Collaboration:

This applies equally to collaboration with the patient and collaboration with the wider team. Ensure that everyone is clear about their roles and responsibilities, and the treatment frame. The importance of personal responsibility and self-management should be emphasised. The Care Program Approach (CPA) can be very valuable in helping clarify roles and promote consistency. CPA meetings provide a valuable opportunity for professionals and the patient to assess needs and risk and develop an appropriate care plan collaboratively. While it is recommended that patients at the more severe end of the personality disorder spectrum who have multi-disciplinary or multi-agency involvement should be managed under the CPA, any clear written care plan shared between all relevant professionals and the patient is likely to improve care delivery.

Consistency:

Limiting the number of General Practitioners a patient sees to one or two in order to allow a good working relationship to develop can be of value in promoting collaboration and consistency. If a Care Program Approach (CPA) care plan or other written care plan is in existence, then it is important that clinicians (including out of hours staff) are aware and able to easily access the information. Inconsistency, for whatever reason, can lead to significant anxiety and dysregulation. A shared plan can make it less difficult to appropriately maintain limits in the face of pressure. Consider placing any care plan in “special notes” or similar. Often GPs, working within tight clinic schedules or in out-of-hours settings, come under significant pressure from patients in distress to “do something”. This can sometimes result in unhelpful reactive prescribing. It is important to remember that standing by a decision not to prescribe, while validating the patient’s desire for the situation to change and explaining the rationale of the care plan, is in fact often “doing something” therapeutic. If medication is felt to be appropriate, it is recommended that a written prescribing agreement is used. See Medication Section for further details.

Motivation:

Some suggested strategies for increasing motivation to change can be found in General Principles Section.

Validation:

Validation involves active listening and observation, accurate reflection of the patient’s emotions, thoughts and behaviours, and direct validation (the explicit acknowledgement of a thought, emotion or behaviour as valid and legitimate for that person, both understandable in the current context and in the context of previous experiences). It is important to recognise that validation does not necessarily imply approval.

Promotion of self-management:

Supporting self-management across health conditions is a key part of the role of primary care. Further information on how the concept relates to personality disorder can be found in the Self-Management Section. Promoting self-knowledge and self-reflection are a component of self-management which is particularly important in personality disorder. This process may involve provision of general information about the condition but should also comprise more individual-specific knowledge gained by a process of self-reflection. Wherever possible, consider highlighting the importance of attempting to understand the mental state of oneself and others and how thoughts and emotions influence behaviour.