Phases of treatment | Right Decisions

The overall goal in the treatment of personality disorder is to improve adaptation to the environment rather than effect personality change. However, given the complexity of personality disorder, at times it can be difficult to develop a specific treatment plan in the service of this goal, and a structured approach can be of real value. There is expert consensus that phase-based models are important in informing the sequence of interventions in the care and treatment of complex mental disorders such as personality disorder.

The particular model used in this document adapts the work of Livesley (2003) and, like most other phase-based models, comprises 3 main phases. However, Phase 1 (stabilisation) is broken down into a further 3 sub-phases. This finer-grained model is more clinically useful. For example, it can help explain why lengthy hospital admission usually fails to produce stabilisation: while hospital admission has value in the safety phase and to some degree the containment phase, it seldom has a positive effect (and often exerts a negative effect) on promoting self-regulation and control. This is related to the removal of responsibility for self management from the patient.

Any treatment for personality disorder should be based upon an individual formulation with clarity about the goals and purpose of the intervention for the person at that time. Each phase should be worked through sequentially. The phases of treatment comprise:

1. Stabilisation (or MAKING STABLE). The focus is on the present:
a) Safety: Interventions to ensure the safety of the patient and others.
b) Containment: Interventions based primarily on general treatment strategies such as validation and stabilising the environment in order to contain behavioural and affective instability. May be supplemented with medication if appropriate in the short term.
c) Regulation and control: Behavioural, cognitive and occasionally pharmacological interventions to reduce symptoms and improve self-regulation of affects and impulses
2. Exploration and change (or MAKING SENSE). The focus is on the past: Interventions to change the cognitive, affective, interpersonal and situational factors contributing to the patient’s difficulties. This phase may include specific trauma work but may be a more general exploration of long standing patterns of thinking and behaviour.
3. Integration and synthesis (or MAKING CONNECTIONS). The focus is on the future: Interventions designed to promote a more integrated sense of self along with more integrated and adaptive interpersonal systems

A single treatment approach can have a focus in more than one phase area, although usually the focus would be on only one phase at any given time, with sequential working through of the phases. Table 2.1, compares the primary focus areas of several interventions.

Table 2.1: Comparison of primary areas of focus for a variety of interventions.

	DBT	STEPPS	CAS Day Service	Crisis Admission	Crisis Intervention	Structured Admission
Safety	+++	+	+	+++	+++	+
Containment	+++	++	++	+++	+++	+++
Regulation and control	+++	+++	++	+/-	+++	+++
Exploration and change	+++	++	+++
Integration and synthesis	+	+	+++

Phase 1 and case example

People with personality disorder often present to services with emotional and behavioural dysregulation, requiring stabilisation interventions. These can be effectively provided across many settings and may range from supporting the problem-solving of a distressing interpersonal situation, to treatment of an Axis 1 or physical comorbidity, to a specialist psychological therapy targeting parasuicidal behaviour. Stabilisation may require support from several different services or agencies. An overall formulation with clarity about the phase of treatment and including explicit short and longer term goals is valuable in optimising consistency and may
mean the difference between repeated management of symptoms and treatment of the underlying disorder.

Jane, a 25 year old lady with severe borderline personality disorder, presented with multiple difficulties including poorly managed diabetes mellitus, alcohol dependence, housing difficulties, marked emotional dysregulation, self-harming behaviours and multiple suicide attempts. Stabilisation involved input from her psychiatrist who made the diagnosis and stopped the antidepressant tablet which appeared to be contributing to increased emotional dysregulation, her GP who helped her stabilise her diabetes, the Addictions Service which helped her stabilise her alcohol dependence, the Housing Officer who helped her to find appropriate accommodation, the DBT therapist who provided specific psychological therapy with a beneficial effect on parasuicidal behaviours, and her CPN who monitored her overall mental health, helped maintain motivation and consistency, and co-ordinated the overall treatment plan under the Care Program Approach.

Phases 2 and 3 and case example

Historically, less attention has been paid to the second and third phase within mainstream mental health services, which remain more involved with stabilisation than any other phase of treatment. However, it is often the case that patients are unlikely to progress in their recovery once stabilisation occurs if the later phases are not addressed in some manner. Failing to address Phases 2 and 3 can result in relapse and a return to previous unhelpful behaviours, repeated presentations and a sense of frustration and helplessness in patients and professionals.

For the most part, each of the three phases should be worked through in order, but it is important to note that the phases of treatment may overlap slightly and that some interventions will allow for work in more than one phase of treatment. For example, although standard DBT is primarily focused on stabilisation, the emphasis can shift to exploration and change (and even integration and synthesis) once stabilisation occurs. While some patients will require the input of services during all phases of treatment, many will not. For example, someone who has been supported to stabilise by services may then be able to meet the goals of Phase 2 and 3 themselves, or with minimal support.

Attaining stabilisation enables some patients to reflect on longstanding patterns of behaviour and thinking and the skills they have acquired during Phase 1 allow them to make effective changes to these patterns (exploration/change). They may not require specific input from services to complete this Phase 2 work. These changes, as time goes on, may allow for involvement in new opportunities, such as new employment, recreational activities and friendships, leading to a more integrated sense of self within a new, healthier interpersonal context. Others may not require support with Phase 2, but may benefit from Phase 3 input. Occasionally, people may present without requiring specific stabilisation work, but would benefit from work targeted at Phase 2 or Phase 3. The chances of meaningful recovery are increased when the tasks of all the phases are addressed.

Bob was helped to stabilise by the input of his CPN and the STEPPS program. He did not require any specific trauma work and, from his new position of emotional and behavioural stability, he felt confident in being discharged from services. He was then able to work through Phase 2 himself, exploring and making changes to long-standing patterns of thinking and behaviour using the skills of self-observation and reflection which he had learned in Phase 1 of treatment.

He started some new recreational activities locally and eventually he decided to re-enter the work-place. He obtained a part-time job which, together with the recreational activities he was involved with, helped him achieve many of the objectives of Phase 3 work including the development of new roles, responsibilities, activities and relationships, all of which contributed to a more integrated sense of self and a firmer sense of his place within his community.

Timing and sequencing

There is general agreement that patients should receive the right input at the right time and that the different phases of treatment should be as joined-up as possible, although input for each phase may be provided by different services. For example, the available evidence appears to indicate that after a period of 2 months of stability, specific trauma work can usefully be started. Experience suggests that waiting for longer does not provide any particular clinical benefit and a hard-won window of opportunity may be lost. It is therefore of particular importance to strive for a joined-up approach to working through the phases of treatment in a patient-centred way.

It is important to note that psychological interventions are not inert and have the potential to cause harm. For example, undertaking emotionally intense trauma work in an individual who has not been supported to appropriately stabilise first and has not learnt skills of self-regulation and control has the potential to cause harm. The patient is likely to become emotionally dysregulated and use unhelpful and potentially dangerous behaviours in an attempt to re-regulate. Use of the phase-based model can reduce the potential for a psychological intervention to cause harm.

Movement through phases of treatment is not always one way. Occasionally, people will have a recurrence of emotional and behavioural dysregulation after a period of stability. In cases like this, the focus of treatment should return to the stabilisation phase. Almost invariably, the time required to re-stabilise is shorter than the time taken for the initial stabilization work and usually requires a focus on increasing motivation to use pre-existing skills or a brief revision of skills rather than a fresh re-learning of skills.