Phase of treatment

a. Safety and,

b. Containment: The main aims of the first two parts of the stabilisation phase are management of symptoms and crises. Interventions should be kept simple and focused with the goal of returning the patient to the previous level of functioning as soon as possible. It is important to avoid attempting to achieve too much during the safety and containment phases of treatment. See Crisis Management Section.

c. Regulation and control: Once acute behavioural dysregulation has stabilised (even temporarily), work can begin on the third part of the stabilisation phase. The main aims are to promote self-management of impulsivity, self-harming behaviour and emotions. Useful strategies include behavioural analysis which can help the person to identify the antecedents and reinforcing consequences of unhelpful behaviours. Distancing, mindfulness, emotion regulation, distress tolerance and interpersonal effective skills and strategies are likely to be of value in identifying solutions. These generic approaches do not “belong” to any particular psychosocial intervention. However, while it is entirely reasonable for these skills to be taught on an individual basis outwith specific psychosocial approaches like STEPPS or DBT, it is important that the clinician and patient are clear that what is being delivered in such a situation does not constitute a DBT or STEPPS intervention.

A crisis self-management plan can prove very valuable in maintaining stabilisation and preventing dysregulation by providing a clear set of helpful options when a patient’s capacity to think clearly is reduced. STEPPS and DBT are essentially stabilisation treatments which can be considered as adjunctive to standard community psychiatric care (see Psychosocial Intervention Section). If a patient in DBT or STEPPS treatment has contact with a CMHT clinician, reinforcement and generalisation of skills represents a useful focus for therapeutic work. The responsibility should rest with the patient to collaborate with the CMHT clinician in such a way that reinforcement and generalisation occurs. This may include keeping the CMHT clinician up to date on which skills are currently being taught and examples of how they are applying them in their daily lives. While the concept of a reinforcer is built into STEPPS, this concept is not a core concept of DBT. However, if a CMHT clinician has concerns that a patient in DBT is not using their CMHT time to effectively reinforce and generalise skills, then it would be reasonable to alert the DBT therapist, with the patient’s knowledge. Solutions could then be found within DBT individual therapy.

DBT can be considered for patients with severe borderline personality disorder and recent, potentially lethal parasuicidal behaviour or emergency hospitalisation who are also on the Care Programme Approach. STEPPS skills training groups run within each of the CMHTs and this intervention should be considered for moderate borderline personality disorder or borderline traits (the terminology used within the STEPPS program is “emotional intensity disorder”). Ideally, every participant should have a reinforcement team. This is ideally composed of members of the social network and a health professional (CPN, GP, support worker etc). The reinforcers need not have in-depth knowledge of STEPPS but serve to help consolidation and generalisation of skills.

This phase can involve dealing with the effects of trauma and dissociation; treating self and interpersonal problems; and treating maladaptive traits. Post-traumatic stress disorder can be treated via specific psychosocial interventions such as EMDR or trauma-focused CBT, (see Psychosocial Interventions Section).

However, for less severe presentations, psychoeducation and self-directed exposure may be of value. Dissociation is likely to benefit from general improvement in emotion regulation but the patient may also benefit from learning grounding strategies. Intrapersonal (self) and interpersonal problems often relate to maladaptive schemas. These can be addressed through formal psychological interventions or by within general clinical contact by supporting self-reflection, identification of long-standing patterns of thinking and behaviour, and introduction of more adaptive patterns. For example, it might be gently brought to a patient’s attention that they have a pattern of negatively interpreting neutral comments, becoming angry and breaking off relationships. Clearly, this kind of work can very naturally take place within general clinical contact and does not need to be limited to specific psychotherapy settings.

Behavioural strategies which may be useful include challenging behavioural avoidance, environmental management strategies (guided by needs assessment), behavioural rehearsal and role play. No personality trait is intrinsically maladaptive. Maladaptation occurs when the behaviours through which the trait is expressed interact with the environment to prove unhelpful. Some traits can be relatively plastic and amenable to some change but others are less so. In case of less malleable traits, the task is to modulate the trait as far as possible but also to help modify the social and environmental context so that adaptive fit is improved. In many situations, it can be helpful to view traits as relatively stable characteristics which the patient needs to learn to use constructively.

Increase acceptance and tolerance of the trait

Many (but certainly not all) people with personality disorder can be intolerant of their own basic traits in contrast to most non-personality disordered individuals who are usually reasonably comfortable with their traits, even those which they would like to change. Related negative self-judgements and self-invalidation can have markedly detrimental effects in terms of self-view, emotional responses and unhelpful behaviours used to change intolerable emotional states. Mindfulness-based approaches can be helpful in increasing acceptance of traits.

Psycho-education may help reduce internal conflict and increase self-acceptance. Explanation that traits are to a significant extent biologically determined can help people assume ownership of their traits, whereas emphasising the role of environmental influence on traits can help the patient understand that it is possible, within limits, to change the way traits are expressed. Another useful strategy is to encourage patients to identify ways in which their traits might be beneficial if the fit with the environment was more adaptive. A good example is the trait of conscientiousness. Clearly, moderate levels of conscientiousness, attention to detail and orderliness would be regarded as desirable by most people. The realisation that traits are only maladaptive when they are expressed in unhelpful or inflexible ways can facilitate change by helping the person see that they do not need to change a fundamental part of themselves but rather more specific aspects of behaviour related to the trait.

Reduce trait expression

For people at the extreme end of a trait distribution, the threshold for interpreting situations as relevant to the trait is low. Cognitive and behavioural strategies can be of value here in helping to restructure the way situations are perceived so that the tendency to see situations as relevant to a given trait is reduced. For example, the core beliefs and assumptions that are typical for people with high levels of anxiousness can be identified and challenged cognitively and via behavioural experiment. This may modify a tendency to over-estimate the risk associated with particular situations. Increasing behavioural alternatives can also be a useful strategy. For example, someone with high levels of submissiveness can modify trait expression by learning assertiveness skills and putting new, more assertive behaviours into practice. Similarly, teaching effective relaxation skills can provide incompatible behavioural alternatives to becoming anxious for people with high anxiousness levels.

People with high levels of anxiousness and emotional lability traits could usefully attempt to substitute the unhelpful, trait-amplifying behaviours of rumination and catastrophisation with healthier, trait-reducing behaviours of problem solving, distraction and self-soothing.

Promote more adaptive trait-based behaviour: The goal here is not to reduce trait expression but to replace the maladaptive behaviours associated with the trait with more adaptive behaviours. For example someone with high levels of stimulus-seeking may engage in risky sexual behaviour, become involved in fights and misuse substances. More adaptive replacement behaviours could include, for example, high-risk sports.

Promote the selection and creation of environments compatible with the adaptive expression of problematic traits This strategy is about improving the goodness of fit between the person and the environment by modifying the environment rather than the traits. For example, someone with high levels of social avoidance may function poorly in a busy sales job, but may do very well in a relatively solitary occupation such as a long distance lorry driver. Similarly, a person with high levels of compulsivity may do very well in an administrative job which requires methodical attention to detail but do less well in a less ordered work environment. Similar considerations apply to accommodation, leisure time activities and the
interpersonal environment. 

The key difference with this phase, with a primary focus on the future, is not so much about changing existing psychological and interpersonal structures and processes as putting new ones in place. The aim is to promote a more integrated sense of self and a healthier interpersonal environment — this may include development of new leisure activities, occupational or educational activities, together with new roles and relationships. A wide range of activities can help with this process of developing more stable and healthy representations of the self and others by promoting new roles, relationships and responsibilities. The role of the CMHT more likely to be in supporting this process rather than in providing the activities.

Where there are issues of particular complexity or severity, consideration should be given to using the Care Programme Approach or similar approach or process which supports the aims listed below:

• Clarity about roles and responsibilities
• Improved communication and reduced “splitting”
• Regular needs assessment and planning
• Regular risk assessment and planning
• Allowing for the care team, rather than one individual clinician to support the patient to take positive, clinically-indicated risks. This helps avoid scenarios where one clinician is overly risk-averse to the detriment of the patient by ensuring that clinical decisions are taken in a well-reasoned way by a multidisciplinary team.
• Enabling managed transition from one phase of treatment to another and ensuring that all involved are aware of the current treatment phase
• Influencing the interpersonal environment (including the CMHT) to minimise the impact of personality disorder. For example, mental health services can sometimes represent most or all of a patient’s interpersonal contacts. In these cases, the balance between providing support without fostering dependency becomes very important.
• Influencing nature and frequency of contact between patients and other services and agencies with a view to gains in some of the areas described in the needs assessment. This might include involving agencies such as housing in an attempt to help stabilise the environment.
• Highlighting which interventions are helpful at which times and, conversely, which are not.

Many patients with personality disorder carry significant risk issues and a degree of anxiety can be experienced by patients, relatives and professionals as a result. However, elimination of risk is impossible and working in a way which tries to eliminate all risk is often harmful. Clinically indicated positive risk taking with the aim of increasing personal responsibility and development of skills is a key part of the treatment of personality disorder. Unless there is a compelling reason to do otherwise (for example, co-occurring severe mental state disorder), it is important at all times to treat a patient with personality disorder as a competent adult, with capacity to make their own choices and responsible for their own behaviour. Although the clinician is responsible for carrying out clinical practice at a reasonable standard of care, the patient is ultimately responsible for their own behaviour. This understanding is necessary to enable the collaboration between the team and the patient which is necessary for recovery.

At times, patients may pose a risk to other people. Staff should remain aware of what constitutes unacceptable behaviour, taking appropriate action as per NHS Highland policy if such behaviour occurs. If the unacceptable behaviour constitutes criminal behaviour such as displays of aggression or the obstruction of health care workers in the legimate course of their duties, consideration should be given to involving the police rather than treating law-breaking as a health issue in the first instance. The importance of maintaining a safe treatment frame is paramount. Clinical experience suggests that if external behavioural modifiers such as the ability to access police and criminal justice services are inappropriately removed, then clinical, behavioural and functional deterioration is likely. An individual is unlikely to be harmed by appropriately maintaining a limit whereas they are unlikely to be helped by inappropriately ignoring a limit.

Multidisciplinary care planning means that the team jointly accepts any risk associated with a patient, rather than a single clinician. The Care Programme Approach can help formalise risk assessment and management plans and identify roles and responsibilities clearly. At times it may be helpful to document if a person has a chronically raised risk of completed suicide (for example in situations where a history of parasuicidal behaviour is present), which treatments have been offered and what has been helpful, unhelpful or harmful.

It is important to distinguish between chronic and acute risk of suicide. Acute risk increase often occurs in the presence of increased impulsivity or intent.

Important factors to consider in reviewing an adverse event are:

• Was there a foreseeable risk? Appropriate assessment and documentation of risk is crucial.
• Was there a reasonable response? Any decision should be well reasoned, come from a caring, therapeutic position and have a documented cost-benefit analysis. This allows for clinically indicated (but sometimes superficially counterintuitive) responses. For example, not admitting someone with potentially lethal self-harming behaviour to hospital.
• Was there a reasonable standard of practice? Quality of practice should be assured with regular supervision and communication with the rest of the team. Relevant guidance should be followed and reasons documented if it is not. Documentation should be of a reasonable standard.

The issue of carer involvement in the treatment of personality disorder is a contentious one. There is even some controversy over the term carer itself inasmuch as it is deemed by some to be an invalidating term which moves the focus from self-management. Bearing that in mind, the term “social network” is used here.