Personality disorder services
(See E Therapy in clinical practice in Chapter 5, pp. 154-63; Psychological therapy in secure settings in Chapter 8, pp. 428-39; Planning psychotherapy services within psychiatric care in Chapter 10, pp. 462-6; Forensic psychiatry: forensic psychotherapies, applications, and research in Chapter 12, pp. 550-6.)
in one form or another, patients with personality disorder have been treated by mental health services for perhaps as long as services have been in existence. Whether under the guise of the treatment of ‘moral insanity’ in a Victorian asylum or of severe and entrenched relational difficulties in an NHS psychotherapy unit, the treatment of what we would now term personality disorder has long been the remit of mental health services in the UK. As such, services have essentially been treating patients with personality disorder for a lot longer than there have been formal personality disorder services, and it is only relatively recently that PD-specific services have been developed. agreement over their structure, function, and specification is continuing to develop. Ап understanding of the development of Pd services, as well as a working knowledge of what services are—and should be—available locally, can be very helpful clinically, particularly in those (not uncommon) cases where patients can become ‘stuck’ within the system.
Given that the key features of a personality disorder often include problems in engaging consistently with treatment and a fragmented sense of self, it is perhaps not a coincidence that services for patients with personality disorder have struggled to develop in a consistent, integrated, and coherent manner. There has been a long history of ambivalence around the development and maintenance of personality disorder services, which is perhaps not entirely unrelated to the complex way that patients with personality disorder can interact with the system. Until relatively recently, it was often a widely held view that personality disorder was not the remit of secondary mental health services and that personality- disordered patients were essentially ‘untreatable’. Many therapy services would view personality disorder as grounds for exclusion. Treatment in those cases, such as it was, would often be limited to crisis interventions. The personality disorder services that did exist tended to develop in an ad hoc manner as independent ‘silos’. They were often excessively dependent upon the energy and expertise of local specialists or practitioners with an interest in the area. Pathways within and between different parts of services were often rudimentary or not present at all.
The case of Michael Stone is often cited as the main reason for high- profile government intervention in the development of personality disorders services. In 1996, Michael Stone had been deemed untreatable, because of his diagnosis of personality disorder, and therefore could not be detained under the MHA at that time and was thus at liberty to kill his victim Lynn Russell. Although the high-profile and shocking nature of this case was one of the main drivers for a change in government policy, which included removing the ‘treatability clause’ of the MHA, there were already growing levels of awareness of (and frustration about) barriers to treatment and gaps in service provision, as well as the lack of widespread knowledge and expertise in the treatment of patients with personality disorder. Whatever the ultimate cause, it was subsequent to this highly publicized case that the government made a considerable amount of money available for the development of the ‘Dangerous and Severe Personality Disorder' (DSPD) programme and launched the National Personality Disorder Development Programme.
The National Personality Disorder Development Programme was designed with the aim of shifting attitudes towards the treatment of patients with personality disorder; increasing awareness and skill levels; improving the evidence base and theoretical developmental of personality disorder treatment; and the development of more integrated treatment pathways at national and local levels for patients in the community, hospital, secure care, and the prison estate. Central to this was the release, in 2003, of the key policy documents ‘No Longer a Diagnosis of Exclusion’ and 'Breaking the Cycle of Rejection’. These were launched to support service development and to help set a framework for training and workforce development.
in 2004, 11 innovation projects were set up nationally in the community, with the main aim of treating patients with personality disorder, as well as providing information and outcomes to aid for future planning of services. in 2007, the Department of Health and the Ministry of Justice commissioned the development of a national framework to support people to work more effectively with personality disorder—the Knowledge and Understanding Framework (KUF). The framework comprises educational programmes that are delivered by experienced and highly trained personality disorder practitioners and service user consultants. One of the central aims of the framework was (and is) to improve service user experience through developing the skills and expertise of the multi-agency workforce (health, social care, and criminal justice) who deal with the challenges of personality disorder (see E Service user involvement in Chapter 10, pp. 466-71).
The DSPD programme, which was run in medium and high secure hospitals and the prison estate, provided an essential stimulus in setting up and developing areas of expertise in the treatment and management of highly disturbed, high-risk individuals who would have previously been deemed untreatable. Following a major review, the DSPD programme is undergoing decommissioning, but there continues to be a number of patients treated within it at a reduced number of sites for the time being. More recently, the emphasis in the forensic programme has shifted from focusing on intensive treatment for the 'critical few' to attempting to make fundamental changes to the system that manages offenders/high-risk patients to ensure that all offenders within the criminal justice system who have a personality disorder are identified at the earliest opportunity and screened into the personality disorder programme, and that those working with them are offered case formulation and an appropriate pathway for treatment. in essence, this represents a switch from a low-volume/high-intensity model to a higher-volume/ I ower- i ntensity approach, with the aim of having a greater overall impact on those who suffer from the effects of personality disorder (including the victims of violent offences committed by offenders with personality disorder). Part of the rationale for this appears to have been the limited evidence for the efficacy/cost-effectiveness of the original DSPD programmes, despite the good work that was undertaken (see Psychological therapy in secure settings in Chapter 8, pp. 438-9).
Another aspect of the personality development programme which has seen important changes brought in has been the close partnership with service users. Service user involvement is now an integral part of development within the field and is now nationally coordinated by the user- led organization 'Emergence', as well as through local organizations (see E Service user involvement in Chapter 10, pp. 466-71).
As part of the developments, services were organized and clustered to fit in with a national personality disorder pathway model, based on six 'tiers' (see Fig. 8.6). Tier One, with the highest volume of patients who
Fig. 8.6 Tiered model of personality disorder services.
have unmet needs, would be delivered through primary care, social care, specialist outreach, and the third sector. Tier Two would be delivered by mainstream mental health and specialist outreach, whilst Tier Three would see increasingly complex or high-risk patients within local specialist services. Tier Four is the level at which services become residential and involve regional and super-regional specialist services. Tiers Five and Six are essentially forensic levels, Tier Five being medium security and prison Tcs, whilst Tier Six involves the personality disorder treatment units in Ashworth, Rampton, and Broadmoor High Secure Hospitals.
Recent well-publicized changes to NHS structure and commissioning processes brought about by the Health and Social Care Act 2012 have led to some uncertainty over the continued use of this tiered model, primarily as different parts of this tiered pathway are now overseen by different Clinical Commissioning Groups and bodies, leaving certain services liable to decommissioning at a local level. Tier Three services (in particular, the 11 pilot sites for specialist community-based personality disorder treatment services) had been centrally funded through the Department of Health but recently have had to apply to local Clinical Commissioning Groups for ongoing funding at a local level. This has led to some radical cuts and indeed closures of many of these units. Linked to this, Secure Commissioning Groups appear to have tightened the remit of low and medium secure provision, so that only those who present a serious risk of harm to others are admitted. in practice, this appears to mean that patients who had been referred into secure services for their capacity to provide specialist personality disorder treatment and robust relational security and understanding are being transferred to (mostly independent sector) locked rehabilitation placements, often with little specialist capacity to treat complex patients with personality disorder. presently, there are only 60 beds in Tier Four placements, provided by four units in the london region and two in Yorkshire. Clearly, this is insufficient for the numbers of patients requiring residential treatment, and work is currently being undertaken to determine the actual level of need and to think about how this can best be provided on a local or regional level.