In order to ensure that patients receive the most appropriate treatment recommendations, the PDS uses a standardised assessment to produce a formulation and a phase-based treatment plan. The assessment includes:

• current symptoms
• personality traits
• detailed background history (including trauma history)
• and mental state examination.

The information is gathered from various sources including patient history, case-records, informant histories from professionals and social network members and formal structured assessment tools. The main purpose of the standardised assessment is to allow the collaborative development of a formulation of the relevant biological, psychological and social factors into a description of the patient’s life and personality which helps contextualise current problems and symptoms and identify which problems, themes and goals will be the focus of treatment. Usually, 5 to 6 hours are spent face-to-face with the patient. In addition, time is spent reviewing notes, speaking with informants, and constructing the formulation and treatment plan. The assessment, formulation and treatment recommendations are then discussed with the patient. This process usually takes around 8 weeks, at the end of which time a detailed assessment letter, formulation and treatment recommendations are sent to the referrer, with copies to all members of the care team and the patient.

This is a primarily Phase 1 (stabilisation) intervention for patients with severe borderline personality disorder. DBT is an intensive psychosocial intervention largely based on cognitive behavioural principles. It comprises a weekly skills training group, concurrent weekly individual psychotherapy and weekly peer supervision for all therapists. The treatment usually lasts six months to one year.

For patients with co-occurring post traumatic stress disorder (PTSD), the DBT Prolonged Exposure protocol (DBT-PE) may be of benefit. This Phase 2 trauma reprocessing intervention is delivered within the individual component of DBT treatment and bears many similarities to the standard prolonged exposure approach (PE) for PTSD uncomplicated with borderline personality disorder. DBT-PE can only be delivered to patients as part of an overall DBT treatment and not as a stand-alone intervention. 

DBT is an intensive intervention for patients with severe and complex borderline personality disorder. Therefore referrers should only consider DBT if STEPPS or other secondary care approaches are inappropriate for reasons of complexity or severity. To ensure that a holisitic approach is taken to each patient’s care and treatment needs, to allow for effective structuring of the environment, and to optimise communication and collaboration between the patient and the services involved, patients in DBT are required to be on the Care Program Approach.

The CAS (Coping and Succeeding) Day Service for people with personality disorder is a community-based service which takes place at Rowans, New Craigs Hospital. The usual length of treatment is 36 weeks. CAS has been developed in partnership with service users along Recovery principles and represents a co-produced service.

The service is primarily directed at helping a person enhance interpersonal and social connections in order to help them build a life away from mental health services. This process usually has benefits for self-image. CAS has a primary focus on Phase 3 (integration) and, to a lesser extent, Phase 2 (exploration and change). It is not an intervention with an emphasis on Phase 1 (stabilisation). Other interventions such as DBT or STEPPS are more appropriate for stabilisation of harmful behaviours. Furthermore, patients with post-traumatic features are likely to benefit from specific trauma work (Phase 2) before making best use of CAS.

The CAS Day Service includes elements of structured group work, self-directed time and social time. Broad themes covered in the core groups include promotion of physical health and wellbeing; living skills; self-management; and vocational rehabilitation. These themes are addressed by providing direct information and education; enabling direct introduction to new activities/behaviours; and making and highlighting links between people and services. In the spirit of co-production, participants play the major role in planning and organising the content of the group activities and the day to day running of the service. Participants develop and work towards their own goals in the interpersonal, occupational, recreational and educational domains. The overall aims include promotion of self-management and planning for a worthwhile life without mental health services.

The service is not only for individuals with borderline personality disorder, but is for any patient who meets the general criteria for personality disorder or whose personality disorder is in early remission. Potential CAS members must be ready to make changes.

The PDS is currently developing its consultation function. The aims include to provide a range of consultation modes including recommendations on the general management and treatment of personality disorder, discussion of specific aspects of a clinical case, specific supervision for professionals engaged in delivering general or specific psycho-social treatments to patients with personality disorder, full case consultation and formal further opinions. Requests for consultation are welcomed. See the 'How to access these services' for contact details.

Education about personality disorder is of recognised benefit to those who suffer with these conditions, members of their social networks, and the staff, agencies and services involved with this patient group.

​Personality disorder is common in the general population. People with personality disorder frequently have contact with many different services and agencies including primary care, general health, mental health, housing, social work, criminal justice and third sector services. The difficulties with which people with personality disorder present may vary depending on the agency or service involved. For example, an individual may present to the housing services as someone with difficulty in maintaining a tenancy whereas the Emergency Department may view the person’s primary problem as repeated overdoses. For social services, childcare and parenting issues may be viewed as the principal problem, and so on.

The complexity associated with personality disorder means that patients with the condition frequently pose significant challenges to the professionals working with them. Occasionally professionals can find it hard to understand why individuals present as they do, and the emotional responses of professionals to particular behaviours or patterns of behaviour can be intense and sometimes unhelpful. Education with the aim of enhancing knowledge, attitudes and skills can be of real value in helping professionals become more aware of the issues which frequently accompany personality disorder. This includes factual knowledge about these conditions, contributing factors, prognosis and treatment approaches. In turn, improved knowledge and active self-reflection can contribute to more helpful attitudes and more compassionate responses towards patients with these conditions.

The PDS has been developing a variety of educational resources which are explained below:

This learning experience is delivered using a combination of self-directed study (approx 3 hours) and a live online webinar (3 hours).  Webinars can be booked here: Mental health : introduction to personality disorder | Turas | Learn (nhs.scot) (Please note these sessions are only available to NHS Highland staff and partners).

Aim of the Self-directed Study/Webinar:

Participants will feel more confident in effectively supporting the self-management of people with personality disorder.

​Learning outcomes:

• By the end of this course, you will be expected to be able to:
• Explain what is meant by “personality disorder” in basic terms
• Describe current ideas regarding factors (including trauma) which contribute to the development of personality disorder
• Explain how personality disorder affects people who experience it
• Identify where effective treatments and self-management resources are available
• Describe some of the challenges that can be encountered for people with personality disorder, staff members and the team
• Apply the basic principles of effectively engaging with people with personality disorder in your day-to-day work
• Explain the importance of validation in working effectively with people with personality disorder
• Acknowledge the importance of looking after oneself and colleagues at work, and the importance of a supportive team
• Demonstrate a positive attitude to working with people with personality disorder, thereby helping to reduce stigma
• Understand and explain the phase based model or recovery
• Know how to access the Highland Integrated Care Pathway for personality disorder & have an awareness of its content and how to apply to clinical situations.

Who this is for: All staff (NHS Highland Only) who are supporting individuals to maintain positive mental health and wellbeing.

Learning aims:
The aim of this course is for all participants to be able to facilitate Decider Skills groups as well as teach decider skills to patients on an individual basis.

Learning outcomes:
By the end of this course, you should be able to:

• Understand and explain the development and theoretical framework underpinning the decider skills
• Gain knowledge and understanding of all 32 Decider Skills and how these can be taught in both an individual and group setting
• Consider how the Decider Skills can be implemented into your own practice and workplace setting
• Know how to access the Highland Decider Practitioner Support Group.

Decider Skills training can be booked here: Mental health : 32 decider skills | Turas | Learn (nhs.scot)

Who is this for: Anyone who may be supporting a person who experiences emotional distress including staff members, family and friends.

Aim: participants will be able to implement a skills-based approach aimed at supporting people in acute psychological distress to regulate their emotions.

Learning outcomes:

• By the end of this programme you will be able to:
• Demonstrate a structured skills-based response to someone experiencing emotional distress
• Understand the stress response and longer term affects of Chronic Toxic Stress
• Acknowledge the importance of self-regulation as a prerequisite for helping someone else to emotionally regulate
• Understand the importance of validation in supporting emotion regulation and increasing the effectiveness of interpersonal interactions and conversely, the negative impact invalidation can have
• Describe 6 levels of validation
• Demonstrate basic validation skills
• Use a simple structured problem solving approach in collaboration with a person in distress.
• Utilise a crisis self-management plan which can support people when they are experiencing acute psychological distress

This training module comprises of a pre-recorded online webinar with supporting resources which can be accessed here: The 5 Step Approach to Distress | Nhsh Pds Education (nhshdbtservice.wixsite.com)

As well as these regular sessions, the PDS service will consider any request for education on subjects related to personality disorder. See 'How to access these services' for contact details.

The PDS also offers consultation to Mental Health Teams based in the NHS Highland area. This provides teams with protected time with members of the PDS to thoroughly consider any specific problems related to a patient’s care and to identify any potential solutions and actions for the team to take.

The following agreements help to support the consultation process:

• Consultation is a process between the PDS team and the requesting team. The PDS will not make contact with patients or any other parties as part of the process.
• Consultation comprises the requesting team making a case presentation and supplying relevant information to the PDS, then identifying specific issues or questions for discussion. A problem and solution analysis approach will be followed to structure the discussion.
• The consultation process will be informed by the NHS Highland Integrated Care Pathway for Personality Disorder.
• The consultation process differs from supervision in several respects. Supervision as it is provided by the PDS aims to help reflection primarily on the emotional aspects of practice, and is provided on an ongoing basis. While consultation also aims to promote reflection, the emphasis is more on problem and solution analysis of specific issues. Consultation tends to be time limited rather than ongoing.
• Consultation will be based on the information provided to the PDS by the requesting team. The requesting team are responsible for the accuracy of that information.
• Patient care is typically delivered by multidisciplinary teams. In order for consultation to function most effectively the whole multidisciplinary team must be appropriately represented in the consultation process. This supports consistent practice and reduces the risk of splitting and similar unhelpful processes.
• The requesting team at all times remain responsible for care delivery and deciding whether or not to act upon any recommendations.
• Throughout the consultation process, the requesting team and PDS will jointly evaluate benefit on an ongoing basis, with either or both teams being able to bring the process to a close if it is not felt to be helpful.
• A note will be taken during each consultation session by a member of the PDS. Together with the Case Consultation Referral Form, this will constitute the clinical record. A copy will be provided for the requesting team. This should be filed in the patient’s case record in the “Confidential & Third Party Information” section. A copy will be held by the PDS.
• The consultation process is subject to recognised principles of confidentiality.
• The consulting team is responsible for clarifying with the PDS any part of this agreement which they do not understand.

If consultation is required please contact the service directly to obtain a consultation request form. See 'How to access these services' for contact details.