Working with personality disorder
Rampton Hospital is developing therapeutic strategies to help people diagnosed with personality disorder. Allison Tennant reports on progress so far
The personality disorder directorate at Rampton High Security Hospital is an NHS Beacon site and hosts one of the pilot projects that are part of the Home Office and Department of Health initiative concerned with the assessment and treatment of people deemed to be dangerous because of the severity of their personality disorder. The directorate currently has 80 beds and a nationwide catchment area due to its specialist nature.
The therapeutic delivery
Individuals admitted to the directorate have a primary diagnosis of personality disorder and meet the criteria for high secure psychiatric care. The directorate recognises that treatment is a process of change, and the transtheoretical model (TM) of change (Prochaska et al. 1992) provides a useful framework to enable us to gain a better understanding of how we can provide individuals with the appropriate treatment at the appropriate time as they progress through the change process. The TM is used to conceptualise the change process in individuals in order to match treatment interventions to their stages of change. Within this framework, staff have developed a better understanding and more realistic expectation of what individuals are willing to do or are capable of doing at different stages of change.
The case formulation approach is based on an individualised assessment, from which treatment targets can be identified. The treatment interventions are based around a planned combination of group and individual work according to need. One of the strengths of the directorate is its dynamic ability to maintain close inter-professional working while integrating a range of different treatment approaches. The tension of working with and focusing on offending behaviour, and working with the whole person in a more systematic way, represent current themes within inter-professional debates in these settings.
A core issue for those with personality disorder is their difficulties in forming and maintaining relationships; this includes clinical and therapeutic relationships. The dilemmas and unique challenges facing nurses and therapists in this context often means that individuals' distress is met with much therapeutic effort and sometimes leaves the staff feeling frustrated and exhausted by their day-to-day interactions. Psychotherapy is normally a voluntary process, with the individual free to come and go, whereas in secure environments custody and societal protection often form the core agendas. Getting a healthy balance between security and therapy is a tension that requires constant scrutiny. Forensic mental health practitioners inhabit a complex social milieu where they struggle with the paradox of being security-conscious, risk-managing custodians while also attempting to deliver individual and group therapeutic programmes as part of a multi-disciplinary team. As a standard within the directorate, systems are in place to provide staff with clinical supervision.
Dialectical behaviour therapy
Dialectical behaviour therapy (DBT) was developed by Marsh Linehan (Linehan 1993a, 1993b), a clinical psychologist from America. The aim of her work is to develop a structured and practical approach to helping people who are notoriously difficult to treat.
A group of experienced clinicians with differing backgrounds went on an intensive training course and came back invigorated from the excellent training. From that moment our enthusiasm and commitment to DBT became strong.
The main components for patients are a weekly individual session with their primary therapist and attendance at a weekly skills training group. In addition, the DBT therapists meet for a weekly consultation meeting. In the pre-treatment stage the primary therapists work intensively with individual patients, orientating them to DBT and gaining their commitment to the therapy process, while also encouraging a commitment from them to decrease maladaptive behaviours.
This process has been invaluable for both the primary therapist and individual patients as it has enabled both to form a therapeutic bond before the group work commences which has ensured that individuals are less likely to drop out of treatment.
Interest in DBT has grown rapidly and there are projects in a number of high security hospitals (Deu 2000, Secker 2000). As yet there is no published outcome evidence with this population, but the directorate hopes to publish soon the results of a study of male forensic patients who underwent an adapted version of DBT over an 18-month period (Evershed and Tennant, 2001). The DBT programme was adapted in three ways to take account of the group's needs and living environment. Many of the men had a tendency to behave violently towards others, in addition to engaging in parasuicidal behaviour. Therefore violent behaviour, violent ideation and rage were added to the treatment targets and were included on the daily diary cards. Hence, individual therapy focused on violence as well as parasuicidal and therapy-interfering behaviour. The telephone consultation system was not utilised as we are in the process of training ward staff in DBT skills, to enable them to support and coach the patients to practise their DBT skills. Finally we made some minor alterations to some of the DBT materials to make them more applicable to male inpatients. To date 26 men have been involved in DBT and the directorates see DBT as one of the core treatments available to this patient group. An unpublished research study (Gordon and Ryan 2001) details patients' views of DBT and outlines what they think are important issues in the therapeutic process.
New educational and training initiatives
The directorate invests heavily in staff education and training and has recently developed a competence-based diploma/degree programme (Working with Personality Disorders). Programme content evolved through consultation with multi-disciplinary teams, ensuring the educational process enabled practitioners to contribute to the therapeutic tasks of the service.
It is essential that new staff coming into this work have an intense induction to prepare them for their demanding role and the directorate also recognises the importance of providing a framework of clinical supervision to support staff in care delivery. This is central to maintaining service standards and ensuring the psychological health of the workforce.
For further information please contact Allison Tennant, Lecturer/Practitioner, Professional Education Department, Rampton Hospital, Nottinghamshire Healthcare NHS Trust, Retford, Notts DN22 OPD. Email: Allison.Tennant@rampton-hosp.trent.nhs.uk
References
Deu N (2000) Overview of dialectical behaviour therapy and its application to women in a secure forensic setting. Paper presented at Psychological Solutions to Personality Disorder Conference, Leeds.
Evershed S, Tennant A (2001) Outcomes of dialectical behaviour therapy (DBT) with male forensic patients. Unpublished.
Gordon N, Ryan S (2000) Clients' views of dialectical behaviour therapy in Rampton High Secure Hospital. Unpublished.
Linehan M (1993a) Cognitive Behavioural Treatment of Borderline Personality Disorder. New York, Guilford Press.
Linehan M (1993b) Skills Training Manual for Treating Borderline Personality Disorder. New York, Guilford Press.
Prochaska JO, DiClemente CC, Norcross JC (1992) In search of how people change: applications to addictive behaviours. American Psychologist. 47, 9, 1102-1114.
Secker C (2000) Development and research findings from a DBT project with women in a high secure hospital. Paper presented at Dialectical Behaviour Therapy UK Practice Research Network conference, Leeds.