Personality Disorder and Community: A Practitioner's Guide - Brossura

Brossura

ISBN 10: 0470011726 ISBN 13: 9780470011720

Casa editrice: John Wiley & Sons, 2009

Riassunto

Practitioners in Community Mental Health Teams (CMHTs) frequently find that traditional forms of support are ineffective when offered to patients with personality disorder.

This book considers the various difficulties encountered, with reference to current thinking about the origins, maintenance and treatment of personality disorder. Written by practitioners for practitioners, it provides a framework for developing effective care plans with minimal use of technical terms and jargon. Rather than promote an approach based on a single theoretical model, consideration is given to ways in which different approaches can be effectively combined within a multi-disciplinary team. The book is divided into two sections. The first outlines recent government initiatives relating to personality disorder and introduces key theories underlying psychological and biological treatments. The second focuses specifically on the role of the CMHT in relation to patients with these difficulties, including:

• the assessment of personality functioning
• developing coherent plans for treatment and support
• optimising the therapeutic relationship
• managing self-harming behaviour
• particular challenges faced by CMHTs, and how to overcome them
• the views of service users
• involving family, friends and carers.

Personality Disorder and Community Mental Health Teams deals with the reality of services today. It is essential reading for all mental health practitioners in CMHTs working with people with personality disorder.

Su questo libro

Informazioni sull?autore

Mark Sampson works as a clinical psychologist in two Community Mental Health Teams (CMHTs) in South Manchester. He has been a part of these teams for the past five years and during this time developed experience and expertise in working with patients with personality disorder. He originally trained as a general and psychiatric nurse before studying psychology, obtaining a doctorate in clinical psychology from the University of Manchester in 1999. He uses integrative approaches to working with patients with personality disorders, but is strongly influenced by cognitive and cognitive analytic therapies.

Remy McCubbin first studied Biology at Southhampton University, graduating in 1987. He went on to study for a MA in Psychology at Nottingham University, graduating in 1993, before working on an evaluation of three CMHTs in the Midlands. In 1998 he completed a doctorate in clinical psychology, since which time he has worked across several community teams in South Manchester. This has inspired an interest in personality disorder, and has led to a recognition of the importance of such difficulties in the response to treatment of many people seen by these services. He has an interest in several forms of therapy, and the potential advantages of integrating various approaches within multi-disciplinary interventions. Away from personality disorder, he has an interest in the role of affective avoidance in the maintenance of various Axis I and Axis II disorders.

Peter Tyrer is the Head of the Department of Psychological Medicine at Imperial College, London, Honorary Consultant in Rehabilitation Psychiatry, Central North West London Mental Health NHS Trust, and Honorary Consultant in Assertive Outreach (IMPACT team) in West London Mental Health Trust. He obtained his medical qualifications at the University of Cambridge at St Thomas's Hospital London in 1965 and trained in psychiatry at the Maudsley Hospital and Institute of Psychiatry, London. He has carried out research into personality disorder since he was a medical student and has published two books and over 100 original articles on the subject. He is the founder president of the British and Irish Group for the Study of Personality Disorders and the Co-Chair of the Section on Personality Disorders of the World Psychiatric Association. He is a Fellow of the Academy of Medical Sciences, of the Faculty of Public Health, of the Royal College of Physicians, and of the Royal College of Psychiatrists. He is the Editor of the British Journal of Psychiatry and on the editorial board of seven other journals. Despite his academic interests he still regards himself primarily as a ‘coal-face’ psychiatrist, who has learnt most from his patients—and among the most stimulating and challenging of these have been those with personality disorder.

This book considers the various difficulties encountered, with reference to current thinking about the origins, maintenance and treatment of personality disorder. Written by practitioners for practitioners, it provides a framework for developing effective care plans with minimal use of technical terms and jargon. Rather than promote an approach based on a single theoretical model, consideration is given to ways in which different approaches can be effectively combined within a multi-disciplinary team. The book is divided into two sections. The first outlines recent government initiatives relating to personality disorder and introduces key theories underlying psychological and biological treatments. The second focuses specifically on the role of the CMHT in relation to patients with these difficulties, including:

• the assessment of personality functioning
• developing coherent plans for treatment and support
• optimising the therapeutic relationship
• managing self-harming behaviour
• particular challenges faced by CMHTs, and how to overcome them
• the views of service users
• involving family, friends and carers.

Personality Disorder and Community Mental Health Teams deals with the reality of services today. It is essential reading for all mental health practitioners in CMHTs working with people with personality disorder.

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Personality Disorder and Community Mental Health Teams

A Practitioner's GuideBy Mark Sampson

John Wiley & Sons

Copyright © 2006 Mark Sampson
All right reserved.
ISBN: 9780470011720

Chapter One

Personality Disorder: New Initiatives in Staff Training

EDDIE KANE

INTRODUCTION

A good deal is already known about personality disorders. There is also an increasing understanding of what is helpful and unhelpful for people with these disorders. It is therefore important to communicate this knowledge to the increasing numbers of staff, in a wide range of agencies, with whom they come into contact.

With a few notable exceptions, clinicians have for years tended to avoid involvement in the treatment and support of people with personality disorders. Tolerance of these attitudes is rightly declining. This change in attitude has been well supported by new Guidance from the National Institute for Mental Health in England (NIMHE, 2003a, 2003b) developed in the wake of the National Service Framework for Mental Health (Department of Health, 1999). Relatively small sums of new national money have been used to stimulate the growth of new and sometime novel services. As well as service development, training for staff is becoming a higher priority.

Despite these encouraging developments and changes in attitude there is a long way to go. People with personality disorders are still one of the most socially excluded groups in our society. Their experience of services from a wide range of agencies demonstrates a lack of tolerance and awareness of their issues and of them as individuals. Other chapters in this book aim to help redress the situation by offering readers an opportunity to be more aware of personality disorders, the people who experience them and the techniques and support systems that can help them.

BACKGROUND

Recent initiatives from the UK government to improve services for people with a personality disorder have raised the profile and the importance of staff training for a wide range of staff engaging with patients with these problems. No longer can training be the preserve of a minority of interested professionals. Rather, it will need to move centre stage for a much wider range of people, in many different agencies. An appreciation of current thinking and the development of best practice is important for anyone involved in delivering community-based services. In particular, working with people with personality disorders is likely to become an essential area of required expertise for Community Mental Health Team (CMHT) members.

The competencies required for working with people with personality disorders are in many respects similar to those needed to work with other individuals with a range of mental disorders. However, there are some clear differences. Direct professional involvement in the area of personality disorders demands a high degree of personal resilience, the ability to maintain good boundaries and manage hostility and conflict. Individual members of staff also need to be multi-disciplinary team players and be able to appreciate the value of team working and support. Just as important is the ability to tolerate and manage the emotional impact on the multi-disciplinary team's functioning that intensive working with people with a personality disorder can create.

Recent work by the National Institute for Mental Health England (NIMHE) has begun to firm up the agenda for staff training and suggests an integrated 'Skills Escalator' as the most effective framework for staff training and development.

This chapter will:

discuss the context for the recent government and NIMHE initiatives to improve services for people with personality disorders

outline these initiatives, particularly those related to staff training

reflect on how these initiatives could help CMHTs work more effectively.

Taking this training and development framework forward is perhaps one of the most critical areas of mental health services in which progress needs to be made nationally. Without such progress, people with personality disorders will remain one of the most excluded groups of individuals, will be denied relevant and sensitive services, and will continue to be vulnerable in our society. This is a future that ought not to be contemplated in 21st century Britain.

A FRAMEWORK FOR REFORM

The National Service Framework for Adult Mental Health (NSFMH) (Department of Health, 1999) describes a clear set of responsibilities. These responsibilities focus particularly on the provision of evidence-based and effective services for all people with mental disorders, including those with personality disorders (who are debilitated and excluded as a result). As part of the practical implementation of the NSFMH, in January 2003 the National Institute for Mental Health in England published Personality Disorder: No Longer a Diagnosis of Exclusion (NIMHE, 2003a). The guidance was intended to build on standards four and five of the NSFMH, and to ensure the development of specific services for people with personality disorders.

The guidance started from the premise that personality disorders are common and often disabling conditions. Many people with personality disorders are able to manage their lives and relationships successfully on a day-to-day basis. However, there are a significant number of individuals who suffer a great deal of distress. These individuals often receive few or no tailored services and their interactions within their social and their service networks are frequently dysfunctional, and unsatisfactory to themselves and the people to whom they try to relate. Few National Health Service (NHS) organisations and even fewer of the other potential service-providing agencies have specific services for people with personality disorders. In 2002 only 17 per cent of NHS Mental Health Trusts provided a dedicated service for people with a personality disorder (NIMHE, 2003a). The situation is compounded by the fact that even where there is dedicated provision, the services are based on widely varying and occasionally conflicting therapeutic models and approaches. As a result, people are frequently treated or supported at the margins-for example, in Accident and Emergency departments, through inappropriate admissions to psychiatric units, lost in a CMHT's caseload or as frequent and unsatisfied attendees at a GP's surgery.

Underlying this unsatisfactory state of affairs is the belief amongst many mental health and social care professionals that there is nothing that people with a personality disorder can be offered that would help them move towards recovery and an improved ability to cope with everyday life. The guidance also highlighted the danger that the proposed changes in the draft Mental Health Bill would emphasise even further the enormous gap in services and skills by removing the so-called 'treatability test', which has been frequently used as a way of excluding individuals from treatment, particularly by mental health service providers. In effect, some of the most damaged and excluded people in society are refused treatment because individual clinicians make decisions based on their view that people with a personality disorder will not respond to any interventions they have at their disposal. This process of exclusion is legitimised by the current Mental Health Act, which specifies that an individual must be deemed to be treatable before treatment is offered.

Clearly, this was not a position that could continue if the government's commitment to modernise services was to be delivered. Not only was new investment needed in direct service provision, but also a major initiative was required to provide new training opportunities to ensure that not only clinicians and practitioners but also staff in a wide range of agencies had access to training, ranging from 'awareness training' to specific high-level treatment skills.

In summary, Personality Disorder: No Longer a Diagnosis of Exclusion (NIMHE, 2003a) recommends that services should:

Assist people with personality disorder who experience significant distress or difficulty to access appropriate clinical care and management from specialist mental health services.

Ensure that offenders with a personality disorder receive appropriate care from forensic services and interventions designed both to provide treatment and to address their offending behaviour.

Establish the necessary education and training to equip mental health practitioners to provide effective assessment and management.

Translating these specific aspirations for personality disorder services into action on the ground has become one of the major challenges for mental health and other services providers, trying to deliver the spirit and the targets set out in the NSFMH. However, the publication of the guidance, the promise of new money and the setting of specific delivery targets for the NHS has led to a focus on these services as areas where performance improvement is expected by the Department of Health, NHS Trusts, Strategic Health Authorities and Primary Care Trusts. This in turn has stimulated a number of developments aimed at improving services, and appears to have introduced tentative discussions about 'recovery', aligning clinical and organisational responses to people with personality disorder to the mainstream of modern mental health policy and development.

Amongst the developments are 11 new, community based services funded by the Department of Health. These new services are very diverse. Some are to be provided within specialist mental health services, others will be run directly by service users and another group will be delivered through local voluntary organisations. The client groups being targeted through these new services are equally diverse. They include young people, adults and those who have severe substance misuse problems. It is hoped that with the establishment of these new services, and their subsequent independent evaluation, there will be a significant shift upwards in the evidence base about what works and what does not work in treating and supporting people with personality disorders. The evaluation of the bids to provide these new services has had close involvement from a national service user reference group. This group was instrumental in making the final choices and their opinions genuinely weighed as heavily as those of their colleagues from the statutory agencies. After such a positive experience, it is hoped that the pattern of closer involvement of service users in developing and evaluating services will become the norm for services to people with personality disorders, which in the past it certainly has not been.

THE TRAINING GAP

The key to delivering new services and transforming the response of existing mainstream mental health and social care services for people with personality disorder is the development of a workforce that is more aware of the issues that affect people with personality disorders and the way they react to them. This should be a minimum requirement affecting staff in many agencies, both statutory and voluntary, which provide a wide range of essential services including housing, emergency and primary care, employment and benefits advice. Developing personality disorder awareness is important if staff are to better understand the behaviours and attitudes with which they may be presented from time to time, and be able to respond more effectively. It is also a vital ingredient in challenging the stigma that is associated with the diagnosis of personality disorder. To date, that label has more often than not resulted in the exclusion of people from help and support, and has restricted their ability to participate properly as full members of society. The weight of stigma is still a major obstacle for individuals attempting to seek help with their problems. It is fuelled to a large extent by the absence of personality disorder perspectives in mainstream professional training. This difficult and perverse position is summed up well by the following observation: 'In Britain we have the remarkable phenomenon that large numbers of quite severely disordered people who require considerable therapeutic effort are deemed untreatable' (Gunn, 2000).

Although a vital component of service reform, personality disorder awareness is not of itself sufficient. There is also a need for some staff groups to develop new ways of working with people with personality disorder, drawing on the currently small but expanding evidence base, to find ever more effective interventions and support mechanisms. These staff groups are in a wide range of agencies and often in roles not traditionally associated with delivering services to people with personality disorders. In the background survey work carried out prior to the development of Personality Disorder: No Longer a Diagnosis of Exclusion, groups other than those traditionally associated with delivering services to people with a personality disorder emerged as high priorities for new training initiatives. These groups included health visitors, district nurses, junior doctors in Accident and Emergency departments and local authority housing officers. New ways of delivering training to these groups need to emerge and existing training technologies need to be adapted to meet what is a growing need, which will translate into a growing demand for relevant, accessible and high quality training programmes.

TRAINING INITIATIVES: THE NATIONAL CONTEXT

The new service developments for people with personality disorders are taking place in a rapidly evolving mental health training and educational context. This evolving context includes new structures and partnerships, as well as the arrival of new players. Key to these new programmes and partnerships are the Regional Development Centres of NIMHE. Each of the regional offices has the responsibility to work with a broad range of local agencies delivering services to people with personality disorders, and has been given funding to help move the training and development agenda forward.

The regional initiatives already underway comprise a wide range of approaches and objectives. For example:

pilot 'personality disorder awareness cascade' courses

mapping of existing training programmes

development of multi-stakeholder training specifications

development of CD-ROM and internet-accessed training packages

tailored training for primary care staff.

In addition to developing tailored training packages that reflect local need, there is much still to be done to embed awareness of personality disorders into the pre- and post-registration education. Key targets are clearly professionals working directly in therapeutic relationships, but also other professionals who come into contact with people with a diagnosis of personality disorder, including GPs and other primary care staff. This breadth of approach is vital if effective and co-ordinated support networks for individuals are to be established.

There is evidence of an encouraging recognition of the need to change both pre- and post-registration training to incorporate the dimension of personality disorder, by several of the key national registration bodies. These include the Royal College of Psychiatrists (RCoP), the British Psychological Society (BPS) and the Nursing and Midwifery Council (NMC). There is also growing enthusiasm from organisations such as the Prison Service, which at any one time has custody of large numbers of people with personality disorders and whose staff are often ill equipped to develop or deliver a productive set of interventions.

It is also important to acknowledge that whilst good quality, multidisciplinary training is in short supply it does exist. There are some examples of existing good practice, including well established training programmes, manuals and other training materials. These at least represent a foundation for future national, regional and more local developments and consideration needs to be given to how best to apply these tools to new and wider audiences. One possibility which has been discussed is the development of a 'capability benchmark' process for these products and programmes, which would act in the same way as the quality kite mark in ensuring consistent standards. The benchmark process would be led through NIMHE and its education partners. Assessing the quality of existing training programmes and media will be an important first step.

Continues...

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Dettagli dell?edizione

• Editore: John Wiley & Sons
• Data di pubblicazione: 2009
• Lingua: Inglese
• ISBN 10: 0470011726
• ISBN 13: 9780470011720
• Rilegatura: Copertina flessibile
• Numero di pagine: 388
• Redattore: Sampson Mark
• Contatto del produttore: non disponibile
• Persona responsabile: non disponibile