Consistency

Appropriate treatment frame management for anyone treating people with personality disorder is a key therapeutic skill. Treatment frame refers to the agreed structure and “ground rules” which are sometimes called the “limits” or “boundaries” of any therapeutic intervention.

These include limits of:

Key aspects of the frame such as those outlined above should be made explicit and agreed at the start of treatment. Some aspects may remain implicit but may need to be made explicit when necessary—for example, in a situation where a patient offers the therapist a gift. Once treatment has begun, it is the clinician’s responsibility to maintain a secure treatment frame. A secure frame is one which is firm but not rigid, and which marries clarity, consistency and reliability with sensitivity of response to the patient’s needs.

An insecure frame lacks consistency, reliability and predictability and often leads to a deterioration of the patient’s condition. At times there may be pressure to modify a limit or boundary within treatment. It is important to recognise when such a modification would help maintain the treatment frame and when the
modification would threaten the frame. Any threat to the frame should be openly discussed within treatment with a view to repair. This includes acknowledgement of errors of frame management on the clinician’s part or unavoidable interruptions to the frame. In these situations, the aim should be re-establishment of a secure treatment frame at the earliest opportunity.

However, on rare occasions, such severe pressure will be put on the treatment frame by some patients that it may be necessary to terminate the treatment contract. This should be considered when it is likely to represent a less harmful option compared with continuing treatment within an insecure frame. It is important to remain aware that resisting pressure to inappropriately modify the frame will not make the patient worse, whereas giving in to pressure to inappropriately modify the frame will not be helpful to the patient.

In situations where several clinicians have contact with a patient, the treatment frame should be clearly shared and agreed by all involved. This helps reduce the risk of “splitting”. Patients with personality disorder frequently experience the world in a polarised way which is sometimes described as experiencing the world “in black and white”. This can mean that one team member is experienced as “all good”, while another is experienced as “all bad”. This can affect the behaviour of the clinicians involved. For example, the team member experienced as “all good” may be more likely to want to offer the patient an overly nurturing care plan at the expense of the patient taking responsibility for their own safety and recovery, whereas the team
member experienced as “all bad” may begin to think that the patient is not being helped by the team and should be discharged. Dynamics such as this can contribute to team conflict, especially if there are pre-existing professional or personal differences, can lead to the creation of insecure treatment frames which are harmful for patients, and can leave professionals feeling unsupported and uncontained. This process is sometimes known as “splitting”.

Splitting can also occur between different teams involved with a patient’s care, leading to a potentially destabilising inconsistency of approach. This form of splitting is especially likely if conflicting theoretical and attitudinal positions are held by different teams, particularly in situations where communication between teams is sub-optimal and the ability to consider alternative perspectives is reduced.

Therefore, good communication between everyone involved, regular self-observation and reflection, and a consistent treatment frame are necessary not only for the benefit of the patient, but also for the benefit of the professionals and services involved. In particularly complex cases, consideration should be given to use of the Care Programme Approach which helps ensure regular meetings, good communication and the provision of a clear written care plan (incorporating the treatment frame) for all involved, thus optimising consistency. Appropriate supervision also has an important role to play in helping professionals recognise and manage
splitting processes.

Clinicians should recognise that withdrawal or ending of treatments, and transition from one service to another, may evoke strong emotional responses in some patients. Such changes should be highlighted and discussed as far ahead in time as possible and a crisis self management plan should be in place. Changes should be managed in a structured way which is made explicit within the treatment frame. Collaboration between services and patients is crucial at times of transition from one service to another to ensure as little inconsistency as possible. When a patient is referred for assessment or treatment to another service, consideration should be given as to whether support arrangements would be appropriate in the interim.