difficulties they have in doing this. to carefully position yourself in the relationship so that you are neither overly supportive nor overly demanding – expecting the service user to demonstrate more independence and competence than they are capable of at that point in time. Sometimes we call this being not too close and not too distant.

39 An overly supportive relationship (doing a lot for the service “I was in the preparation user) undermines autonomy, does not help to develop group for about a year, personal agency and risks encouraging dependence. It may but it probably took at also invite an overly strong attachment to the worker, leading to very intense emotions which get in the way of the primary least six months of task. An overly demanding relationship, on the other hand, is overdosing, self abuse, likely to lead to hostility or disengagement because the neglect and some major service user feels that the worker does not understand how tantrums at staff before hard it is for them to do what is being expected. So we need to occupy the middle ground between these two extremes. I was able to see that my care and more Another way of thinking about this is in terms of professional boundaries.We want to establish a importantly my recovery relationship that is warm, friendly, compassionate and non- is MY responsibility and judgmental. At the same time, the relationship has a it’s not up to the staff purpose and a time-frame, which is the achievement of the or my family to make primary task within a defined period of time. everything better, only I can. I’m sure it was at MIGHT HELP TO FOSTER MIGHT INTERFERE WITH THE that point that I was ‘PERSONAL AGENCY’ DEVELOPMENT OF THE SERVICE USER’S PERSONAL AGENCY then able to start to take control of my recovery • What help do you need • Leave it with me – I’ll sort to do this yourself? it out for you. and move forward.” • At what point do you get • Is there someone you can stuck filling in this form? So ask to do this for you? why don’t you do it up to • I was planning to take that point and then I can leave that day but if you help you think what to put really need me to go for that question. with you I could always • I don’t know any more about cancel that. this than you. Is it worth • You may not feel like doing it looking on the internet? but sometimes you have to • I wonder whether you are make yourself do things you more capable than you think don’t want to. you are. I remember when • You can’t go on expecting you did X and you felt you’d other people to do that for handled it very well. you – It’s time you did it • Is there something specific yourself. about this situation that makes you feel you won’t be able to do it? Is there a way round that?

40 PRACTICAL GUIDANCE

What might get in HOW CAN WE DEAL WITH OUR OWN AND OTHERS’ the way of achieving INTENSE EXPRESSIONS OF EMOTION? In order not to get caught up and overwhelmed by intense a boundaried feelings that the service user may have, it helps to be aware relationship? that they have strong feelings, and to ‘step back’ a bit. Allowing a slight psychological distance, makes it less likely that we will react thoughtlessly. It also enables us to Often what gets in the way of identify the emotion and put words to it. If you can’t tell achieving a boundaried exactly what the person is feeling, it helps to at least relationship is strong emotion acknowledge that they are feeling very stirred up or upset. and challenging behaviour on the part of both the service We need to identify our own emotions privately to ourselves – user and the worker.We know it is not usually helpful to tell the service user how their that people who may attract a behaviour makes you feel, but sometimes how we feel is a clue diagnosis of personality to how they are feeling. If you start to feel very frustrated disorder have difficulties with with them, for example, it may be that they are feeling very their emotions, their behaviour frustrated with you or the situation they are in.We need to and their relationships.This is help the service user to identity their feelings in an open and bound to emerge in the explicit way.This can best be achieved by adopting an attitude relationship with the worker. of curiosity about the service user’s emotions. If we talk with The direct expression of strong certainty (‘you are very angry’) this risks sounding patronizing emotion may evoke the same and overbearing. Saying ‘Something about this situation has in the worker. If a service user really got to you’or ‘We all feel angry when things don’t work gets very angry with a worker, out the way we want’is less judgmental and more comradely. maybe because they have not responded to a request, this COMMENTS THAT MAY HELP COMMENTS THAT MAY MAKE may make the worker feel very RESTORE COMMUNICATION THINGS WORSE WHEN anxious and lead to him/her SOMEONE IS ANGRY reacting by trying to calm the anger but in doing so the worker • Something about this situation • You can’t always get what may risk doing too much for has really upset you. you want. the service user in a way that • Can we think together what it • You know there is nothing interferes with the development is that has upset you so much. I can do about this. of personal agency. Conversely, • I’m sorry – I realize that would • Calm down. the worker may get angry and have been upsetting for you. • I’m not going to speak to behave accordingly, so that • I realize this is very frustrating you while you are shouting the service user feels for you but can we think at me. misunderstood and rejected. together about how to try • We’ve been here before and and sort it out, and how to my answer is the same as it avoid this happening again. was last time: I can’t do that. • I get the sense you are • Your behaviour is starting to feeling under tremendous make me very angry. pressure – is that right?

41 How can we deal But these boundaries need to sit • Taking overdoses of alongside an acknowledgement medication. with challenging that challenging behaviour behaviour? serves a function, either • Deliberately not taking emotionally for the service prescribed medication. user, or in the relationship • Misusing drugs or alcohol. Challenging behaviour in the between worker and service service user, usually in the • Hitting or punching oneself, user, and that the person form of self-harm or or head-banging. needs help to manage these aggression, is a problem for impulses in a different way. • Engaging in risky sexual the worker because it makes Sometimes one of the primary behaviours like unprotected them feel anxious or angry, tasks of a service will be to sex with strangers. and therefore less able to address these challenging respond in the interests of • Deliberately starving oneself behaviours with the service user the service user. It’s a problem or binge eating. and to think together about for the service user because what has triggered the • Deliberately consuming it can invite rejection from behaviour, what the service user substances that are the worker. It is also often is thinking and feeling at that poisonous or cause regretted afterwards, and it moment, and whether there is disgust or illness. can get in the way of someone a different way of dealing with Self-harm and suicide usually learning about themselves these thoughts and feelings or have different intentions; if and how to deal with their with similar situations. someone is self-harming they feelings constructively – with do not usually intend to kill ‘emotional growth’. themselves, though sometimes It helps if there is clarity about Self harm the behaviour can result in what the consequences are if accidental death. In fact, these challenging behaviours many people use self-harm ‘Self harm’ is when someone occur.This should be made explicit as a coping strategy to stop damages or injures his or her own in the service’s operational themselves committing body on purpose.There are many policy. For example, the service suicide. Regardless of the forms of self harm including: might have an explicit policy injury or degree of harm it is that verbal abuse of reception • Cutting, biting, burning or helpful to find out what the staff will not be tolerated, or picking at the skin. person intended, rather than that anyone cutting in the make assumptions. building will be sent to A&E.

42 PRACTICAL GUIDANCE

THERE ARE MANY REASONS “When I was self-harming or suicidal, although I may WHY PEOPLE SELF-HARM; not have realised it at that time, it was a call for help. HERE IS A SMALL SAMPLE I just wanted someone to care for me and love me OF EXPLANATIONS: and not to treat me like I was trouble and meaningless. • To get bad feelings ‘out’ When people used to say I was ‘attention seeking’ of the body (through bleeding or vomiting, they used to say it like I was being bad but I was for example). attention seeking because no-one ever paid me any • To help the person feel attention or cared for me.” in control if they are struggling with feeling You can see that it would be a mistake to put forward any one trapped, desperate reason why people self-harm.There are many reasons and and powerless, or out sometimes more than one reason will be operating at once.The of control. important message is to be curious about what has led a • To give a concrete form particular individual to do this at this particular time. to emotional pain. • To make the person feel alive when they feel Responding to self harm ‘dead’ or numb. • To relieve the tension of One of the things that gets in the way of workers responding lots of pent up emotion, compassionately to someone who has self-harmed is that it can like anger or hurt. make us feel angry that someone has done this to themselves, particularly when it may be our job to treat people who have • To engage people’s suffered through accidents or illness.The person who harms concern or to provoke themself seems to be making our job more difficult. But they are a response. suffering too. No-one does this to themselves if they feel they can • To bring the person into express themselves or get what they need in other ways. the present when they Self-harm may also make us feel disgust, particularly when feel lost in bad memories someone has done something extreme.They may be very cut off of the past. from their feelings and feeling very little at that moment, but we • To protest about how feel the shock of the injury they have inflicted. It can sometimes they are being treated. feel like an assault on our own body. • To punish him or herself, At times someone self-harming can leave staff feeling very or others. anxious.We feel frightened that the injury is life-threatening, or that it signals that the person is at risk of suicide, or we are not sure what they may do next.

43 In all these situations, staff The NICE Guideline on Self Harm (2004) has specific advice on need to support each other to good practice for people working in primary care, emergency talk through these feelings, so departments, in secondary mental health services, and with that they can help the service older people as well as children and young people. user by being curious, www.nice.org.uk/cg16 concerned and practical: The Royal College of Psychiatrists also provide guidance for • Assess the risk associated staff from all settings, in responding effectively to self harm. with the injury and respond www.rcpsych.ac.uk/healthadvice/problemsdisorders/self-harm.aspx accordingly (for example, do they need an ambulance, or do they have a wound that “I remember being on the ward and having a dressing needs suturing?) put on a wound that I had caused myself. Although • What needs to be done everyone was very professional and were treating now to make the person it properly I think I wanted someone to ask me safe? (Do they still have about it: to ask me why I did it. I wonder if they pills or instruments that were afraid of what I might say.” could be used to harm themselves further?) • Is it possible to understand ical, curio what triggered this behaviour ct us ra , on this particular occasion? p co , n Has the situation that d c • e PRIMARY TASK e triggered this been resolved n r r n e e or are they still at risk? c d n , When the immediate situation o

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44 PRACTICAL GUIDANCE

HELPFUL THINGS TO APPROACHES THAT MAY “I couldn’t understand CONSIDER IF SOMEONE BE UNHELPFUL HAS SELF-HARMED my behaviour and why I reacted like I did and • Ask the individual if they know • Avoid saying things which the most helpful thing what would be helpful to them reinforce a sense of shame at that moment – but don’t and failure like,“oh but you for me was when I was assume that they will be able to were doing so well”,“It’s able to explore where tell you.They may not know. been so long I thought you’d stopped doing that”. that behaviour started • Try not to appear overwhelmed by the injury,but at the same • Avoid seeing this as not a and why I acted in time do not ignore or shut off real problem – “We’ve got those ways.” your own emotional response.If people here with real you do,you may come across as injuries to deal with cold and uncaring. you know”. • Even if the person does not • Avoid implying that the appear to be emotional,it may service user has done this Practical suggestions be helpful to acknowledge that by choice to ‘get attention’. they may feel very upset or for helpful ways • If you have a negative stirred up. emotional reaction to to respond to • If you need to touch the person someone who has self- to treat an injury,remember that harmed, but don’t step someone who they may have a history of being back and reflect on this, has self harmed abused or assaulted;explain you may subtly what you are doing and why. communicate your negative feelings to them and risk • Ask whether there is a friend or Evidence suggests that the making them feel worse. someone they would like to have attitudes and behaviour of with them while receiving staff towards people who physical treatment. self harm is the most significant factor affecting their experience of care. In thinking about dealing with challenging behaviour we have explored why it can be so difficult to respond well; an empathic and non-judgemental approach is crucial.

45 There are different approaches to helping people who self-harm frequently:

HARM MINIMISATION One view is that trying to make people stop self-harming by reducing access to harmful objects can actually make injuries worse. Many people who self-harm do so regularly and have a routine to their behaviour which keeps risk at a level they are familiar with. If people’s usual methods are removed, they can resort to other, more dangerous methods of self- harm.Working with people to support them to minimise risk, and explore alternative coping strategies and distraction techniques may be more helpful. If we understand that self- harm serves an emotional function, exploring alternative ways for that function to be met is crucial to reducing self- harm.

ALTERNATIVE APPROACHES TO SELF HARM Some therapies, such as DBT, collaboratively establish with the service user how to work with them to reduce the likelihood that that will have urges to self harm, and explore alternative strategies to coping with any urges, and managing difficult emotions.This may also involve agreeing how to limit access to the means of self harming (tablets, blades, etc).

46 Learning points from Chapter 4

Be clear about what the purpose of your meetings with the service user is: the primary task. — Whatever your primary task, your relationship needs to support the service user’s personal agency; this can best be achieved by establishing a relationship that occupies the middle ground between support and demand. — The management of high levels of emotion requires awareness, identification and naming. — You and your service user need to be clear about the limits of your tolerance of challenging behaviour. Always remember that challenging behaviour serves an emotional and interpersonal function. Your service user may need help to do things differently. — When someone has self-harmed, attending to any immediate dangers from injury or self-poisoning should be a first step. — The person may not always know why they have self-harmed, but being curious and concerned, and attending to their physical health needs with sensitivity is always helpful; think with them how to find alternative coping strategies.

47 5 What help might be available? How do we know when someone needs help? People with the problems of personality disorder may first present as needing help in a range of places. PRACTICAL GUIDANCE

Here are some examples In any of these situations, an interview with a worker who of places people may has a basic awareness of personality disorder should raise the first present: question for the worker of whether the person has personality • At the GP with physical difficulties that are contributing to their other problems, and symptoms. People with if so, how they can be helped. personality disorder Most people with personality disorders will never access specialist often have significant help, but will rely on support from friends, relatives, their GP,and physical health problems. other agencies such as religious organisations, voluntary People can also experience agencies, or social services. But people with severe problems physical symptoms, which, associated with personality disorder require timely and effective on thorough investigation, help, possibly from a range of agencies. do not have any obvious medical explanation. The services available will vary from one area to another. It is a good idea to find out what is available in your locality, and how • To drug and alcohol services. you can help people to access different kinds of help. Not everyone • In the criminal justice wants to be seen by doctors or professionals; many people prefer system with convictions self-help or voluntary agencies and for others a combination is for repeated crimes such helpful. It is important therefore to take into account what the as theft or assault. person has tried already, what appeals to them, and whether there are forms of help that they want to avoid. • Being homeless and sleeping rough. • To mental health services. What might be available? • To A&E with repeated self-harm. 1) SELF-HELP, VOLUNTARY AGENCIES AND SOCIAL SUPPORT • To eating disorder services with anorexia or Voluntary sector organisations and self help resources can be key bulimia, or obesity that to enabling people to build resilience and reduce isolation. It is poses a threat to health. often helpful to gather together information about a range of resources for people to be able to choose what they feel might be Through a social services • helpful to them at any one time.This might include: safeguarding alert for lack of self-care or vulnerability • Websites, online forums, and phone lines can provide both to exploitation. information and support. A list of useful websites is in Appendix 2. • To friends when in crisis, • Details of voluntary sector organisations in your area which offer who then recognise support and information. Although there are only a few which focus that there is some on personality disorder, many offer support and activities regardless underlying problem. of diagnosis.These can be often be found at your local Community Voluntary Sector Centre, local service user group, within mental • People finding out health NHS Trust websites or through a simple online search. about it for themselves on the internet.

49 • Peer support/social activities. Spending time with others who Secondary mental share similar experiences can be immensely powerful in generating health services hope, learning new coping strategies and making connections Access to these services almost with others.The availability of peer support varies across the always requires a referral by country, but your local mental health Trust or service user group the person’s GP.Some mental might be able to signpost you to a group/organisation. health services have a specific • Books. For many who struggle with being among other people, team working with people with books provide an ideal way of finding out more about the complex needs or personality diagnosis, reading of other people’s experience, developing disorders; in other areas, self understanding and new coping strategies. A list of useful generic teams may work with literature is available in Appendix 2. people with a range of different problems, but within • Wellness Recovery Action Plan (WRAP).This is an international the team there will usually be resource to support people to think through and develop personal workers with special expertise resources and tools which can be used in situations which the in personality disorder. individual finds difficult. It is designed by people with lived experience of mental distress and there is now also a WRAP app available. When someone first has More information is available at: www.mentalhealthrecovery.com contact with a mental health team, the first step will usually be an initial appointment or 2) LOCAL MENTAL HEALTH SERVICES assessment, when the worker, who may be a mental health Improving Access to Psychological Therapies (IAPT) nurse, a psychologist, a social The most easily available and least intensive form of help for mental worker or a psychiatrist, tries to health problems is the short-term therapies provided within IAPT get a picture of the person’s services.These interventions may be for a very short period of time difficulties including their (4-6 weeks), or medium term (16-20 weeks), depending on the childhood history, the history severity of the problems.They are usually fairly practical of the problems and what help interventions designed to treat anxiety and depression.They are has already been tried.They available through self-referral or referral by a GP.Some people with may draw on information from personality disorders may benefit from this type of help, if they are relatives, friends or carers, or experiencing anxiety and/or depression and their personality they may use some structured difficulties are not too severe. For others, particularly those who measures like standardised have difficulties in relationships, such short-term treatments may be interviews or questionnaires unhelpful. Short-term treatments are very unlikely to help the person to add to this picture.This to change their underlying personality difficulties, but may well bring information is put together so to the surface very difficult issues without the space to safely explore as to allow a care plan to be these. As a result, treatments of 3 months or less are not recommended collaboratively developed with by the NICE guidelines for people with borderline personality disorder. the service user. It is advisable for anyone with more severe personality difficulties to seek help at the next level up, from secondary mental health services.

50 PRACTICAL GUIDANCE

Some teams will put quite a would like their life to be, what 3) SPECIALIST PSYCHOLOGICAL lot of emphasis on arriving at problems need to be resolved THERAPIES FOR a diagnosis (see Chapter 2 to achieve this, and how to PERSONALITY DISORDER. ‘Why is the diagnosis so approach solving these Psychological therapies or controversial?’), while others problems. It treats the service ‘talking therapies’ for will put more emphasis on user as an active and personality disorder all share arriving at a plan with the responsible participant in their some common elements: service user about what the care, not as a passive recipient issues are that they need help and is, therefore, very much a • Recognizing the influence with. If the service user is collaborative, shared of the past on the present. unhappy about the way enterprise. It may involve some The therapy will take into they are being described or motivational work, and some account the individual’s treated, it is usually helpful help in managing intense history, their experience of to speak up and to try and emotions and impulsive close relationships in early have a conversation about behaviour. Sometimes service childhood, the patterns of their concerns. users attend problem solving relating which they have groups as well as one to one established, and the impact on appointments. them of any trauma they have Structured clinical experienced, particularly management, or The care plan should always when growing up. structured clinical care include a crisis plan so that if the person experiences a • Acknowledging and Current best practice in worsening of their problems, working with difficulties relation to standard care for they and other people involved in engagement. Someone someone with complex needs in their care, have an who struggles with forming or personality disorder is agreement about how to or sustaining relationships,or ‘structured clinical manage this, and where they who often feels hurt, management’ or ‘structured should turn for help if they threatened or misunderstood clinical care’.This is different can’t manage on their own. in relationships, will often from some traditional mental find it difficult to make a health care approaches. It is For many service users, relationship with a person structured, involves regular structured clinical care provides who is trying to help them. agreed appointments, is time- an effective way to meet their The worker will need to be limited (even though possibly needs and support their compassionate and have of long duration) and seeks to progress at a comfortable an understanding of the establish agreement with the pace. For other people, more service user’s anxieties about service user about what they intensive treatment might be seeking help and to be able would like to get out of their needed and specific to work with the conflicting care.This would include psychological therapies may feelings which the person thinking about how they be considered. has about seeking help.

51 Many people want help, yet “I knew I needed help, I asked for help but when I got a also fear getting involved or social worker I didn’t trust them to be able to understand dependent, and this may or care about me. For a long time I was testing her to lead them to feel hostile towards someone who is see how she responded and even after that went offering help.The worker through phases of drawing her in and pushing her needs to be able to away. My whole life experience up ‘til then had understand what lies behind taught me that other people couldn’t cope with my apparent reactions of hostility or lack of interest emotions and getting close to someone would cause on the part of the service me pain. My behaviour exasperated my social worker user.Workers will also need so much, she did what I had always expected her to to have the skill to work and handed me over to someone else in the team, constructively with a service with a warning that I was difficult, i.e. she left.” user when something seems to have gone wrong or the person disengages from the • Helping people shift from action to thought. People with personality therapy or the service. disorders may at times resort to action when they cannot bear to think about their feelings, or don’t know what to do with their • Knowledge of self and feelings.This may be particularly true of people with more ‘impulsive’ other. Staff working with personality disorders like borderline or antisocial personality disorder. people with personality Someone who feels they have been shown up and humiliated may disorders need to be good at become very angry or violent; someone who feels very pent up and understanding others, but distressed may harm themselves because they don’t know what else also need to have a good to do,and they find that self-harm gives a feeling of release or relief. knowledge of themselves. Psychological therapies for people with personality disorders usually People with personality include ways of helping the person to think about, and speak disorders are often very about their feelings, rather than expressing them through actions. sensitive to the way others treat them, and workers • Understanding and managing transitions, endings and loss. need to be aware of how If someone has a history of being rejected or abandoned, or they, the worker, comes feeling unsafe in relationships, he or she may find endings of across and the impact they relationships particularly difficult. Any therapy for people with have on others. personality disorders will not only help people to cope with endings or losses they are facing or have experienced in their lives, but should also pay attention to how the service user will manage the end of the contact.With good quality psychological therapies, the ending of the therapy is planned in advance, the therapy is often longer than for other types of problems, and the therapist will pay attention to the range of feelings which the client has about ending, and where they will obtain support after the therapy has finished.

52 PRACTICAL GUIDANCE

Specific psychological There are also many other types of psychological therapy, beyond therapies that may be helpful those listed here. In particular, there are newer treatments which do not yet have an evidence base but may still be helpful. There are a number of psychological therapies which A brief description of the psychological therapies that may be have been shown in research available is included in Appendix 1. trials to help people with A service user will not always be ready to use therapy that is personality disorders. Almost all offered at the point when it is first made available. Establishing of this research has been done a good working relationship with the service user, and providing with people with borderline them with a good experience of engagement, will provide the personality disorder.There is best foundation for any treatment. Building trust, confidence very little research on and optimism for change can be crucial foundation stones, treatments for other forms of especially for someone who has had few good experiences of personality disorder, which engaging with other people in caring roles, or with professionals. does not mean that they Building these foundations for constructive engagement and cannot be treated, it just development is something that everyone can contribute to. means that we have to rely The Enabling Environments initiative can help to create a culture on ‘practice-based evidence’ – within an organisation where service users can start to feel that is, the experience of listened to, respected, and eventually, safe. practitioners and clinicians in knowing what is likely to be helpful.The therapies outlined 4) THERAPEUTIC ENVIRONMENTS in Appendix 1 can be offered It is likely that the ‘atmosphere’ or ‘culture’ of a service has an by a range of professionals impact on whether people engage and stay, or feel out-of-place with different trainings – and leave.Words which describe a helpful culture in ordinary psychiatrists, psychologists, language are: welcoming, warm, informal, friendly, safe, open, nurses, psychotherapists and easy-going, belonging, non-judgemental, humane – and not: others – but usually they will stuffy, stiff, strict, harsh, bureaucratic, secretive, scary, have had some specialist intimidating or rigid. training in the particular form of therapy. Sometimes someone The Royal College of Psychiatrists Centre for Quality Improvement may be offered therapy that is has defined the values base for a healthy psychosocial not the exact therapy described environment in a project called ‘Enabling Environments’ (see in this guide, but is a variation www.enablingenvironments.com).The Enabling Environments Award of one of these therapies. is a quality mark given to services that can demonstrate they are achieving an outstanding level of best practice in creating and sustaining a positive and effective social environment. It would be good if all organizations providing health and social care became ‘Enabling Environments’.

53 ENABLING ENVIRONMENTS ARE: You can see similarities between these values and the • Places where positive relationships promote well-being ‘core childhood needs’ for all participants. proposed by Jeffrey Young and • Places where people experience a sense of belonging. described in Chapter 3 – the • Places where all people involved contribute to the growth need for secure attachment to and well-being of others. others (safety, belonging, involvement), autonomy • Places where people can learn new ways of relating. (communication,empowerment), • Places that recognise and respect the contributions of spontaneity and play all parties in helping relationships. (development, openness), and realistic limits and self-control How well would your organisation rate on these criteria? (boundaries, structure). It looks Would you be in a position to apply for this award? as though those experiences The Enabling Environments Award is based on core values that foster healthy that contribute to healthy relationships. The values are: development in children have 1) BELONGING – The nature and quality of relationships are adult equivalents that foster of primary importance. healthy organisations – organisations that encourage 2) BOUNDARIES – There are expectations of behaviour and the development of their processes to maintain and review them. service users and their staff. 3) COMMUNICATION – It is recognised that people There is more about the communicate in different ways. characteristics of healthy 4) DEVELOPMENT – There are opportunities to be organisations in Chapter 7. spontaneous and try new things. 5) INVOLVEMENT – Everyone shares responsibility for the environment. What do the NICE 6) SAFETY – Support is available for everyone. guidelines advise? 7) STRUCTURE – Engagement and purposeful activity is actively encouraged. ‘NICE’ Guidelines4 have been 8) EMPOWERMENT – Power and authority are open to discussion. developed for common 9) LEADERSHIP – Leadership takes responsibility for the conditions treated within the environment being enabling. NHS, to summarise the research evidence and to 10) OPENNESS – External relationships are sought recommend best practice in and valued. treating different conditions. So far NICE Guidelines have only been produced for two personality disorders,

4 National Institute for Clinical Excellence (‘NICE’) Guidelines (Clinical Guideline 77 on Antisocial personality Disorder, 2009; Clinical Guideline 78 on Borderline Personality Disorder, 2009)

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borderline and antisocial experienced rejection, Develop comprehensive personality disorder which are abuse and trauma, and multidisciplinary care plans in the most commonly recognised encountered stigma. collaboration with the service personality disorders. user (and their family or carers, • Do not use brief where agreed with the psychological interventions person). The care plan should: BORDERLINE PERSONALITY of less than 3 months duration. DISORDER Identify clearly the roles • Drug treatment should not • and responsibilities of all NICE reviewed all the published be used specifically for health and social care evidence for treatment of borderline personality professionals involved. Borderline Personality Disorder disorder or for the individual and produced guidelines in symptoms or behaviour • Identify manageable short- 2009.The overall result of the associated with the disorder. term treatment aims and literature search was that specify steps that the • Work in partnership with there was not enough person and others might people with borderline evidence yet to be able to say take to achieve them. personality disorder to definitely what treatment or develop their autonomy • Identify long-term goals, treatments should be offered and promote choice. including those relating to for borderline personality employment and disorder, although some • Fears of abandonment and occupation, that the person looked promising. It confirmed previous experiences of would like to achieve, which the government’s position that unsatisfactory endings mean should underpin the overall ‘personality disorder IS treatable’ that many people with long-term treatment and made suggestions for borderline personality disorder strategy; these goals should further research. find the ending of treatment be realistic, and linked to the or discharge from a service Here are some of the points short-term treatment aims. especially challenging. raised by NICE as relevant to • Develop a crisis plan that practitioners working with • Specialist services should identifies potential triggers borderline personality disorder: not be restrictive and that could lead to a crisis, should offer more than Explore treatment options specifies self-management • one type of intervention to in an atmosphere of hope strategies likely to be meet the predominantly and optimism, explaining effective and establishes complex needs of service that recovery is possible how to access services users and allow for and attainable. (including a list of support flexibility and choice. numbers for out-of-hours • Build a trusting relationship, teams and crisis teams) work in an open, engaging when self-management and non-judgemental CARE PLANS strategies alone are manner, and be consistent Here are recommendations not enough. and reliable. from the NICE Guideline for Be shared with the GP • Bear in mind that many how suitable care plans • and the service user. people will have should be developed:

55 ANTISOCIAL PERSONALITY • People with ASPD tend to be aggression, anger and DISORDER excluded from services and impulsivity. Pharmacological interventions for comorbid Antisocial personality disorder staff should work actively mental disorders, in is often linked in people’s to engage them. particular depression minds with criminal behaviour, • Positive and reinforcing and anxiety, should be in and around 50% of people in approaches to treatment line with recommendations prisons might meet criteria for are more likely to be helpful in the relevant NICE antisocial personality disorder; than those that are clinical guideline. however, only 47% of the negative or punitive. people who meet criteria for As yet there is limited evidence antisocial personality have • Work in partnership with about effective treatments for significant arrest records (NICE people with ASPD in order to antisocial personality disorder. CG77, 2009). develop their autonomy by This does not mean that encouraging them to be ‘nothing works’, only that this The companion guide to this actively involved in finding group are less easily studied one,‘Working with Offenders solutions to their problems, than, say, people with anxiety with Personality Disorders in even when in crisis, and symptoms or depression, and the Community’ (Ministry of encouraging them to interventions have tended to Justice, 2011; www.justice.gov.uk) consider different treatment focus on reducing criminal contains a great deal of options or life choices behaviour rather than treating helpful information and advice available to them, and the the underlying personality about working with offenders consequences of choices difficulties. NICE recommend with personality disorders, that they make. group based cognitive and whether this is antisocial or behavioural interventions other personality disorders. • Provision of services for people with ASPD often focused on reducing offending Whether or not someone with involves significant inter- and other antisocial behaviour, antisocial personality disorder agency working. Pathways and to address problems such has a criminal record, all people between services should be as impulsivity and with antisocial personality clear, and communication interpersonal difficulties. disorder have mental health between organisations As more research is conducted needs, and antisocial personality should be effective. on helpful treatments for disorder is often co-morbid people with personality • Pharmacological with depression, anxiety and disorder, it may well be that interventions (drug alcohol and drug use. the recommendations for treatments) should not effective treatments for The NICE guideline for antisocial be routinely used for the people with ASPD will broaden personality disorder (ASPD) spells treatment of antisocial to include a wider range of out some recommendations for personality disorder or treatment options. good practice: associated behaviours of

56 Learning points from Chapter 5

Someone who struggles with forming and sustaining relationships will find it difficult to make a relationship with a person who is trying to help them, so the worker will need an understanding of the service user’s anxieties about seeking help. — It’s helpful to know what services are available in your locality for people with personality disorder. — Talk to the service user about what sort of help they would prefer – some people prefer to get help from voluntary agencies or online resources, whereas others may want professional or specialist help. — Medication is not recommended for the treatment of the two most common personality disorders, antisocial and borderline personality disorder, but it may be useful to treat symptoms such as depression or anxiety which are associated with the personality disorder or related disorders. — All psychological therapies for people with personality disorders take into account the childhood history of the person, difficulties they may have in engaging with therapy, as well as problems they may have around endings or moving on. — Care plans, developed with the service user, should include short and long-term goals as well as a crisis plan, and should normally be shared with the GP. — Contact with services should be medium or long-term, hopeful, collaborative and empowering.

57 6 Service user involvement What does the term ‘service user involvement’ mean? Service user involvement can take many forms, but all types of involvement are focused on ensuring that the views of people who use services help to shape the way we understand mental health and the services provided, leading to real, sustainable changes and improvements in those services. PRACTICAL GUIDANCE

There are many different What are the types of service user ways of doing this, but involvement? common examples include encouraging service users to be actively involved in their In practice, service user involvement in mental health services in own care, or to have a say or community settings can be applied across five main areas: an active role in the design, Service users involved in their own care: for example, someone’s own delivery and evaluation of view of their difficulties being taken into account in assessment, the mental health services. The service user having a say in their treatment and care plans, being principle which underpins this listened to in care planning meetings. You might think about this is that people with lived as a shift from doing things to people, to doing them with people. experience of mental health issues/using services have a In service planning and evaluation: for example, giving feedback valuable perspective; making on the service; taking part in focus groups; service users working a contribution in this way is as researchers to evaluate the service, membership in clinical beneficial both to that person governance and service development structures. and their development, and Recruitment and training of staff: service users sitting on staff beneficial to the development interview panels with an equal say to other members; facilitating of services. training; running staff inductions. Co-production is a term that is In service delivery: This might be through direct service delivery becoming increasingly popular. such as service users facilitating groups, working alongside It refers to a broad range of staff to co-facilitate assessments, providing service inductions. involvement activities where Another approach is to involve service users in reflective forums staff and service users enter for staff such as case management meetings, case formulations, into a collaborative complex case forums, group supervision. relationship, working together and recognising one another’s different skills and experience Approaches to involvement as equally valuable.This approach draws on the understanding that both staff As with any large, diverse group of people, there are widely varying and service users need to be views, experiences and ways of understanding personality disorder empowered to be able to work among service users. There is no single service user perspective. in partnership together. To overcome this sometimes people might ask for a service user ‘representative’, whose role is to represent others. If you choose a representative model it important to think about who the individual needs to represent (i.e. identify their constituency) and how they will gather the views and ideas of those they represent (e.g. through a service user group meeting or via a service user network).

59 What is unique and different in respect “How can I represent to service user involvement and others’ views when I have no way to personality disorder? access other service users, or only As highlighted in other chapters, many service users with a diagnosis become aware of the of personality disorder have complex histories of trauma, abuse, issues to be neglect or loss.These histories often go hand in hand with years discussed the day of chronic invalidation, rejection and simply not having their before the meeting?” experiences or opinions heard or respected. Some service users with personality disorder have also experienced turmoil or difficulties in their relationships with others, so their interactions with mental health practitioners can often be fraught and Another approach to problematic.This has often led to individuals being described as involvement is to involve ‘difficult to work with’,‘attention seeking’,‘manipulative’ or those with specific experience ‘untreatable’ and frequently excluded from services. and skills and recognize that Due to these kind of experiences, many service users may mistrust this is valuable in itself. authority and service providers. For some who do speak up, their Sometimes people working to feedback or opinions are often minimized or dismissed outright this model are known as because of stigmatising or discriminatory views about personality experts by experience. Experts disorder; this serves to perpetuate feelings of invalidation and by Experience are valued in mistrust on both sides. their own right and asked to bring their own perspective to the table rather than representing others. “When I gave what I thought to be considered and There are also independent thoughtful feedback about the service I was service user led organizations receiving, it was immediately dismissed because which work collaboratively the common opinion amongst the service was that with those providing services all that service users with personality disorder do, in service development, is complain… One member of staff even said to evaluation, training and so on. me;‘well you would say that, that’s because you In thinking about involvement have personality disorder’, Another member of it is important to ask yourself staff said ‘it’s part of your pathology’ as if my what you hope to gain, and internal difficulties were the reason the service to use this to inform what was poor and not because of the service or the approach you take. trust’s failings.”

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It is extremely common for people with personality difficulties to Although the growth of struggle with problems of identity; many people find it impossible authentic and meaningful to hold onto a sense of who they are. As people progress through service user involvement in the treatment this can become more pronounced; as past coping field of personality disorder has strategies are left behind, people often ask ‘what’s left?’‘Who am been problematic, there is I if I’m no longer ‘a self harmer’ or ‘an alcoholic’ or ‘the crazy one?’ nonetheless room for immense Involvement activities can provide a space for people to begin to optimism when both the concepts explore new roles and ways of relating to people.This uncertainty of personality disorder and about identity is a core feature of the experience of personality involvement are understood disorder, so there is immense therapeutic potential in providing and worked with appropriately spaces where this can be experimented with. as Haigh et al (2007) describe: One of the most misunderstood aspects of personality disorder is that individuals who attract the diagnosis may be bright, articulate “Many users of services may have and have extremely high functioning sides alongside the poorer a complex history of abuse, functioning and the complex emotional difficulties associated neglect or rejection and the with their diagnosis.These ‘opposites’ can pose a number of opportunity to embark upon challenges for service users and practitioners alike. Sometimes activities that shape and direct there is surprise or shock at just how well someone can contribute: the services they receive promotes inclusion and therapeutic growth in itself. Many service users exceed “I was invited to sit on a clinical improvement group for expectations, not only in terms my community mental health team, chaired by the of their individual recovery, but senior medical consultant of the team. At the end of in their subsequent my first meeting, the consultant turned his head to me contributions to services and and said ‘I’m surprised, you made a very valuable their ability to sustain work and contribution to the meeting’, what did he expect a meaningful activity in the service user to do, sit and dribble in a corner? That future. The social implications comment made me realise that the expectations of are phenomenal and cover service users were low and involvement was a tick box numerous areas: pathways back exercise… they genuinely didn't expect a service user to work or education become could make a valuable contribution. I then went on to realistic; appropriate use of think, if this was the view of the head consultant, what other NHS services provides sort of example was he setting for the rest of the substantial financial saving; team? And no wonder the service was poor. I felt his problems with housing and back-handed compliment was humiliating and social services can be resolved; disrespectful and subsequently lost all hope in the offending behaviour reduced or service to help or understand me or others like me.” stopped; and most importantly the quality of life for the user improves dramatically, with new- found social inclusion and a life felt to be worth living.”

61 What are the everyone has a shared currently using a particular principles of good understanding of the role. service; for others it might be • What skills are needed? Most helpful if someone has service user involvement activities require moved on or graduated from involvement? skills of some sort – if you can the service. identify this at the beginning • Beware of ‘cherry picking’ you can help people decide individuals, and instead 1) SUPPORT whether they are right for identify what experience It’s important not to make the role, or go through a people need to have to assumptions, but to have an recruitment process, to avoid undertake the role. open, honest conversation difficulties later. about what someone might • What can be changed/ 5) DIVERSITY need to enable them to influenced and what are the In thinking about who to participate. Ask yourself and limits of the involvement? Be involve ensure you consider those involved: honest about the limits of the diversity of the population • What support might service users’ influence. you work with and try to someone need? This might be ensure involvement activities emotional support, but may 3) PAYMENT reflect this. It might be helpful also be practical support. It is widely accepted as good to ask yourself: • Who is the best person to practice to pay people for their • Who uses our service? Who is provide emotional support, involvement (except in their eligible to, but does not related to the involvement own care).This demonstrates access our service? activity, if needed? that the work of service users • Consider people from minority is valued and on a more equal ethnic communities, those 2) CLEAR EXPECTATIONS footing with the views and who identify as lesbian, gay opinions of staff. Provide realistic expectations or bisexual, gender, including for involvement – both to A good starting point is the those who identify as professionals and service/ report produced by the Mental transgendered, religious ex-service users. It may be Health Research Network (see groups and those with helpful to consider; Appendix 2) physical disabilities/ • Why do you want to involve sensory impairments. service users? 4) WHO TO INVOLVE? • Often it is helpful to adapt • Why does the service user Careful consideration needs to involvement activities so they want to get involved? be given to the question of are more appealing to those • What does the role entail? who to involve. It might be who might not generally join For example what is the time helpful to consider: in, for example, consider the location, linking in culturally commitment, responsibilities, • What type of personal appropriate creative details of the role? It is often experience is important? workshops, collaborating helpful to write a role Some involvement activities with community groups. description to ensure that are directed at those who are

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6) ISSUES OF POWER • Power differences can also arise from lots of other factors such There is an inherent power imbalance between people who use as age, gender, level of services and staff that provide the service.Traditionally most education and social class.These professional trainings and services were based on a view of staff equally need to be attended as holders of knowledge and expertise, and service users as ill, to and carefully considered. damaged, and therefore incapable. On a conscious level, many staff no longer believe this but services are usually framed with • Both staff and service users this model of ‘knowledgeable professional helper’ (staff) and benefit from reflective space ‘person to be fixed/helped’ (service user) at its core. where these issues can be honestly explored. • Meaningful involvement requires everyone to reconsider and try to step outside these roles. 7) FEEDBACK • Letting go of a position of ‘knowing’, which is so often a part of our professional identity, and inviting others to see our The process of involvement uncertainty, is often very unsettling and can be uncomfortable. does not end with the activity This can also be the case for service users; for some, inhabiting a itself; feeding back what has position of responsibility and authority will be a new experience happened as a result of service which challenges assumptions they may hold about their own users’ input is crucial. capabilities and identity. • We’ve all been in situations • This does not mean devaluing the expertise and knowledge which where we are asked our views staff have, but rather, recognising that service users have different and then hear nothing more – forms of expertise and knowledge.The potential of involvement it’s frustrating and prompts the to deliver change and improve services arises from bringing question, what was the point? together these two different types of knowledge and expertise. • Providing feedback helps to maintain involvement in future activity.

IDENTIFY INVOLVEMENT REVIEW THE OPPORTUNITIES PROCESS: WHAT WORKED WELL CONSIDER THE AND WHAT MIGHT NATURE OF THE YOU DO DIFFERENTLY ROLES/ACTIVITIES/ NEXT TIME? WHO/HOW

FEEDBACK WHAT HAS HAPPENED UNDERTAKE WITH THE CONSULTATION/ INFORMATION COLLABORATIVE GATHERED PROVIDE WORK SUPPORT AND PAYMENT AS NEEDED

63 What are the • It takes too much time! users will be strengthened Consulting others, working if service users feel that their challenges collaboratively, these do all views and contribution are associated with take time but try to think taken seriously. Involvement service user about the process as well as activities offer a chance to the end result – by involving see people in a different involvement? people well you are working role and to see their abilities towards your therapeutic and growth. aims as well as service Some of the named challenges development. to involving service users in BENEFITS FOR SERVICE USERS service design, development • It’s always the same people! Service users can feel and evaluation include: Welcome the input of empowered by getting involved regulars while continuing to • They’re unreliable! Stigma in this work, and it has been seek new people.Word of and discrimination can shown to strengthen self- mouth is the best way to underpin the belief that confidence and self-esteem. attract people – make people service users are ‘ill all the Peer support from other service want to get involved. time’ and therefore users can also contribute to unreliable. Service users do recovery.The increase in have considerable coping confidence, as well developing skills, strengths and What are the new skills, has led many service resources. benefits associated users into paid employment. Involvement offers an • They’re TOO well! On the with service user opportunity to explore new other hand, service users can roles and identities beyond be ‘too well’,‘too articulate’ involvement? that of service user. or ‘too vocal’. Some workers are often looking for the Involving service users in the ‘typical patient’,often development and running of someone who is passive and the mental health services “Evidence shows that will not challenge the system or they use has benefits for all: involving service the practitioner viewpoint service users, staff, services users with a and commissioners. • We can’t pay them! Does diagnosis of your organisation have a personality disorder policy in place for paying BENEFITS FOR SERVICES can be therapeutic service users? If you cannot AND STAFF itself, by improving pay people, how will you Staff can find out more about self-confidence and reward service users for their what service users want and input? There are other ways self-esteem.” can develop responsive to give back – can you organise services.The relationship a meeting around a working between staff and services lunch and provide food?

64 Learning points from Chapter 6

Service users with personality disorders have often had experiences of feeling mistreated or invalidated, both as they were growing up, and later if treated unhelpfully by services. — Becoming involved in contributing to services can enable the person to use their past experiences in a constructive way, to contribute to the review, evaluation, delivery and planning of services. — Service user involvement enables the service user to feel empowered, to try out new roles and to use their knowledge and skills, and may be a stepping stone to paid employment — Services benefit from attending to service users’views and perspectives,which are often refreshing, challenging and different — It is important that service user involvement is set up carefully, with thought about who to involve, establishing appropriate expectations, providing support when necessary, and payment or expenses if appropriate.

65 7 Surviving or thriving at work: what helps staff? All encounters with other people have the potential to leave us feeling fulfilled and engaged, or stirred up, unsettled, frustrated or depressed.Working with people with complex emotional needs or personality disorders is no different. PRACTICAL GUIDANCE

We all know that this work can be rewarding, engaging, often moving, sometimes funny, and ultimately very worthwhile. But personality difficulties shape how a person relates to others, and so the relationship between a worker and service user can be complicated. Because people with personality disorders have often had unhappy, difficult or traumatic experiences with those who were meant to care for them in childhood, they may be wary of people who try to help them in adulthood. This poses particular challenges for frontline staff who work with them.

On first impression, Everyone needs time and a service user who attracts Working with people in pain space to recognise, and a diagnosis of personality or distress is painful and process what they are feeling disorder may appear to reject distressing at times. It is not in relation to their work, and in help, or to be intent on harming always easy to admit to the particular, in relation to service him/herself or another person. feelings we may have users who stir up strong In fact, the service user who towards people we are feelings in the worker.This is appears to reject help may be meant to be trying to help. rather like digesting a meal: communicating that in her/his we need time to chew things Most frontline staff experience, ‘help’ can be over, reflect on them, come to (if they are honest) will abusive and should be treated terms with them, and take have encountered service with suspicion. Rejecting help in and learn from the users in relation to whom cannot be taken at face value. important lessons.With help at times they felt: This makes the work demanding from others, we can also work and stressful for staff. • Frustrated. out what are our own issues, and what might be an To be skilled at this kind of • Hopeless. understandable reaction to work, a person needs to be • Confused. the service user’s issues. emotionally affected by the • Anxious. work, but being affected by There are many ways of • Aware of uncomfortable the work may sometimes mean getting this support. parallels between the that we are overwhelmed, service user’s life and The work of trying to upset, or do not function as their own. understand these kinds of well at work as we would like feelings can be done in • Guilt that they are not to.This aspect of working with groups, such as reflective offering enough. people means that services practice groups or group need to be designed to provide • Angry and resentful that supervision, or through thinking spaces or reflective the service user seems discussions with a supervisor forums, where staff can ungrateful. or colleague. discuss feelings in relation to • Guilt – or relief – that their the task, roles and principles life is not so troubled as of the service. that of the service user.

67 Some professions, like Wellbeing and burnout counselling and psychotherapy, require trainees to have personal If we feel supported by the team, managers, and the organisation therapy so that the person in which we work, this can be extremely rewarding work. However, has an opportunity to explore staff who feel unsupported or confused about what is expected their own issues and their of them, or who feel that they are expected to do things for which reaction to the work while they are not equipped, can experience burnout. training. Some workplaces offer access to a limited Ask yourself the following questions to see whether you number of sessions might be suffering from burnout in relation to your work: of counselling every year to 1) Do I feel run down, drained and exhausted, without any employees.This can be a very obvious physical explanation like being unwell? helpful way of ‘digesting’ the challenges of your role. 2) Do I get irritated with my colleagues and team for no good reason? Talking to friends or partners outside work is not usually a 3) Am I sometimes less sympathetic with service users than good idea if what is stressing I should be? you is a particular client or 4) Do I talk about clients in a cynical or harsh way? service user, because of the 5) Am I feeling that there is more work to do than I can need to respect the possibly do? confidentiality of the service user. It is better to find someone within your ‘Well-being’ is feeling energetic and committed to what we are workplace, who is bound by doing, and feeling that we get satisfaction from our work.When the same rules as we experience well-being, we usually have the energy to engage confidentiality as you, a in a helpful way with service users, colleagues, and the job that friend, colleague or manager, needs to be done. to discuss problems in relation ‘Burnout’, on the other hand, occurs when there is an expectation to a particular service user. of someone being involved in difficult work that is not matched by them having a manageable workload or by them getting appropriate support and supervision. Organisations which allow staff to burn out are damaging not just for the staff member, but will ultimately not be helpful for the service user. If we as individuals, and the teams and organisations that we work in, do not recognise how stressful the work is sometimes, we may develop a particular set of defences to try and protect ourselves from this stress.These defences are understandable, and may assist us in the short term to feel better, but they do not create a helpful and constructive work culture that is sensitive to the needs of service users.

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Common defences against the distress What do you stirred up by getting involved in the work need in order to do this work? • Cutting off from service users and treating them in a distant, superior or critical way. Work in this area is demanding, • Retreating to the relative calm of paperwork or unnecessary and the business of providing staff meetings. services is complicated. Front- • Getting promoted to management roles where there is less line staff and their managers contact with service users. need to be working in teams which are functioning well • Passing cases on to someone else when you feel hopeless enough to: about being able to help. • Recognise (notice). • Becoming cynical about the work or resorting to ‘sick’ humour with colleagues. • Take in (digest). • Becoming very business-like and efficient but at the risk of • Make sense of (think about). being insensitive. • Decide how to respond When these defences get built into the culture of the (intervention decision). organisation, they can lead to rigid, distancing and inhuman Teams need to do this in practices.There have been some very high-profile examples of response to a variety of things going badly wrong in health service organizations and challenging situations on a care homes. But the factors that led to these and other daily, sometimes hourly, basis. profound human service failures exist in embryo in every service. These are ordinary human Every service needs ways of supporting its staff to cope with capacities but they can be being exposed to human pain and distress, and without such affected by the strains of safeguards, unhelpful practices may develop. doing the work and by problems within the STAFF TRAINING organisation. Organisations can design clear structures One particular programme, the Personality Disorder Knowledge but if the team is not attended and Understanding Framework (PDKUF) was commissioned by to with the same degree of the Department of Health and Ministry of Justice specifically to care, it will be difficult to get help staff working with people with personality disorders. It is the work done well. worth finding out whether there are PD KUF courses available to staff in your area. Individuals may access the PD KUF training individually, or book a course for their whole team.Teams that train together are more likely to develop helpful shared working practices.

69 CHECK OUT YOUR TEAM Developing your capacity to work with – HOW GOOD IS YOUR TEAM AT: people with personality disorders Recognising The qualities a worker needs, in order to work effectively in human Assessing the situation services, are rarely routinely developed in professional training ; for thoroughly; listening to example, trainings for many roles and professions are aimed at what is said, what is ‘what to do’, but not ‘how to be’.Yet it is this ‘how to be’ that is so communicated through important to the service user, and ultimately to the work which action, and the hidden the worker is able to carry out. Of course, the training in ‘what to messages about how do’, is important but how that is used will depend on the unique someone feels that may personality of the worker.Working with people with personality not be put into words; disorder does not suit everyone. Some people feel more at home attending to detail; seeing working with those who have different types of problems. the bigger picture (not just the service user’s difficulties Some of the qualities which are useful for someone working in but also their strengths as the field of personality disorder: well as their family, friends, • A strong enough sense of your own self. carers, dependent children). • Sufficient interest in and curiosity about others. Taking in and making sense • Ability to show compassion – empathy and kindness,without obligation. Discussing, reflecting, trying to understand complex and • Appreciation of the complexity of human beings. sometimes confusing or • Flexibility in relating to others. contradictory information, • The capacity to bounce-back from difficulties. considering alternative courses of action. • Clarity about boundaries and limits.

Deciding how to respond • The ability to be responsive without being reactive – taking personal comments seriously, without getting personal in response. Being clear among yourselves and with the • Ability to learn from experience, and to bear making mistakes. service user and other • Ability to be connected to someone but separate, so that you do involved agencies about a not intrude on them, nor let them intrude inappropriately on you. recommended course of action; recording and These qualities come and go in daily life: under conditions of stress communicating the plan or anxiety, people fall back on more inflexible ways of operating, taking into account and seek to push away discomfort and threats (and, sometimes, confidentiality and the responsibility too) by looking for simple solutions. It is useful, service user’s wishes, as therefore, to think in terms of people being in different states of well as who needs to know. mind – one like the state which allows for the qualities listed above, and a second state which is characterised by the more inflexible way of being, in response to stress or anxiety.

70 PRACTICAL GUIDANCE

It is possible to think of the Working in teams first state as being more or less ‘open’ to the complexities of life, and the second as being Working in teams (i.e. groups of three or more people focussed on more or less ‘closed’ or the same task) is the best possible way to deliver services to inflexible, as a way of coping people with complex psychological, social and behavioural with, or dealing with, life. difficulties. In a team we can share ideas, think together, support each other, share responsibility for difficult decisions, and make it Both states of mind have their more likely that somebody will be available who knows about a place in work and in life – there particular service user if they need urgent help. are times when more openness, is needed to foster All teams need to be clear about what they are doing, who is receptivity and mindfulness, going to do what, and agree how to go about it. If these things and times when more of an aren’t clear, workers will feel confused and service users are likely inflexible state is required, so to suffer. Because people with complex needs are often experiencing that decisions can be made confusion themselves, or may be very sensitive to neglect or and action can be taken. Most mistreatment, it becomes particularly important that teams are of the time, whether at work consistent and convey consistent messages to service users. or elsewhere, we all move back and forth, or ‘oscillate’, BEING CLEAR ABOUT THE TASK OF THE ORGANISATION between these states It benefits staff and the service user if services clearly describe These states of mind are part their purpose, or task, and the ways they go about this task. It is of what makes workers and also useful to describe what the task is NOT. In this way, the sense service users similar to each of limits, or boundaries, of the service can also be understood from other, but are also where the start. Services usually have an overall primary task, with difference arises: the worker different sub-tasks contributing to the main task. needs to be able to move more flexibly, and to respond to the immediate situation “My keyworker at the Vocational Support Service had appropriately, in order to be able trained as a counsellor, and he behaved as if he was to help the service user, who my counsellor, but I needed help to find and get onto may be more likely to get stuck a particular training course. I didn’t want to talk about in a particular way of thinking. things endlessly, I wanted to do something to make A worker’s capacity to function me feel better about myself. That’s what they told as well as possible at work, will depend a great deal on the me they would do with me. I left the service, because team and organisation in I couldn’t explain to anyone that I didn’t think he which they work, how this was doing the job he was supposed to be doing.” functions, and the support which this provides to each Service User individual worker.

71 “In this new team, we are ARE YOU CLEAR ABOUT THE TASK OF YOUR very clear about our ORGANISATION OR SERVICE? WOULD YOU BE ABLE primary task, but we are TO COMPLETE THE FOLLOWING SENTENCES? really struggling because different team members • My service exists in order to ... take different • There are services we don’t offer, like ... approaches to this task • There are people whose problems fall outside our – some workers remit.This would include ... approach the young • A mistake that people commonly make is to think people as if they cannot we do ... help themselves, and try to do everything for them, get involved in all aspects of their lives. Others take the view that the young people BUILDING A SHARED PICTURE have to be helped to Service users benefit if services have a clear and shared approach, take responsibility for an idea about how personality disorder develops, or how the personality of a human being becomes organised in ways that their situation. This seem to be different from what is expected by the community difference is very they live in. In other words it helps if services have a ‘model of the confusing for the people human mind’. who use our service, and There are a range of useful models of the development of it’s leading to a lot of personality disorder (see Chapter 3 How does personality conflict in the team.” disorder develop?). It will be important that the way the service thinks about personality disorder makes sense to the service user. Team Manager While it helps to have a shared, coherent view of personality disorder, it can be unhelpful if this becomes fixed or rigid. If you are working with a model in your service which seems fixed, like a kind of ‘bible’, you probably need to think about why such certainty is necessary. Sometimes it is hoped that sticking rigidly to one point of view will give workers a sense of safety and security, but often it makes a service less safe, as it cannot respond flexibly to different individuals, situations or needs.

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ORGANISATIONAL VALUES ROLES AND RESPONSIBILITIES AND CULTURES In addition to clarity about the task and values of the service, it It also benefits the service user helps if there is equal clarity about people’s roles and responsibilities. if the shared model or Within your organisation do you know who to turn to for advice approach is explicitly linked to or authority: an ethos, or set of values, which describes why the • If you need to go home early because you are unwell. service exists. An example of • If you think a particular service user needs additional help from a set of values can be found the normal service that you offer. in relation to the work of developing Enabling • If you think that someone is now ready to leave your service. Environments (see Enabling • If you discover an emergency situation at 4pm on a Environments in Chapter 5 Friday afternoon. What help might be • If you think one of your colleagues is over-involved with a client. available?). In the absence of a clear value-base, hidden or tacit assumptions can hold more power; the risk is that Even though it may take some time to establish clarity and these tacit assumptions can consistency of these features, taken together they can be destructive or discriminatory. begin to provide a reliable environment for service users, and a good working environment for staff. An example of a tacit assumption would be the These features of services offer a foundation for making unspoken idea that anyone decisions about work – such as what to do, when, how who has had one unsuccessful and where. attempt at treatment is bound to fail if offered a different form of treatment. If a service has an explicit policy that everyone’s needs will be assessed irrespective of their previous engagement with services, then everyone knows where they stand.Without such a policy there is a risk that someone who has had a negative experience with a previous service might be seen as ‘difficult’ and workers might avoid offering them help.

73 SUPPORT AND REFLECTION Teams need a place and a time to think together about the work.This enables members of a team to develop shared agreements about their task and values, and a shared model of the work.It also enables staff members to share with each other the challenging, difficult aspects of the work, as well as their successes. Shared decision-making about risk assessment and management reduces the burden on the individual. It also makes it more likely that decisions will be made in the long term interests of the service user, rather than to reduce the anxiety of a team member. A place and time to think is not a luxury, but a necessary part of the work. Each service has to develop its own versions of thinking spaces. Some examples of thinking spaces include: mindfulness groups; reflective practice groups; work discussion groups; supervision groups; case discussion forums.

74 Learning points from Chapter 7

Some people do not like working with people with personality disorders, and may not be suited to this work. There are staff members who feel more comfortable working with service users who are more obviously ‘ill’. — There are also many of us who like working with people with personality disorders, who we can see are similar to ourselves, except that people with personality problems have got particularly caught up in unhelpful patterns of thinking, feeling and behaving, often in response to trauma or difficulties in childhood. — Whatever the primary task of your organisation, and your role and responsibilities, it is likely that it is how you relate to people using your service, which will have a big impact on whether they benefit. — Being open to observing, engaging with, and thinking about the people you work with, will at times leave you exposed to feeling troubled, upset, anxious, confused, and frustrated. — To do this work, we need the support of teams, and clarity about what we are doing and how we are going to do it. Space to think, reflect, discuss, and get ideas and support, are essential to being able to do this work well, and being able to maintain wellbeing at work.

75 Appendix 1: Specific psychological people and feel very stirred up, their ability to mentalize therapies which may be available for breaks down and they make people with personality disorders inaccurate assumptions about others. In MBT the therapist adopts a non-judgemental, The availability of different therapies varies across localities, curious stance, and jointly with but these therapies are all in use in different parts of the UK. the client tries to understand No one area will have all of these therapies available, but one the client’s mental states, and or more of the following may be offered in your area through so aims to strengthen the mental health services, psychological therapies services, ‘IAPT client’s capacity to mentalize, for PD’ services, specialist personality disorder services, or even when they are stressed through voluntary or other agencies: or upset.

A) DIALECTICAL BEHAVIOURAL B) MENTALIZATION-BASED C) COGNITIVE ANALYTIC THERAPY (DBT) THERAPY (MBT) THERAPY (CAT) DBT is a highly structured MBT is a relatively new CAT is usually offered as a time- treatment, developed to treat approach which is gaining in limited one-to-one therapy, with particularly the suicidal and popularity.The standard MBT a course of 16 or 24 sessions. In self harming behaviour that approach is a combination of the first 4 or 5 sessions the can be a feature of Borderline individual and group therapy therapist will work with the Personality Disorder. It consists similar to the format of DBT. individual to arrive at an agreed of weekly individual therapy, In some cases, it can also be formulation of the person’s weekly group skills training, offered as a group or an problems, and will think of these and out of hours telephone individual therapy.The capacity in terms of repeating patterns in contact to support the service to ‘mentalize’ is the capacity relationships, and associated user in responding to to think about our own and coping strategies. Usually in CAT emotional crises. In the first others minds, in terms of this formulation is both written year or so of treatment the aim mental states, thought, down in the form of a letter from is to help the service user to feelings and intentions.We the therapist to the patient, and stabilise impulsive and life- learn how to mentalize by is drawn as a map showing how threatening behaviours by having other people, originally the person shifts from one state replacing them with emotion our caregivers in childhood, of mind to another. Once the regulation and distress think about us and what is in therapist and client have agreed tolerance skills.There is also an our minds. Some experiences, on the key issues which the emphasis on developing some particularly trauma, can person wants to address, these psychological distance from disrupt our capacity to become the ‘target problems’ difficult thoughts and emotions mentalize. Some people with to think about and to try and by the practice of mindfulness, personality disorders can change during the course of or learning to pay attention to mentalize quite well when they therapy. CAT emphasises that the experience of the present are feeling settled and stable, the relationship between the moment without judgement. but if they become attached to

76 therapist and client is a repeated patterns in the problematic behavioural collaborative one, working individual’s relationship with patterns. It is assumed that together to understand how the others which are unhelpful. In these core beliefs and client has come to develop their IGP,the exchanges between problematic behaviours particular relationship patterns members of the therapy group, developed as a result of often and coping strategies, and what and between the individual distressing and traumatic would enable them to change. and the therapist, are seen to childhood experiences, usually be an important source of with care givers. After the initial information about the key five or so sessions to develop D) TRANSFERENCE FOCUSSED themes which preoccupy that the formulation, the client and PSYCHOTHERAPY (TFP) individual.There is a focus on therapist work collaboratively TFP is one type of the conflict between the to develop new more adaptive psychodynamically-based person’s wishes (often for ways of thinking about self therapy that has been found comfort and care) and their and others and more effective to help people with BPD.TFP is expectations of others (often ways of coping. a one-to-one therapy that that they will be rejected or specifically focuses on the split abused).The therapy explores G) SCHEMA THERAPY (ST) in people with BPD between, where these wishes and on the one hand, their wish for expectations come from in the ST is primarily aimed at treating idealised, perfect care from person’s childhood history. those who have entrenched another person, and their difficulties, associated with a experience, which is often of diagnosis of personality F) COGNITIVE THERAPY very disappointing, neglectful disorder, in their sense of their FOR PERSONALITY or abusive treatment.TFP own identity, and in relating to DISORDERS (CBTPD) makes a point of recognising others.The approach assumes and addressing the aggression CBTpd is developed for the that personality difficulties and rage which may be felt treatment of borderline and develop from unmet core very acutely by people with antisocial personality emotional needs in childhood, BPD, and the ways in which this disorders. It is an effective leading to the development may be a response to short therapy for self-harming of unhelpful emotional and disappointment in relationships. and suicidal people with cognitive patterns called ‘Early borderline personality disorders Maladaptive Schemas’ (EMS). and for men with antisocial Problematic behaviours are E) INTERPERSONAL GROUP personality disorder who are thought to be driven by PSYCHOTHERAPY (IGP violent and living in the underlying schemas. According FOR BPD) community. CBTpd is delivered to the model, schemas have There are a range of individually in 30 sessions over different levels of severity and approaches to group therapy one year.Therapy is based on a pervasiveness.The more for people who might be written formulation, agreed entrenched the schema, the diagnosed with a personality between therapist and service greater number of situations disorder. IGP,like CAT, aims to user, focussing on core beliefs that activate it, the more identify and understand about self and others and intense the negative emotions

77 and the longer it lasts. It is Some localities have day The aim is that individuals assumed that everyone can hospital or day programmes, will be helped with their relate to at least some of the where people attend up to 5 own problems, but will schemas described in the days per week, usually for a also be empowered by model, although these may be programme of different discovering their capacity more rigid and extreme in therapeutic groups and to take responsibility and service users who seek activities such as art and to help others. treatment. Cognitive and music therapy. behavioural techniques are core aspects of the J) ARTS THERAPIES I) THERAPEUTIC intervention, but the model There are different forms of COMMUNITIES gives equal weight to emotion- arts therapy, most common are focused work, experiential TCs were started during art therapy, music therapy, techniques and the therapeutic World War II, as a way of drama therapy and dance relationship. ST is a normally a treating veterans who were movement therapy.They long-term intervention (2-3 psychologically traumatised by usually take place in a group years); even with people with war.Therapeutic communities and service users do not need less severe personality disorders, can be residential, or any prior experience, skills, or fewer than 20 sessions is sometimes run as a day abilities in the particular art. rarely enough.Therapy involves programme over a number of They are all based on the a gradual weakening of the days a week.They operate a principle of creating a safe and dysfunctional parts of the programme of different trusting environment where an personality structure through therapeutic groups and individual can access and the strengthening of the healthy, activities.TCs challenge the express strong emotions.They adult part of the person. rigid split which sometimes enable people to express exists between ‘professionals’ emotions non-verbally that and ‘patients’ and aim to work they might not otherwise feel H) INTENSIVE THERAPEUTIC as a community in which every able to express. PROGRAMMES member is seen to have a Most psychological therapies valuable contribution to make are provided on an out-patient to other people’s development. basis, with appointments once Service users usually have a say or twice weekly as in DBT and in day-to-day decision making in MBT Many people can about how the community is benefit from these run, and staff and service users approaches, but a few people will together make decisions find they struggle in the gap about handling crises, or when between appointments, and someone is ready to leave. need more intensive help.

78 Appendix 2: References and resources To find out about local mental health charities check the local phone book, contact MIND www.mind.org.uk to see if REFERENCES: The person’s GP may be able to they have an organisation in offer support themselves, or Moran, P.,Leese, M., Lee,T., your area, ask at a local GP refer the person to specialist Walters,P.,and Thornicroft, G. surgery or local library. mental health services. If the (2003) Standardised GP surgery is closed they will Emergence is a specialist assessment of personality – have an out of hours’ service service-user-led organisation Abbreviated Scale (SAPAS): that can be contacted instead. supporting all people preliminary validation of a affected by personality brief screen for personality The Samaritans are there disorder through support, disorder. British Journal of to listen 24 hours a day. advice and education.The Psychiatry, 183, 228-232 Call on 08457 90 90 90. Emergence network as a The Samaritans’ website gives Turner,K., Lovell, K. and whole has access to a large information about call charges Brooker, A. (2011) ’...And they amount of information about all lived happily ever after’: www.samaritans.org personality disorder, different ‘Recovery’ or discovery of the Saneline offers emotional treatments and services. If you self in personality disorder? support out of office hours cannot find the information Psychodynamic Practice: and is open every day 6pm to you need on their website Individuals, Groups and 11pm on 0845 767 8000. please do contact them at organisations, 17 (3), 341-346 [email protected] Most areas have a mental and they will try their best health crisis team available 24 to help. hours a day; their contact details USEFUL RESOURCES: should be available via the local For immediate help: council or social services, or they GOVERNMENT POLICY Call 111 if someone needs can be contacted via A&E. DOCUMENTS AND GUIDANCE: medical help fast but it’s not a National personality 999 emergency. A team of GENERAL SUPPORT: disorder website: advisors, supported by nurses www.personalitydisorder.org.uk and paramedics, will ask Local mental health charities questions to assess the – most local mental health Personality Disorder: No situation and give healthcare charities have information longer a diagnosis of advice or will direct the person about support available in exclusion. NIHME, 2003. to a suitable local service. the area. Many also run Available online: services such as day centres www.personalitydisorder.org.uk/ With a life-threatening and social groups themselves. assets/resources/56.pdf emergency, call 999 or go to the nearest A&E.

79 Recognising Complexity: Review of the pilot projects Anthony Bateman and Roy Commissioning Guidance for in personality disorder Krawitz (2013) Borderline Personality Disorder Services services (2011) personality Disorder: An (2009) Available online at www.personalitydisorder.org.u Evidence-Based Guide for www.pn.counselling.co.uk/ k/news/wp-content/uploads/ Generalist Mental Health recognising_complexity_june_ Innovation-in-Action.pdf Professionals. Oxford: Oxford or University Press. (Contains 09.pdf www.personality Learning the lessons. information on Structured disorder.org.uk/recognising- Evaluating services for people Clinical Management). complexity-commissioning- diagnosed with personality guidance-for-personality- disorder. NIHR (2008) David Healy (5th edition, 2009) disorder-services/ www.nets.nihr.ac.uk/__data/ Psychiatric Drugs Explained. Breaking the Cycle of assets/pdf_file/0020/81380/ Churchill Livingstone, Rejection – The Personality RS-08-1404-083.pdf Elsevier Ltd Disorder Capabilities Jeffrey Young, Janet Klosko Framework. NIMHE 2003. Personal accounts of living and Marjorie Weishaar (2003) www.spn.org.uk/fileadmin/ with and overcoming Schema Therapy: A spn/user/*.pdf/Papers/ personality disorder: Practitioner’s Guide. personalitydisorders.pdf Rachel Reiland (2004). Get Me NY: GuiIldford Press NICE Guideline on Borderline Out of Here: My Recovery from Michaela A.Swales and Heidi Personality Disorder Borderline Personality L. Heard (2009) Dialectical www.nice.org.uk/CG78 Disorder. Hazelden, USA. Behaviour Therapy: Distinctive NICE Guideline on Antisocial Kiera Van Gelder (2010) The Features. Routledge. Personality Disorder Buddha and the Borderline: Heather Castillo (2003) www.guidance.nice.org.uk/ CG77 My Recovery from Borderline Personality Disorder: Personality Disorder Through NICE Guidance on Self-harm Temperament or Trauma? Dialectical Behaviour Therapy, www.nice.org.uk/CG16 London: Jessica Kingsley Buddha and Online Dating. Publishers. Department of Health and Oakland CA: New Harbinger Ministry of Justice approved Pubs Inc K Turner, S Gillard, M training and courses in Neffgen (2011) personality disorder: General and Understanding Personality www.personalitydisorderkuf. specialist reading: Disorders and Recovery. org.uk/ Available via Emergence: Ministry of Justice (2011) [email protected] Working with Personality Disordered Offenders. A practitioner’s guide. Ministry of Justice Offender Management Service, Crown Copyright. Available online at www.justice.gov.uk

80 SELF HARM: WEBSITES: National Self Harm network: A directory of phonelines www.nshn.co.uk is available via the Helplines Partnership: Lifesigns – a User-Led organisation working around http://search.helplines.org self injury providing guidance Mindfulness meditation – and opportunities to network web based supported with others:www.lifesigns.org.uk meditation programme For health professionals www.getsomeheadspace.com wanting to know about the CBT based self help resources: toxicity of ingested drugs, The www.getselfhelp.co.uk/ National Poisons Information selfhelp.htm Service can be contacted on 0844 892 011 for advice on complex cases or multiple ACTIVITIES PEOPLE WITH ingestions.This service is for LIVED EXPERIENCE OF health professionals only; PERSONALITY DISORDER members of the public should RECOMMEND: call 111 or 999 as appropriate. Volunteering – For opportunities and to find local volunteer centres go SERVICE USER INVOLVEMENT: to www.do-it.org.uk MHRN Service Users & Carers Meetup – to find a group of Payments Policy Benefits like-minded people or those Conditions and Systems with similar interests. around Paid and Voluntary www.meetup.com Involvement Version 3.0 August 2013 is available online dragoncafe.co.uk – a physical www.mhrn.info/pages/mhrn- café in London, which also model-payment-policies-for- offers a range of online service-users-and-carers-.html resources for anyone affected by mental health issues. NSUN National Service User Network: www.nsun.org.uk The Ramblers – Find local walking groups at www.ramblers.org.uk

81 This publication is available online at www.emergenceplus.org.uk

July 2014