Thoughts from those working in personality disorder services

This section is for questions relating to therapy, assessment, formulation and other aspects of working with people in mental health services.

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Thoughts from those working in personality disorder services

Post by MRE95 » Fri Jan 05, 2018 6:53 pm

Hi all,

I am an AP currently assisting my supervisor to design and set up a new pathway for young people (aged 14-25) with a diagnosis of personality disorder/complex trauma. I have been looking at NICE guidelines and trying to find information about existing PD services nationally, but I thought it could be really helpful to hear from clinicians who work in similar services about what they feel works well (or not so well) in their experience. I am particularly interested in hearing about individual therapies (as a real range seem to be recommended - schema therapy, EMDR, metallisation-based therapy, ACT), but any general thoughts and recommendations are very welcome, as is signposting to any useful resources.

Many thanks!

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Re: Thoughts from those working in personality disorder serv

Post by Esuma » Fri Jan 05, 2018 7:40 pm

We have an EMDR therapist at our service who very strongly believes EMDR has made a huge difference in even the most ‘difficult’ patients with personality disorders. I did a systematic review on EMDR for patients with personality disorder for my dissertation - sadly there isn’t much research in the area and like most research within PD the studies I found were mostly about patients with borderline PD. If you’re interested I can send you my dissertation.

Our service isn’t just PD it’s a forensic mental health service but we have art therapists, drama therapists, DBT, CBT, EMDR to name a few! Therapeutic communities might be worth exploring too..

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Re: Thoughts from those working in personality disorder serv

Post by secret squirrel » Sun Jan 07, 2018 7:11 pm

You might find it useful to read "the great psychotherapy debate," which summarises the evidence for different therapies for different issues, and suggests that there is not much evidence for x therapy being useful for y presenting issue. it is summarised here: ... to-debate/ Therefore offering a range of therapies could be helpful. evidence about the effects of trauma suggests body based therapies can be helpful such as adapted yoga or dance therapies. look at "the body keeps the score" for more info on this.

i have personally found cognitive analytic therapy a useful approach for working with interpersonal difficulties.

i would suggest you think carefully about your inclusion criteria and resist, if possible, giving anyone a diagnosis of personality disorder.

the service user group "personality disorder in the bin" have a website and are active on twitter, and i am sure would be happy to give you ideas from their lived experience. https://personalitydisorderinthebin.wor ... dinthebin/

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Re: Thoughts from those working in personality disorder serv

Post by MRE95 » Sun Jan 07, 2018 7:42 pm

Thanks Esuma, I would love to have a read of your dissertation if you are still happy to share it - I will PM you.

Secret squirrel - thank you so much, I will certainly have a look at the websites you suggest and look into CAT. I absolutely agree re: a 'personality disorder' diagnosis and I am aware of the many issues that surround this. Ultimately there is a need for a service for YP who have experienced developmental and relational trauma who have interpersonal and emotional regulation difficulties, and sadly PD is still the dominant diagnostic label used in our Trust (and generally). 'The body keeps the score' is a great book!

I also meant to say in my original post that this will be a community/outpatient treatment pathway.

Look forward to hearing any further thoughts or suggestions that people have :)

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Re: Thoughts from those working in personality disorder serv

Post by Amina » Tue Jan 09, 2018 9:25 pm

Hi there,

I work in a specialist service within children's services, specialising in input for families where children are considered 'in need' or 'at risk' due to family/parenting difficulties. We have 'themes' of learning disability, substance misuse, mental health, sexual risk and domestic abuse.

For most of our families, one or both parents have themselves experienced childhood situations which have led to attachment/developmental trauma issues. As a service, we operate in a very trauma/attachment informed way.

Often other professionals are asking for diagnostic labels but in General, we are far more likely to assess and write reports and recommend interventions based on an understanding of 'complex trauma or 'developmental trauma rather than screening for PD. Obviously children who experience trauma and attachment issues are often then reacting to these life events in a way which would lead to them having a diagnosis of PD as the grow up. However, as previous posters have highlighted, this label can be extremely unhelpful. I do understand that you need to work within the constraints of a service though!

In terms of interventions, we have a team who specialise in EMDR, DBT, CBT, systemic family therapy, narrative therapy , VIG and various other things such as MI for substance misuse issues.

We try to focus on being flexible, not on offering only a small set of interventions. For example, many of our parents have had/are having children removed from their care and fostered or adopted. They may need counselling and key worker support as well as access to non-judgemental contraception (some women in other services are only able to access counselling if they are on specific contraception, which I believes infringed their human rights). We have a specialist project for parents whose children are now in care.

Other families are experiencing issues with substance misuse. We have an FDAC - family drug and alcohol court which offers almost daily support, keyworking, substance misuse and supportive family work as well as comprehensive assessment. This is a far more intensive but less alienating experience for most families, with far better outcomes overall than mainstream child protection services.

I realise that is all rather off topic, but I do think it demonstrates that services should be driven by individual/family needs rather than simply a label. This is true even in the somewhat restrictive and prescribed world of child protection.

Books of interest to you might be

Treating complex traumatic stress disorder and evidence based guide. By courtois and ford.

Also treating complex trauma in adolescents and young adults. By briere and lanktree

Hope this helps!

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Re: Thoughts from those working in personality disorder serv

Post by Spatch » Wed Jan 17, 2018 5:49 pm

I am currently the clinical lead for a service focussed on , higher risk individuals with complex mental health presentations, that typically come under the PD category or fall between the cracks of IAPT and secondary care.

Treatments we offer are based on CBT/DBT and CAT (individual work) and we run a DBT skills training workshop (10 weeks) and a year long mentalisation based therapy group within the service. Treatments are informed by compassion focussed frameworks, but also things like radical acceptance.

Beyond the specific treatments and interventions, our philosophy plays an important part. We are aware of things like splitting and abandonment so we often work systemically with the various agencies linked to the people under our care. The service users are encouraged to form attachments with the service (rather than an individual clinician) so we don't engage for short term work, but they get to know the various clinicians. There is consistency and continuity of care, and the knowledge that we aren't just itching to discharge them, and we are around for as long as people need us. This is often in contrast to other services people attend, and they notice this.

The ethos plays a big part of what we do. We have a strict "no asshole rule" policy (Sutton 2010) when it comes to staffing, and we operate airline rules (we make sure we look after ourselves before we can take care of others).
Shameless plug alert:

Irrelevant Experience: The Secret Diary of an Assistant Psychologist is available at Amazon ... 00EQFE5JW/

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