Borderline Personality Disorder /Complex Trauma

Transcription

CONSULTATION DRAFT August 2010
Borderline
Personality Disorder
/Complex Trauma
Integrated Care
Pathway
For use by all professionals working in Mental Health Services and
Partner Agencies, for all people with a diagnosis of Borderline
Personality Disorder/Complex Trauma in Lanarkshire
Prepared by:
Reviewed by:
Endorsed by:
Responsible Person:
Previous Version/Date:
Version Number/Date:
Review Date:
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Borderline Personality Disorder ICP Development Group
Mental Health ICP Steering Group
Mental Health Service Improvement Board
Karen Robertson, Associate Director of Nursing,
Mental Health and Learning Disabilities
N/A
Consultation Draft August 2010
N/A
borderline personality disorder/complex trauma integrated care pathway
Contents
Page
1. Introduction .......................................................................................... 4
1.1 Rationale for Developing the ICP.......................................................5
1.2 How to use the Complex Trauma/Borderline
Personality Disorder ICP........................................................................5
1.3 Patient Journey .....................................................................................6
2. Management in Primary Care............................................................ 7
2.1 Recognition and Management in Primary Care .............................7
2.2 Crisis Management in Primary Care...................................................7
2.3 Referral to Community Mental Health Services ...............................8
3. Management in Secondary Care...................................................... 9
3.1 Assessment, Diagnosis and Care Planning .......................................9
3.2 Risk Assessment and Management ...................................................9
3.3 Psychological Treatment .....................................................................10
3.4 Management of Crises.........................................................................11
3.5 Discharge to Primary Care ..................................................................11
4. Medication ........................................................................................... 12
4.1 Notes on the Prescribing of Psychotropic Medicine in BPD ...........12
4.2 Algorithm for Prescribing of Psychotropic Medication in BPD .......14
5. Training and Support ........................................................................... 15
5.1 General Training Requirements ..........................................................15
5.2 Specialist Training Initiatives.................................................................16
6. Service Development.......................................................................... 17
6.1 Potential Service Models......................................................................17
7. ICP Monitoring...................................................................................... 18
Appendices.............................................................................................. 19
References................................................................................................ 32
Glossary/Abbreviations .......................................................................... 33
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1. Introduction
The group developing this Borderline Personality Disorder/Complex Trauma (BPD/CT)
ICP recognised that this patient group represents a particular challenge, differing
significantly in many ways from that posed by the other groups being addressed by
the ICP initiative. This is due to various factors, including:
♦ the relatively recent recognition and acceptance of this diagnosis, around which
there still exists some ambivalence and at times resistance,
♦ the fact that effective treatments (essentially psychosocial) for this group have only
in recent years begun to emerge and are still at an early stage in terms of an
evidence base,
♦ finally and, perhaps above all, the fact that the diagnosis represents in many ways
an indication of clinical ‘severity and complexity’ with considerable so-called ‘comorbidity’ the rule rather than the exception. (It has been calculated that there
are 128 different ways in which a patient’s symptoms may meet formal criteria for
this disorder - without even considering levels of severity which are recognised to
vary considerably.)
This is manifest in the many different ways in which this group may present to many
different services. Such patients may present for example, to Community Mental
Health Teams (CMHTs), Accident and Emergency, services such as psychology or
psychotherapy, substance misuse, eating disorders or for survivors of abuse. This
inevitably makes care planning and delivery problematic. An additional challenge in
offering appropriate care and treatment to such patients is that a key aspect of their
difficulties lies in the relational and interpersonal domain. These may not only make
the personal lives of patients difficult but can often, as is well recognised, complicate
and undermine attempts to deliver care and also constitute a source of stress for
professionals, especially if attempting to work alone over long periods of time with
such patients.
An additional complication in formulating appropriate care pathways for patients with
this diagnosis lies in the changing ways on which it is conceptualised with increasing
recognition (see NICE 2009) that these disorders do not simply constitute fixed
personality traits which cannot be altered, but rather represent, broadly speaking, a
group of disorders with common roots in complex developmental trauma and/or
deprivation, in the possible context of some neurobiological vulnerability (for example
around impaired impulse control).
One consequence of this is that it is virtually certain that in forthcoming American and
WHO classifications this diagnosis will no longer exist in its present form which will further
complicate attempts to construct a care pathway around a clear diagnostic
category. A further consequence of this complex and evolving situation (which was
confirmed by feedback from a local survey), is that very few staff, whether generic or
specialist will have received any formal training in the recognition or treatment and
management of such disorders. This further contributes to the stress staff experience in
attempting at present to do so.
It is also recognised that unlike other major diagnostic categories (e.g. depression,
psychosis and dementia) very few services either locally or nationally hitherto have
specialist practitioners or formal services addressing this group.
A final major challenge is that, whilst encouraging treatment approaches are being
developed, the number of patients with what is increasingly considered at least a
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partially treatable disorder is very large indeed. Typical estimates of the prevalence of
this diagnosis would be about 2-3% in the general population, about 20% in Outpatient
/Tier 2 populations, and about 40% for in-patient or many Tier 3 type services.
1.1 Rationale for developing the ICP
The ICP was developed from the NHS QIS standards for mental health integrated care
pathways, which specify both generic and BPD-specific care standards and in this
case also suggests principles of management to promote good care of people with
this diagnosis. It has been put together by a local development group consisting of
NHS staff, service users and carers, local authorities, voluntary organisations and the
independent sector (see Appendix 1 BPD/CT ICP development group members). In
Lanarkshire various terms are used to describe the people who use mental health
services which include, “clients”, “patients” and “service users” and to simplify this we
have used the single term “patients” in both the Generic ICP and this conditionspecific ICP.
Within NHS Lanarkshire’s mental health service, there is currently no specialist service
provision for this group which means that they are absorbed into the generic system,
usually at times of crisis. The implementation of the generic and condition-specific ICP
standards should enable us to provide appropriate care and treatment for people
with this diagnosis, incorporating evidence based effective treatment approaches,
examining and acting upon the training needs of staff working with these people and
generally raising awareness of the condition.
1.2 How to use the Lanarkshire Borderline Personality Disorder/Complex Trauma ICP
The Generic ICP will automatically be used for people accessing mental health
services in Lanarkshire (with the exception of those people with depression who do not
require specialist assessment and treatment in which case only the condition-specific
ICP for depression will be used). For all others the Generic ICP will apply and if
appropriate, this condition specific ICP for Borderline Personality Disorder/ Complex
Trauma will also be used as required. This ICP is designed to be used for any person
over the age of 16 who presents with a primary diagnosis of borderline personality
disorder/complex trauma (additionally, people with learning disabilities can access
services via the Lanarkshire Learning Disabilities Service). For young people aged 16
or under services can be accessed through the Lanarkshire Child and Adolescent
Mental Health Service.
These ICPs are based on a stepped model of care as described in the Lanarkshire
Mental Health Strategy. They encompass a culture and values which aim to enable
person-centred recovery and strengths-based focus with a move towards positive
management of individual risk, maximising choice and access to evidence-based
interventions (see Appendix 2, Guidance and Policy Base).
The ICP is intended to provide a standard model of good care based on the current
evidence base and expert opinion. It is important to note that the ICP is a guide to
good care but it should never replace sound professional judgement. The
professionals’ assessment and judgement will always override the advice of the tool
where this is necessary. The ICP is part of the patient record and as with all such
records, it will be private and confidential with access governed by the usual rules of
confidentiality. By using this ICP we will be able to produce data about the care and
interventions provided to people in Lanarkshire with borderline personality
disorder/complex trauma. This information (variance data), will allow us to compare
the actual care and interventions given with those planned in the ICP and enable us
to identify areas where the ICP should be modified to improve the quality of care
provided. The variance information will also identify resource issues, gaps in service
availability and future staff training and supervision requirements.
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1.3 Patient Journey for People with Borderline Personality Disorder/Complex Trauma
To communicate the
findings of this ICP we
have created a series of
flow charts which show the
major levels of therapeutic
activity (boxes)
connected by a series of
relationships (arrows), but
we are aware that not
every potential activity or
relationship can be
covered in a diagram. In
the interests of simplicity
we have only included the
current major pathways.
The accompanying
narrative gives further
detail of each tier of the
patient journey.
Fuller guidance on the
management of
Borderline Personality
Disorder/Complex Trauma
can be found in the
current NICE guideline:
http://www.nice.org.uk/nicem
edia/pdf/Borderline%20person
ality%20disorder%20full%20gui
deline-published.pdf
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complex trauma/borderline personality disorder integrated care pathway
2. Management in Primary Care
The principles for the recognition and management of borderline personality
disorder/complex trauma in primary care are based on the guidelines from NICE
(2009 - full version and quick reference guide). Key priorities from the guideline
surrounding treatment for this patient group are reproduced for reference in
Appendix 3. They include consideration of access to services, autonomy and
choice, developing an optimistic and trusting relationship, managing endings and
transitions, assessment, care planning in CMHTs, role of psychological treatment,
role of drug treatment, and the role of specialist personality disorder services.
2.1 Recognition and Management in Primary Care
Consider referral to community mental health services for people who present with
a history of probably complex psychological trauma with a range of problems
which can include:
♦ Frequent intense and unmanageable feelings which lead to desperate coping
behaviours which may include: self harm, substance abuse or abnormal eating
behaviours
♦ Overt anxiety or depression
♦ Intrusive memories/flashbacks relating to previous traumatic experiences
♦ Instability and uncertainty about personal identity and sense of self
♦ Anxieties about abandonment and desperate attempts to seek help, or
alternatively outbursts of angry and unmanageable feelings
♦ Difficulty in interpersonal relationships, including with health service staff, due to
the above underlying problems.
GPs may also consider the use of screening tools such as the Personality Structure
Questionnaire (PSQ) (Appendix 4) and/or CORE (Appendix 5) as part of the
assessment and referral process. (Scores above a cut-off point of 28 on the PSQ
suggest BPD/CT type problems and a clinical score of above 20 on the CORE
suggests 'moderate to severe’ problems.)
Guidelines for recognition and management in Primary Care (NICE)
http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1281753086
2.2 Crisis Management in Primary Care
♦ Assess current level of risk, using the Lanarkshire Suicide Assessment and
Treatment Pathway if appropriate.
♦ Ask about previous episodes and effective management strategies used
♦ Help manage anxiety by enhancing coping skills and focusing on current
problems
♦ Encourage the person to identify manageable changes to enable them to
deal with the current problems
♦ Offer a follow-up appointment at an agreed time.
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2.3 Referral to Community Mental Health Services
Consider referral when:
♦ Levels of distress and/or risk of harm to self or others are increasing
♦ Levels of distress and/or risk of harm to self or others have not subsided despite
attempts to reduce anxiety and improve coping skills
♦ The person requests further help from specialist services.
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3. Management in Secondary Care
3.1 Assessment, Diagnosis and Care Planning
Effective recognition and assessment procedures should be in place for this group
of disorders at Tier 2 level consistent with the emphasis in general on developing
common and effective screening and assessment procedures. This will enable
collaborative and informed decisions to be made about recommending types of
intervention (if any) which are appropriate either at Tier 2 level or about referral for
more specialist and possibly intensive treatment.
It is recognised that specialised or research-based instruments (such as the SCID 2)
would not be appropriate at this point but brief screening instruments such as the
PSQ and/or a broad psychological screening instrument such as the CORE (Evans
et al.) should be considered. The latter measures overall psychological distress
and disturbance as well as risk and is increasingly used by many services and can
serve as an indication of ‘severity and complexity’ (both of these instruments are in
the public domain and are ‘copy-left’). It may also be that a set of clinical
‘prompts’ such as incorporated in our Staff Questionnaire (Appendix 6) may be
equally or more useful in initially screening for this group of disorders. However it is
recognised that broader brush instruments such as HONOS are not adequately
sensitive in screening for psychological disorders or for monitoring their progress.
These assessments would complement the broader clinical and risk assessment
procedures being recommended by the generic ICP. For patients being
considered for formal specialist treatment more rigorous assessment should include
use of a specific instrument such as the Personality Disorder Questionnaire (PDQ)
(Hyler et al).
3.2 Risk Assessment and Management
This should be undertaken as per NHS Lanarkshire Generic ICP and in addition:
♦ Agree explicitly with the person the risks being assessed and develop
collaborative risk management plans that:
address both long term and more immediate risks
relate to the overall long-term treatment strategy
take account of changes in personal relationships, including therapeutic
relationship.
♦ Manage risks with a multidisciplinary team with good supervision arrangements,
being particularly cautious evaluating the risk if the person is not well known to
the team or if there have been frequent suicidal crises. To assess suicide risk use
the Lanarkshire Suicide Assessment and Treatment Pathway.
o
o
o
♦ Regularly review (at least annually) the team members’ tolerance and
sensitivity to people who pose a risk to themselves and others.
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3.3 Psychological Treatment
The NICE guideline stresses that formal treatment should ideally be delivered in the
form of clear, coherent, structured, longer term (typically 1-3 years) programmes
and that very short term (less than three months), low intensity (less than twice
weekly input) are not effective or appropriate for such disorders. The
appropriately-nuanced NICE guideline reviewed a range of ‘brand name’ models
of treatment and concluded that certain common overarching principles of
multidisciplinary, intensive treatment approaches are undoubtedly most critical.
These include the criteria that:
♦ any model should be clear and coherent to staff and patients,
♦ be well structured and be collaborative and proactive in style.
Ideally treatment programmes should address the whole range of symptoms and
problems characteristic of these disorders although it is recognised that at present
no one model does so fully. NICE stresses that emphasising apparent differences
between different ‘brand name’ approaches may be more misleading than
helpful. (In addition it is widely accepted in delivering psychological treatments
that common factors [such as quality of therapeutic alliance and therapist
competence] will be as, if not more, important than ‘brand name allegiances’
although it is stressed that adhering to a clear model is also important for
effectiveness for any therapist or service.) However in the future it is likely that
these different emphases and strengths will be more clearly teased out and
evaluated (through ‘dismantling’ studies) and that ultimately a range of types of
intervention (ranging from those directed at more behavioural problems through
to those of a more interpersonal and relational nature) will need, variably, to be
employed in more personalised treatment packages.
In addition, the recently published ‘Matrix’ document from the Scottish
Government, (although it does not provide a systematic review of BPD specifically)
provides health boards with a comprehensive review of the evidence base for
psychological therapies and guidance as to how these should be delivered
(Appendix 7, MATRIX Evidence Base). There is evidence for the (differential)
efficacy of various models which may be considered. These include:
♦ Dialectical behaviour therapy (DBT) – long term* intensive team based approach
♦ Mentalisation – individual therapy usually employed within a team approach
♦ Schema-focussed CBT (S-CBT) – long term intensive individual therapy
♦ Transference focussed analytic therapy (T-PA) – long term intensive individual
therapy
♦ Cognitive analytic therapy (CAT) – medium term individual and/or team based
approach
♦ STEPPS programme – CBT based systemically-informed long term group approach
♦ Therapeutic community (TC) – long term large group psychosocial approach
*‘Long term’ describes treatment programmes in general lasting over one year
Exactly which approach is used as a basis for any treatment service will depend
partly on local expertise and resources and also should ideally be responsive to
informed patient preference. The provision of these and other therapies identified
in the NHS Lanarkshire ICPs is being managed through the Psychological
Therapies Strategy Implementation Plan which will determine the therapies that
will be available across Lanarkshire and agree future development timescales.
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[The survey undertaken by the working group suggests that] there is a limited and
patchy expertise available in some of these models at present in NHS Lanarkshire
(notably S-CBT, T-PA, CAT, and very patchily DBT, STEPPS and TC approaches).
Evidence also generally suggests the superiority and preferability of a
multidisciplinary team-based model of treatment provision (including possibly
adjunctive therapies such as mindfulness training or creative therapies) rather than
one offered solely by individual practitioners. Such an approach is also,
importantly, less stressful for practitioners. Regular supportive supervision for
practitioners working with this patient group should be offered and is recognised to
be of fundamental importance. Finally, it is generally accepted that social
rehabilitation plays an important role in outcome for such patients and should play
an active part in any treatment approach.
3.4 Management of Crises
These require high levels of support and frequent review in secondary care
settings. A new model for alternatives to admission/crisis support is being
developed in Lanarkshire. This model should support prevention management
and recovery from periods of crisis and will be carried out on a partnership basis.
The model follows the journey of care for people in Lanarkshire known to mental
health services and new referrals. Good practice includes:
♦ Ideally prior creation of advance directive/crisis card stating joint plans and patient
preferences for treatment/management in cases of crisis or detention under the
Mental Health Act.
♦ Assessment as per the Generic ICP, including the Lanarkshire Suicide Assessment
and Treatment Pathway if appropriate.
♦ Review of any co-morbid conditions, e.g. depression, acute anxiety, psychosis, and
any need for direct treatment of these. This may require judicious use of short term
medication (see medication algorithm and notes section).
♦ Availability of advice and support from more specialist colleagues through a
‘forum’ or specialist team.
♦ Take into account all other alternative options for support, i.e. family and
community, before consideration of brief crisis/respite hospital admission bearing in
mind these may be counter-productive.
♦ Arrange follow-up for monitoring purposes as per Lanarkshire alternative to
admission/crisis support model.
3.5 Discharge to Primary Care
When discharging:
♦ The process should be discussed and negotiated beforehand with the person and
also family or carers whenever possible.
♦ A care plan should be agreed which specifies steps to take to manage distress,
how to cope with future crises and how to re-engage with any specialist treatment
programme if ongoing and with community mental health services if needed.
♦ Support the person in their journey towards recovery. To assist with the process a
number of support methods and tools are available (should the person wish to
choose them) which include, Advance Statement, My RAP, etc. (see Appendix 8,
Information and Resources).
♦ Discharge arrangements as per Generic ICP.
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4. Medication
4.1 Notes on the Prescribing of psychotropic medication in borderline personality
Disorder/complex trauma
This section is intended as guidance on the problematic issue of prescribing for the
‘severe and complex’ group of disorders currently described as borderline
personality disorder/complex trauma - particularly in the light of recent rigorous
systematic reviews conducted and reported in the current NICE guideline (2009).
What has emerged clearly from that review is that, whilst there is encouraging
emerging evidence for the efficacy of psychological and psychosocial treatments
for BPD/CT, there is currently NO good evidence to support any prescribing of
psychotropic medication for BPD/CT as such. These findings have emerged
despite previously reported preliminary and very limited evidence for ‘judicious’
prescribing in BPD/CT for different symptoms such as affect dysregulation,
impulsive/aggressive episodes or fleeting psychotic symptoms.
What is more the NICE review and others strongly highlight the dangers of so doing
given the well-recognised pressures experienced by psychiatrists and staff teams
when treating this patient group to offer some form of help - but also the problems
associated with long-term dependency and habituation as well as possible misuse
in subsequent self-harm attempts or as a means of ‘numbing’ during periods of
distress. Such misuse may then effectively become part of the clinical problem. It
is noted that typically patients finish up unwittingly being offered a polypharmacy
which becomes at times effectively a therapeutic ‘counsel of despair’. This may
then be very hard to reduce or discontinue. It is further noted that certain drugs
(e.g. benzodiazepines) may result in paradoxical dyscontrol or disinhibition
syndromes which is particularly problematic in patients prone to impulsive self
harm. In addition, most patients diagnosed with BPD are young women of child
bearing age (see NICE guideline on Ante Natal and Post Natal Mental Health
2007) and many drugs up to now commonly prescribed for BPD/CT (e.g.
benzodiazepines, neuroleptics, mood stabilisers, anti-depressants) may have
harmful effects on the foetus.
However one of the recognised problems with this patient group is so called ‘comorbidity’ - although it has been argued that this is simply a reflection of the
complexity and severity of the diagnosis. This may include acute anxiety, acute
psychotic episodes, depression (often of a more empty ‘existential’ type given the
typically high levels of affect seen in BPD/CT) as well as problems such as anorexia,
binge-eating or substance misuse. It is recognised that clearly defined co-morbid
conditions may need to be treated in their own right as appropriate and this may
include use of psychotropic medication. It is stressed however that these should
be used only after a careful risk-benefit analysis of the issues involved in prescribing
around BPD/CT. Such prescribing should be ideally only ever be undertaken on a
time-limited basis although clearly this may not be possible for some conditions
such as depression or psychosis.
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If any psychotropic medication is prescribed however for BPD/CT itself in the
absence of any other clear formally-diagnosed disorder, prescribers should be
aware that this represents ‘off label’ use of drugs which should ideally only be
undertaken with the informed (and preferably written) consent of the patient as
per routine BNF guidance. It would be anticipated however that the
implementation of improved (psychosocial) treatments for this group of patients
would result in much less pressure to prescribe and a corresponding reduction
ultimately in levels of so doing.
Finally, it should be noted that whilst disorders such a severe depression (actually
quite rare in overt BPD/CT) may need to be considered and treated in their own
right, treatments such as ECT in the context of BPD/CT are recognised to be greatly
compromised in their efficacy and are not generally recommended. In particular
there is no evidence for the use of ECT for BPD/CT in itself (APA 2001; NICE 2009).
page 13
4.2 Treatment algorithm for prescribing of psychotropic medication in borderline
personality disorder/complex trauma
♦ If there is a clear diagnosis of BPD/CT – offer psychologically informed
management and support and consider referral for specialist psychosocial
treatment approaches.
♦ If there is a clearly defined acute or chronic co-morbid condition – consider
other forms of appropriate, specifically-targeted treatments following careful
risk-benefit analysis of prescribing in the context of BPD/CT and in conjunction
with informed consent from patient or relative if appropriate (e.g. in context of
treatment under a section of the Mental Health Act).
Management of
Co-morbidities
Review diagnosis and comorbid condition
Review previous and
current treatments
If major
psychosis,
dependence on
alcohol or class
A drugs or
severe eating
disorder, refer to
or seek advice
from appropriate
service
If co-morbid
condition
follow the
NICE/SIGN
clinical
guideline for
co-morbid
condition
Ref: NICE Clinical Guideline 78 January 2009
Management of
Crises
Consider short term drug
treatments:
Choose drugs with low side effect
profile:
- Low addictive properties
- Minimum potential for misuse
- Relative safety in overdose
Use minimum effective dose
Prescribe fewer tablets more
frequently if significant risk of
overdose
Agree with person: target
symptoms, monitoring
arrangements, anticipated duration
of treatment
Agree plan for adherence with
person
Discontinue a drug after a trial
period if target symptoms do not
improve
Consider alternative treatments
including psychological treatments if
target symptoms do not improve or
level of risk does not diminish
Management of
Insomnia
Provide general
advice on sleep
hygiene
Short term management:
Use zaleplon, zolpidem
and zopiclone as per
NICE guidance 77
Consider sedative
antihistamines
Review and Follow-up:
Review drug treatment
Plan to stop treatment within 1
month
Review of psychological treatments
including role in overall treatment
strategy
If drug cannot be stopped within 1
month review regularly
ICP Standard 26a: The care record shows that a treatment algorithm for drug
choices based on best practice is followed.
page 14
5. Training and Support
5.1 General Training Requirements
All clinical staff should be familiar with the use of basic screening and assessment
procedures and tools. A brief training package (possibly half a day long) offering
an update on the recognition and principles of treatment for BPD/CT should be
offered and rolled out to all staff on an ongoing basis given the continuing rapid
evolution of understandings and treatment approaches in this area.
All generic and specialist staff who may be expected to work with and manage
this group of patients should have these basic skills as well as basic psychological
treatment skills across a range of modalities ranging from the behavioural and
cognitive through to the interpersonal and relational in line with the types of
treatment packages recommended by recent systematic reviews notably the one
from NICE (2009).
Service user and carer organisations both locally (e.g. Lanarkshire Links, SAMH) and
nationally (e.g. ‘Emergence’) should be involved on an ongoing basis in planning,
developing, monitoring and evaluation of services. Feedback from Lanarkshire
Links with regard to the ICP development process suggested a need to focus on
various issues notably staff training. Key issues included:
Involving service users and carers:
♦ Problems of not having a diagnosis –
♦
♦
♦
♦
♦
♦
therefore not being part of this
particular pathway
More information
Make user and carer feel more
valued and listened to – including
our experience and opinions
Show how our opinions and
experience can make a difference
Encourage and enable involvement
Keep it relaxed and informal
Outline the benefits
Important areas to measure:
♦ Consistent approach
♦ Standards
♦ Time delays – reduce gaps in
♦
♦
♦
♦
♦
provision
Relevant staff training
Recognise that everyone recovers at
a different rate
Interventions to avoid long hospital
admissions
Other agency involvement
Community based treatment
(Lanarkshire Links Summer Meeting 17th June 2009)
page 15
5.2 Specialist Training Initiatives
In light of questionnaire feedback and working group impressions there appears to
be a pressing need for a brief (?mandatory) training package (? ½ day in length)
which covers:
♦ awareness, understanding and recognition of this group of disorders,
♦ principles of treatment for all mental health professionals in NHS Lanarkshire
(?and other agencies, e.g. Social Services, non-statutory agencies).
This should ideally be formulated and delivered by a group of trainers (ideally in
conjunction with an outside educational organisation(s)) who would come from a
small (?virtual) specialist team in line with most current guidance.
There is a need for a substantial number of colleagues with specialist training in
appropriate treatment modalities (e.g. schema based CBT, DBT, CAT,
Mentalisation and so forth). This should continue to be addressed in conjunction
with initiatives implemented by the IAPT approach. Trained practitioners should be
available to assess and offer treatment to this patient group both in various
secondary care teams and also in any specialist BPD/CT team. Some training
initiatives may require external resources whilst others could be developed and
rolled out essentially ‘in house’ and make use of currently existing expertise.
page 16
6. Service Development
6.1 Potential Service Models
In order to implement these initiatives and to continue to support, train and
supervise staff and offer in-depth assessment and more intensive treatments (in line
with recent reviews such as NICE 2009) for the large number of patients falling into
this diagnostic group there should ideally exist a multidisciplinary psychological
treatment team offering treatment for such disorders in each locality. The
composition and role of such a team would be comparable to that embodied in
other tertiary level specialist services. Ideally this team would have access to a
small number of in-patient beds to deal with the need for intermittent crisis
admissions although these should be greatly diminished overall by the existence of
such a team. Given the large numbers of patients with such disorders (as with any
Tier 3 type service) only a small number of more severe cases would be directly
treated but such a team would nonetheless represent an important referral,
assessment, and treatment option for generic workers in services in other Tiers.
page 17
7. ICP Monitoring
Monitoring of the service provided to each person will take place using:
♦ Variance Analysis – questions to be agreed in conjunction with ICP
development groups and national QIS ICP programme team. Aspects of the
ICP which would require monitoring would include, e.g. number of patients
identified and diagnosed, numbers of crisis plans formulated, numbers of
admissions, prescribing levels, episodes of deliberate self harm, suicide rates
and overall treatment outcomes.
♦ Staff, Patient and Carer Surveys – to be developed in conjunction with ICP
development groups, national QIS public involvement group, etc.
page 18
Appendices
Appendix 1: Complex Trauma/Borderline Personality Disorder ICP Development Group Members
Gordon Barclay, ST5, NHS Lanarkshire
Stuart Baxter, Nurse Specialist, Crisis Resolution and Home Treatment
Service, NHS Lanarkshire
Martin Benes, Consultant Psychiatrist, NHS Lanarkshire
Caroline Brown, Clinical Governance Co-ordinator (Mental Health),
NHS Lanarkshire
Avril Cleary, Community Psychiatric Nurse Team Leader, NHS
Lanarkshire
Norma Cruickshank, Nurse Consultant Psychological Interventions,
NHS Lanarkshire
Eileen Dickson, Charge Nurse, NHS Lanarkshire
Jackie Donaghey, Senior Social Worker, North Lanarkshire Council
Shay Griffin, Consultant Psychiatrist, NHS Lanarkshire
Pauline Hanlon, Senior Nurse Clinical and Professional Practice
(Mental Health), NHS Lanarkshire
Alison Howley, Forensic Community Psychiatric Nurse, NHS Lanarkshire
Ian Kerr, Consultant Psychiatrist and Psychotherapist, NHS Lanarkshire
(Chair)
Scott Lees, Community Psychiatric Nurse, NHS Lanarkshire
Ana Lopez, Consultant Psychiatrist, NHS Lanarkshire
Roy McGregor, Nurse Therapist, NHS Lanarkshire
Dorothy McMonagle, Charge Nurse, NHS Lanarkshire
Claire Nelson, Consultant Psychiatrist, NHS Lanarkshire
Debra O'Neill, Chartered Clinical Psychologist, NHS Lanarkshire
Loraine Ratter, Community Psychiatric Nurse, NHS Lanarkshire
Gwen Scott, Team Leader, Rutherglen Community Mental Health
Team, South Lanarkshire Council
Lisa Marie Smith, Community Psychiatric Nurse, NHS Lanarkshire
Derek Thomson, Community Psychiatric Nurse, NHS Lanarkshire
Hermione Thornhill, Clinical Psychologist, NHS Lanarkshire
Brenda Vincent, Service Manager, Equals Advocacy Partnership
Caroline Watson, Ward Manager, NHS Lanarkshire
Alison Wilson, Psychiatric Assessment Team Co-ordinator, NHS
Lanarkshire
Caroline Lennon, Psychotherapy Nurse Practitioner, NHS Lanarkshire
ICP Team:
Patricia Kent, ICP Manager
Janis Dickson, Mental Health ICP Project Assistant
page 19
Appendix 2: Guidance and Policy to support Values
page 20
Appendix 3: NICE Quick Reference Guide (pages 4 – 6)
page 21
page 22
page 23
Appendix 4: Personality Structure Questionnaire (PSQ)
IMPORTANT—PLEASE READ THIS FIRST.
This questionnaire is about aspects of your personality. People vary in all sorts of
ways. Some people feel themselves to be constant and all of a piece. Other
people are quite variable and find themselves shifting between two or more
distinct states of mind. Most people are in the middle between these two
extremes.
A state of mind is recognized by a typical mood, or a typical way of relating to
other people. In some states people feel in control and in others more out of
control. States of mind can change quickly or may last for days. Sometimes
changes in state of mind happen because of a change of circumstances or an
event of some kind.
There are two statements per question. Please indicate which description applies
to you most closely.
Please complete all 8 questions and cross one box per question only like this ⌧.
1
Very
True
2
True
3
May or
may not
be true
4
True
5
Very
True
1
My sense of myself is always
the same.
How I act or feel is
constantly changing.
2
The various people in my
life see me in much the
same way.
The various people in my
life have different views of
me as if I were not the
same person.
3
I have a stable and
unchanging view of myself.
I am so different at times
that I wonder who I really
am.
4
I have no sense of opposed
sides to my nature.
I feel I am split between
two (or more) ways of
being, sharply different
from each other.
5
My mood and sense of self
seldom change suddenly.
My mind can change
abruptly in ways which can
make me feel unreal or out
of control.
6
My mood changes are
understandable.
I am often confused by my
mood changes which seem
either unprovoked or out of
scale with what provoked
them.
7
I never lose control.
I get into states in which I
lose control and do harm to
myself and/or others.
8
I never regret what I have
said or done.
I get into states in which I
say or do things which I
later deeply regret.
Thank you for completing this questionnaire
Copyright ©2009 John Wiley & Sons, Ltd.
page 24
Clin. Psychol. Psychother. 16, 77-81 (2009)
DOI: 10.1002/cpp
Appendix 5: Clinical Outcomes in Routine Evaluation (CORE)
page 25
Appendix 6: Lanarkshire Staff Questionnaire
Borderline Personality Disorder – Integrated Care Pathway (ICP)
Background Questionnaire for Staff
As part of the work of the Borderline Personality Disorder ICP workgroup, which will aim to
implement objectives of the ICPs overall and specifically to improve services for this patient group,
we are initially attempting to obtain a background picture of both the prevalence of this disorder
locally and of views of colleagues about their confidence and abilities in working with them.
Addressing this patient group is probably significantly more problematic than for many others,
partly given the complex nature of their presentations, but also due to changing views and
understandings of their origins and nature as well as the emergence of encouraging treatment
methods for them over the past decade or so. Broadly speaking, it is now much better understood
that this group of patients who present with often a range of complex and ‘hard-to-help’ difficulties
have common origins in, usually, childhood and developmental histories of serious deprivation,
emotional trauma and at times overt abuse. This has often occurred in the context of dysfunctional
family dynamics and of adverse and sometimes traumatic life events. The range of problems
associated with this sort of disorder (broadly described as borderline personality disorder although this label is contentious and not always helpful) is very wide. These may include:
i) Frequent intense and unmanageable feelings which lead to desperate coping behaviours
which may include, e.g. self harm, substance abuse or abnormal eating behaviours
ii)
Overt anxiety or depression
iii) Intrusive memories / flashbacks relating to previous traumatic experiences
iv) Instability and uncertainty about personal identity and sense of self
v) Anxieties about abandonment and desperate attempts to seek help, or alternatively outbursts
of angry and unmanageable feelings
vi) These may then lead to difficulty in interpersonal relationships, including with health service
staff
This picture is recognised to start emerging already in late childhood or adolescence. Clearly,
given this range of difficulties (often referred to as ‘co-morbidity’), such patients frequently present
to very different services, both in primary and secondary care, including for example, services for
survivors of abuse, eating disorder services, substance abuse services, therapy services or more
generic secondary care services due to behaviour such as self-harm or symptoms such as anxiety
and depression. More recent reviews and guidelines have stressed the partial effectiveness at
least of newer treatment approaches and have clearly stated that these should be routinely
available to such patients. The consensus in such guidelines is that whatever model is being used,
it should be clear and coherent to those involved, including patients, and should inform more
intensive and multi-disciplinary team-based specialist services which should ideally exist for the
more severe and complex and ‘hard-to-help’ cases.
As part of our attempt to inform further development of Mental Health and other services in
Lanarkshire, we would be grateful if you could answer the following questions about:

The frequency with which you consider that you encounter such cases in your workload ideally identifying them through initials and date of birth

The extent to which you might feel confident or otherwise about understanding and
working with such patients
Please note that the questionnaire feedback is entirely confidential.
page 26
Borderline Personality Disorder
Integrated Care Pathway Development
Mental Health Services
Borderline Personality Disorder ICP Background Questionnaire
Thank you for taking the time to complete this questionnaire. (Please continue on another sheet if
necessary.)
Background Details:
Name:
Professional Role:
Work Setting:
Qualifications:
Any specialist training in Psychological Treatments:
Prevalence
1. Given the outline description of this patient group on Page 2, could you please try to indicate
approximately what percentage of your current workload such patients might represent?
%
2. In terms of actual numbers, how many would this be?
3. Can you please identify these cases by Initials and Date of Birth so that we can cross reference them
in terms of contact elsewhere from other staff and services and also the principal and any other
diagnoses which have been given to these patients?
No.
Initials
Date of Birth
Principal Diagnosis
Other Diagnoses
1
2
3
4
5
6
7
8
9
10
Any other comments:
page 27
Borderline Personality Disorder
Integrated Care Pathway Development
Mental Health Services
Borderline Personality Disorder ICP Background Questionnaire
Thank you for taking the time to complete this questionnaire. (Please continue on another sheet if
necessary.)
Name (optional):
Professional Role (optional):
Your views on working with this patient group:
(please put a cross in the box as appropriate)
Strongly
Agree
Agree
Unsure
Disagree
Strongly
Disagree
1. I feel confident about recognising this patient
group and about my clinical understanding of
it.
2. I feel confident about my skills in trying to
work with this patient group.
3. I currently feel rather anxious and uncertain
about working with this patient group.
4. I feel confident about obtaining advice and
support in working with this patient group.
5. I would welcome any further basic training
initiatives to help with my attempts to work
with this patient group.
6. I feel confident about knowing where to refer
on for more focused and intensive treatment
of this patient group.
7. I would welcome the support of a specialist
service for this patient group.
8. I feel that attempts to help this patient group
are often complicated by other nonpsychiatric factors (e.g. lack of social
support).
9. I feel that the use of the term ‘borderline
personality disorder’ is often inappropriate
and unhelpful in working with such patients.
10. I feel that attempts to work with such patients
are often undermined and complicated by
pejorative and hostile reactions which they
may elicit from health professionals.
Any other comments:
page 28
Appendix 7: MATRIX Evidence Base
MATRIX Borderline Personality Disorder Evidence Base
Level of
Severity
Level of service
Intensity of
intervention
What intervention?
Recommendation
Severe
Secondary/
Specialist
Outpatient
High
CBT for personality disorders
Individual therapy (30 sessions over 1 year)
A2
Schema Focused CBT
Twice weekly over 3 years
A3
STEPPS -Systems Training for Emotional
Predictability and Problem Solving (CBT
approach) 20 group sessions group + usual
treatment
A6
Transference-focused psychotherapy
(twice weekly sessions plus weekly
supportive treatment over one year)
A4
Dialectical Behaviour Therapy (DBT)
Involves group + individual therapy +
telephone support (Several times per week
over one year)
A1
Mentalization based Day Hospital
(Several times per week over 3 years)
A5
Severe
Secondary/
Specialist
Partial Day Hospital
High
Multi-modal
Lessons learned from the evaluation of pilot services in England suggests that due to the complexity of personality disorder most services
should offer more than one type of intervention (Crawford et al, 2007)7.
page 29
MATRIX BORDERLINE PERSONALITY DISORDER REFERENCES
1. Linehan, M.M. et al., (2006) Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts
for Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry 63, 757-766.
2. Davidson K, Norrie J, Tyrer P, Gumley A, Tata P, Murray H, Palmer S (2006) The effectiveness of cognitive behaviour therapy for
borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. Journal of
Personality Disorder 20, 450–465
3. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz, A. (2006) Outpatient
psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy.
Archives of General Psychiatry, 63, 649–658
4. Clarkin J.F., Levy K.N., Lenzenweger M.F., Kernberg O.F. (2007) Evaluating three treatments for borderline personality disorder: a
multiwave study. American Journal of Psychiatry, 164, 922–928
5. Bateman A, Fonagy P (1999) The effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized
controlled trial. American Journal of Psychiatry, 156, 1563–1569
6. Blum N, St. John D, Pfohl B, Stuart S, McCormick B, Allen J, Arndt S, Black D (2008) Systems Training for Emotional Predictability and
Problem Solving (STEPPS) for Outpatients With Borderline Personality Disorder: A Randomized Controlled Trial and 1-Year Follow-Up.
American Journal of Psychiatry, 165, 468–478
7. Crawford, M & Rutter, D (2007) Lessons learned from an evaluation of dedicated community based services for people with personality
disorder. Mental Health Review Journal, 12, 55-61.
page 30
Appendix 8: Information and Resources
Information and Resources
Reading:
♦ Borderline Personality Disorder Demystified: An Essential Guide for
Understanding and Living with BPD, Robert Friedel
♦ Stop Walking on Eggshells: Taking your Life Back when Someone you Care
About has Borderline Personality Disorder, Paul T Mason
♦ The Borderline Personality Disorder Survival Guide: Everything you need to know
about living with BPD, Alex Chapman
Websites:
♦ Scottish Personality Disorder Network:
http://www.scottishpersonalitydisorder.org/
♦ Elament - an online mental health and wellbeing information website:
http://www.lanarkshirementalhealth.org.uk/
♦ For information on suitable drugs and their uses:
http://www.choiceandmedication.org.uk/
♦ My RAP - a self management tool developed by a multi-agency group in
Lanarkshire to support people in their recovery, available at:
http://www.lanarkshirementalhealth.org.uk/News/myrapavailable
♦ Scottish Recovery Network - an affiliation of individuals and organisations with a
common interest in recovery, which also aims to share information and ideas:
http://www.scottishrecovery.net/
♦ Lanarkshire Links – an organisation for mental health service users and carers in
Lanarkshire: http://www.lanarkshirelinks.org.uk/
Information Leaflets:
♦ What is Borderline Personality Disorder? – available from the Scottish Personality
Disorder Network website:
http://www.abdn.ac.uk/~wmm075/uploads/files/leaflet.pdf
♦ Patient Information Leaflets - can be accessed via NHS Lanarkshire Intranet
Pharmacy Mental Health pages
page 31
References
1. Bedford A, Davies F, Tibbles J (2009) The Personality Structure Questionnaire (PSQ): A
Cross-Validation with a Large Clinical Sample. Clinical Psychology and Psychotherapy
16, 77-81. Published online at Wiley InterScience (www.interscience.wiley.com).
2. Evans, C., Connell, Barkham, M., Margison, F., McGrath, G., Mellor-Clark, J. and Audin,
K. (2002). Towards a standardised brief outcome measure: psychometric properties
and utility of the CORE-OM. British Journal of Psychiatry, 180, 51-60.
3. See also www.coreims.co.uk
4. Hyler SE, Skodol AE, Kellman HD, Oldham J and Rosnick L. (1990). The validity of the
Personality Diagnostic Questionnaire: A comparison with two structured interviews.
American Journal of Psychiatry, 147, 1043-1048.
5. Mental Health in Scotland: A guide to delivering evidence-based psychological
therapies in Scotland – ‘The Matrix’, Scottish Executive, 2008.
6. National Institute for Clinical Effectiveness (NICE) (2009). Borderline Personality Disorder:
Treatment and Management. National Clinical Practice Guideline No 78, London.
7. Standards for Integrated Care Pathways for Mental Health, NHS Quality Improvement
Scotland, December 2007.
Borderline Personality Disorder References from more recent literature
1. Bateman, A S. and Fonagy, P. (2009). Randomized Controlled Trial of Outpatient
Mentalisation Based Treatment Versus Structured Clinical Management. American
Journal of Psychiatry, 166, 1355-1364. (shows effectiveness of intensive mentalisation
package with partial superiority over psychologically-informed, coherent, proactive
psychiatric care package.)
2. Chanen, A.M., Jackson, H. McCutcheon, L. K., Jovev, M., Dudgeon, P., Yuen, H.P.,
Germano, D., Nistico, H., McDougall, Weinstein, C., Clarkson, V. and McGorry P.D.
(2008). Early intervention for adolescents with borderline personality disorder using
cognitive analytic therapy: randomised controlled trial. British Journal of Psychiatry,
193, 477-484. (shows effectiveness of 24 session CAT with partial superiority over
psychologically-informed, coherent, proactive psychiatric care package).
3. Chanen, A.M., Jackson, H. McCutcheon, L. K., Jovev, M., Dudgeon, P., Yuen, H.P.,
Germano, D., Nistico, H., McDougall, Weinstein, C., Clarkson, V. and McGorry P.D.
(2009). Early Intervention for adolescent with borderline personality disorder: quasiexperimental comparison with treatment as usual. Australian and New Zealand Journal
of Psychiatry, 43, 397-408. (shows effectiveness of 24 session CAT with partial superiority
over psychologically-informed, coherent, proactive psychiatric care package, with
both showing marked superiority over historic ‘treatment as usual’.)
4. Doering, S., Horz, S., Rentrop, M., Fisher-Kern, M. et al. (2010). Transference–focused
psychotherapy v. treatment by community psychotherapists for borderline personality
disorder: randomised control trial. British Journal of Psychiatry, 196, 389-395. (shows
effectiveness of twice-weekly modified psychoanalytic ‘transference focussed’
therapy (for one year) for borderline symptomatology, social function and personality
organisation compared to control group receiving non-specific therapy by
experienced ‘community’ therapists.
5. McMain, S.F., Links, P.S., Gnam, W.H., Guimond, T., Cardish, R.J., Korman, L., and
Streiner, D.L. (2009). A Randomized Trial of Dialectical Behavior Therapy Versus General
Psychiatric Management for Borderline Personality Disorder. American Journal of
Psychiatry, 166, 1365-1374. (shows effectiveness of intensive DBT package but with no
superiority over psychologically-informed, coherent, proactive psychiatric care package.)
page 32
Glossary/Abbreviations
Cognitive Analytic
Therapy (CAT)
Cognitive
Behavioural
Therapies (CBT)
Diagnostic and
Statistical Manual of
Mental Disorders
(DSM IV)
Dialectical
Behaviour Therapy
(DBT)
Electroconvulsive
Therapy (ECT)
Health of the Nation
Outcomes Scale or
HONOS 65+
Cognitive Analytic Therapy is a relational approach which involves a
therapist and a client working together to look at what has hindered
changes in the past, in order to understand better how to move forward in
the present. CAT focuses its attention on discovering how problems have
evolved and how the procedures devised to cope with them may be
ineffective. It is designed to enable clients to gain an understanding of how
the difficulties they experience may be made worse by their habitual
coping mechanisms. Problems are understood in the light of clients' inter
personal and social histories and life experiences. The focus is on
recognising how these coping procedures originated and how they can be
adapted and improved. Then, mobilising the clients' own strengths and
resources, plans are developed to bring about change. Promoting
integration of the self is a major additional focus in working with BPD/CT
This umbrella term describes those therapies which share the central idea
that thoughts generate emotions and behaviour(s) and that negatively
biased thinking generates unhelpful emotions and unhelpful behaviour(s);
from which emotional disorders may arise. Such therapies focus on
monitoring thoughts, beliefs and behaviours in the here and now in order to
help people evaluate how helpful or unhelpful they are. Therapist and
client/patient work collaboratively to achieve explicitly agreed goals in a
time limited fashion.
Psychiatric Diagnoses are categorized by the Diagnostic and Statistical
Manual of Mental Disorders. The manual is published by the American
Psychiatric Association and covers all mental health disorders for both
children and adults. It also lists known causes of these disorders, statistics in
terms of gender, age at onset, and prognosis as well as some research
concerning the optimal treatment approaches.
Dialectical Behaviour Therapy is an innovative method of treatment that
has been developed specifically to treat this people in a way which is
optimistic and which preserves the morale of the therapist. The core
strategies in DBT are 'validation' and 'problem solving'. Attempts to facilitate
change are surrounded by interventions that validate the patient's
behaviour and responses as understandable in relation to their current life
situation, and that show an understanding of their difficulties and suffering.
This is a procedure sometimes used to treat severe depression and other
conditions in which an electric current is briefly applied to the brain. ECT is
only offered if other kinds of treatments have not helped to relieve
depression.
In 1993 the UK Department of Health commissioned the Royal College of
Psychiatrists’ Research Unit to develop scales to measure the health and
social functioning of people with severe mental illness. The initial aim was to
provide a means of recording progress towards the Health of the Nation
target ‘to improve significantly the health and social functioning of mentally
ill people’. Development and testing over three years resulted in an
instrument with 12 items measuring behaviour, impairment, symptoms and
social functioning (Wing, Curtis & Beevor, 1996). The scales are completed
after routine clinical assessments in any setting and have a variety of uses
for clinicians, researchers and administrators, in particular health care
commissioners and providers. The scales were developed using stringent
testing for acceptability, usability, sensitivity, reliability and validity.
page 33
Mentalisation
NHS Quality
Improvement
Scotland (QIS)
National Institute for
Clinical Excellence
(NICE)
Personality Structure
Questionnaire (PSQ)
Schema Focussed
CBT (S-CBT)
Scottish
Intercollegiate
Guidelines Network
(SIGN)
Systems Training for
Emotional
Predictability and
Problem Solving
(STEPPS)
Therapeutic
Community
Approaches (TCs)
Transference
Focussed Analytic
Therapy (T-PA)
Variance
page 34
Mentalisation based therapy is a type of psychotherapy that focuses on a
person’s ability to “mentalise,” or recognize thoughts, feelings, wishes, and
desires, and see how these internal states are linked to behaviour.
NHS Quality Improvement Scotland was established as a Special Health
Board by the Scottish Executive in 2003, in order to act as the lead
organisation in improving the quality of healthcare delivered by NHS
Scotland. By 'improve', they mean the improving of the experiences of
patient/clients and the outcomes of their treatment while in the care of NHS
Scotland. They work to achieve these goals through an analysis of scientific
evidence, by listening to the needs and preferences of patient/clients and
carers, as well as the experiences of healthcare professionals. Web address:
www.nhshealthquality.org
NICE is part of the NHS. It is the independent organisation responsible for
providing national guidance on treatments and care for those using the
NHS in England and Wales. Its guidance is for healthcare professionals and
patient/clients and their carers, to help them make decisions about
treatment and healthcare. NICE guidance and recommendations are
prepared by independent groups that include healthcare professionals
working in the NHS and people who are familiar with the issues affecting
patient/clients and carers. Website address: www.nice.org.uk
The PSQ was devised to measure deficits in personality integrity, and
represents an assessment measure of the multiple self-states model of
cognitive analytic therapy which has however been validated for broader
use. This conceptualizes disturbances in personality, with a gradation from
healthy identity development to the extreme of a dissociative identity
disorder. The PSQ consists of eight bipolar self-rated items for which there is
a range of possible responses scoring from 1 to 5 with higher scores (over 28)
indicating greater identity disturbance.
Schema therapy (also called schema-focused therapy) is an integrative
approach based on cognitive-behavioural or skills-based techniques along
with object relations and gestalt approaches. It directly targets deeper
aspects of emotion, personality and schemas (fundamental ways of
categorising and reacting to the world). The treatment also focuses on the
relationship with the therapist (including a process of "limited re-parenting"),
daily life outside of therapy and traumatic childhood experiences.
SIGN was established in 1993 by the Academy of Royal Colleges and
Faculties in Scotland. Its objective is to improve the quality of healthcare for
patients in Scotland by reducing variation in practice and outcome,
through the dissemination of national clinical guidelines containing
recommendations for effective practice based on current evidence. For
further information contact: www.sign.ac.uk
This cognitive-behavioural, skills training approach is based on a systems
approach to treatment of individuals with Borderline Personality Disorder
originally developed by Bartels and Crotty (1992).
Therapeutic community is a term applied to a participative, group-based
approach to long-term mental illness, personality disorders and drug
addiction. The approach is usually residential with the clients and therapists
living together, is based on milieu therapy principles and includes group
psychotherapy as well as practical activities.
Transference-focused psychotherapy is a modified psychoanalytic
psychotherapy based on Dr. Otto Kernberg's object relations model. It
begins with a treatment contract, which helps contain acting-out
behaviours and sets a frame for discussing deviations from the contract.
The treatment emphasises analysis of transference to help the person
integrate disparate representations of the self and others in order to
develop better affective control.
A deviation from an activity set out in an ICP.

Borderline Personality Disorder /Complex Trauma

Transcription

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