Personality disorder integrated care pathway
Collaboration is not only important between patients and professionals but also between different professionals, teams and agencies. Good communication and joined-up working helps ensure consistency. A shared care model will often be valuable in working with this patient group, in which different clinicians and services work together to implement different parts of a treatment plan.
Collaboration
Building and maintaining a collaborative relationship (also referred to as the therapeutic alliance or therapeutic relationship) is fundamental to the treatment of personality disorder. In contrast to some mental state disorders such as major affective disorders and psychotic disorders, there is little which can be delivered ‘to’ or ‘for’ the patient in terms of effective treatment. In other words, if the patient does not wish to engage collaboratively with treatment, then the disorder is untreatable. Shared understanding of this principle is crucial for meaningful work to happen.
Shared understanding is an important component for successful treatment:
- The clinician is responsible for delivering a reasonable standard of care and, unless there are very clear
reasons to assume otherwise (e.g. severe co-occurring major mental illness) - Each patient is assumed to be a competent adult, responsible for their own choices and the consequences of those choices
- Encouraging each patient to take responsibility and engage collaboratively with treatment is necessary to enable valuable positive risk taking to occur
- This approach can also assist clinicians to avoid assuming responsibility for patients and thereby making clinical decisions that are unhelpful in the longer term, such as providing extended hospital admissions
- A collaborative relationship can help instil a sense of optimism and hope, and provide a basis for a collaborative search for understanding. Furthermore, such a relationship encourages the collaborative setting of realistic treatment targets and effective acquisition of skills and knowledge.
- In addition, it enables modelling of effective interpersonal functioning and helps maintain motivation in patients and professionals
Ruptures within the relationship between patient and professional are to be expected. When this occurs, the focus should be on early identification of markers of rupture, exploration of the reasons for the rupture, and exploration and validation of the patient’s thoughts and feelings about the rupture. Rapid repair to the relationship is the aim. This may require finding solutions to prevent the rupture recurring.
Members of the patient’s social network should be involved in the treatment plan where appropriate. Education about the condition, along with a shared understanding of the formulation and the treatment plan (and their role within it) can improve collaboration and outcomes.
Compulsory treatment should be avoided except in exceptional circumstances and voluntary treatment should resume as soon as possible. The potential harm of removing responsibility from the patient and associated loss of collaborative working should be carefully considered.
Any benefit of detention is likely to occur at the safety and containment phases of treatment only. Self-regulation and control are unlikely to occur while the patient’s responsibility for themselves is removed and thus meaningful stabilisation is unlikely. Furthermore, there is no good evidence for the effectiveness of compulsory treatment and some specialist psychological interventions (e.g. Dialectical Behaviour Therapy or DBT) specifically state that patients should engage with the treatment voluntarily. Similar cautions apply to patients who have been instructed to attend a treatment program by the courts or other agencies.
Patient involvement and collaboration is important not only within the treatment of individual patients but also for the development and delivery of services for people with personality disorder.
Patient involvement in services can be conceptualised as a continuum with increasing levels of
input:
• Information: Patients are given information about services. Examples include provision of leaflets and open days.
• Consultation: Information, views and feedback about services are sought from patients. Examples include feedback forms for specific interventions and focus groups.
• Participation: Patients influence the development of the service. Examples include the Personality Disorder Service Steering Group, which includes NHS staff, patients and other stakeholders.
• Inclusion: Patients are involved in the delivery of the service. Examples include the Volunteer Post in the CAS Day Service and co-delivery of education sessions.
• Partnership: Patients are involved in sharing decisions and responsibility. Examples include patients sitting on interview panels for staff and volunteer appointments to the Personality Disorder Service.
• Consultation: Information, views and feedback about services are sought from patients. Examples include feedback forms for specific interventions and focus groups.
• Participation: Patients influence the development of the service. Examples include the Personality Disorder Service Steering Group, which includes NHS staff, patients and other stakeholders.
• Inclusion: Patients are involved in the delivery of the service. Examples include the Volunteer Post in the CAS Day Service and co-delivery of education sessions.
• Partnership: Patients are involved in sharing decisions and responsibility. Examples include patients sitting on interview panels for staff and volunteer appointments to the Personality Disorder Service.