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Click here for more about the Specialist Therapies Service Click here to view RTF version of this file (word-processor compatible.) A FORMULATED CARE PLAN APPROACH TO CARING FOR PEOPLE WITH BORDERLINE PERSONALITY DISORDER IN A COMMUNITY MENTAL HEALTH SERVICE SETTING Mary Dunn, Hull and Holderness Community NHS Trust and Glenys Parry, Professor of Psychotherapy Research, University of Sheffield We are trying to care for a number of clients in our 10-bedded acute units who are repeatedly trying to hang themselves, who cut themselves several times a day, and take risks which result in a high rate of rape or accidents. The staff are often stressed and deskilled; the psychiatrist is frustrated and irritated; and other clients are both traumatised and neglected as a result of the obvious management problems which affect the units. This state of affairs is not unique to one Trust but commonly encountered across the country. The reformulatory approach of Cognitive Analytic Therapy has been used in the Hull and Holderness Community Trust to develop and experiment with the usefulness of formulated care-plans and to explore the issues which arise when the client and the service are examined systematically as they jointly replay the roles of the client's original caregivers. CAT therapists typically spend the first three or four sessions formulating clients' difficulties in terms of the influence of early life experience on repetitive interpersonal patterns which maintain their problems. These repetitive patterns are described by Ryle (1990) as goal-oriented "procedures" which fail to meet their goal; they involve circular sequences of thoughts, feelings, intentions and actions. The formulation of these patterns is shared and worked on with the client in the form of a personal letter and a diagram showing the problematic sequences. The formulation outlines several target problems so that the client can begin to recognise what is going on, and begin to experiment with the new variations on their procedures. Changes are monitored and strengthened by cognitive techniques and psychoanalytic concepts are used to understand how the basic patterns are re-enacted between client and therapist. Many CMHT clients would traditionally be regarded as unsuitable for psychotherapy. When the first author began work as a community mental health psychologist she was struck by the number of clients who generated a lot of chaos and stress in the mental health service; the young man dashing naked round the park; the person who keeps their appointments erratically in spite of repeatedly asking for crisis responses; the young woman who repeatedly presents at A&E with deliberate self-harm or suicide attempts. These are the sort of behaviours which defy diagnosis and arouse negative feelings. Staff say "this is not mental illness: it is attention seeking, or 'acting out', or 'behavioural' or badness". Mental health practitioners are baffled and irritated, but they are not in a position to refuse a service. They must give some form of care in spite of a lack of an agreed and consistent diagnosis or care-plan or training in working with these difficult clients. Other agencies involved, such as the Police, Social Services, Probation and the Courts apply a great deal of pressure to provide some kind of care for people who cope very badly with life but do not have a clear mental health diagnosis. Often the psychiatrist feels torn between those who think this client should be in hospital and those staff who know that they do not have a coherent plan for treatment. There is an increasing acceptance by psychologists and others of the value of personality disorder as a conceptual grouping for treatment and research, rather than as a diagnostic sin-bin. Recent thinking on borderline personality disorder (BPD) is particularly helpful in making conceptual sense of these chaotic presentations, linking abusive early experience with problems in psychological development, maladaptive coping strategies and a resulting personality structure which is fragile and which encourages rejection from others. This is the client group we have been describing. They are very needy; they generate a lot of stress by demanding a lot of caring responses but finding it impossible to accept care; they absorb a lot of energy and time, but they rarely benefit from the service they are given. Although there has been greater clarity on the clinical definition of 'borderline personality' recently, it remains controversial; one of the difficulties is that most people who could be given this diagnosis will also present to the team assessment with other mental health problems including depression, severe anxiety or obsessive compulsive symptoms. The cluster of 'dramatic/erratic' disorders described in DSM-IV give a broad clinical picture; it is well established that people with these mental health problems put community mental health resources under particular pressure and reduce the likelihood of good outcome from symptom-oriented treatments, particularly brief interventions (Roth and Fonagy, 1996). Research evidence from controlled studies and a much larger literature of clinical descriptive studies, show that difficulties in therapy and 'management' are universally reported. There are high levels of behaviours which challenge staff, including repeated self-injury and suicide attempts, emotional crises, dramatic pleas for help followed by apparent rejection of the help offered. The title of the book I Hate You, Don't Leave Me conveys the dilemma experienced by community mental health staff. Early attempts to derive clinical guidelines for the management of borderline patients have emphasised standardised treatments, treatment contracts, integration of competing theoretical paradigms, and attention to understanding the role of the therapist's mental life interaction with the patient (O'Brien et al., 1985; Miller, 1996; The Quality Assurance Project, 1991). The skilful use of 'counter-transference' is often recommended, as a way of understanding how the mental health worker is becoming part of a pattern of interaction which throws light on the underlying problem (Maroda, 1991; Rosenbluth, 1991). From a cognitive behavioural perspective, research evidence so far favours Dialectical Behavioural Therapy which incorporates group treatment, psycho-education and individual therapy over an intensive treatment period (Linehan, 1993; Linehan et al., 1993). The major difficulty with this admirable advice is that, for most community mental health team members, anything like enough training to achieve the recommended level of knowledge and skills is unavailable and indeed, impractical for the majority. Without an overall grasp of the client's repetitive patterns, many valuable techniques, for example using written treatment contracts, can add to the problem of staff re-enacting punitive, withholding or abusive roles in relation to enraged, overwhelmed or helpless clients. Other team members tend to be pulled in to the 'carer-rescuer' role, believing with some justification, that the problems of these clients have been caused by abuse and neglect, and wrongly, that dedicated empathic care will remedy them. The team can be split, with mistrust and misunderstanding between colleagues, and so frequently, mental health professionals re-enact the relationship dynamics and fail the client. It has even been argued that many of the 'worst' behaviours of borderline clients are essentially iatrogenic, caused by a failure of managing the relationship with the mental health professional and that the most important clinical guideline with this client group is 'first do no harm' (Dawson, 1988). In this article we recommend an approach of using individual cognitive analytic formulations as an aid to team members' working practice with these clients. The aim is to provide a non-blaming supportive and containing framework that everyone, client included, uses to understand what are likely to be unhelpful responses and what is required of the team to avoid making things worse. The care programme is informed by this formulation, and case review refers back to it. The first author has been piloting the use of CAT formulations as an aid to care-planning, both with the staff of an inner-city CMHT and with the staff of their twinned Social Services mental health resource team. The example outlined in this account will illustrate the interactions between client and the mental health services, defined as 'reciprocal roles', in terms of what different theoretical approaches refer to variously as the client's mental representation of relationships, the core conflictual role relationship, the cyclic maladaptive pattern, their early maladaptive relationship schemata or internal object-relations. The formulated care-plan gives treatment options and predicts transference and counter-transference issues between staff and client. The formulation aims to achieve collective ownership of the problem definition to avoid staff 'splitting'. INTERACTION BETWEEN THE CLIENT AND THE MENTAL HEALTH SERVICES: CASE EXAMPLE A woman whose early life experience of parenting might have consisted of unpredictable swings between over-control and unavailable inadequacy is found to be relating to the Mental Health Service as though it were her parents. When her parents were restrictive and punishing, she responded with rebellious rage. When they were inadequate, she was out-of-control and terrified. According to standard CAT practice these 'reciprocal roles' are diagrammed below:
These clients present as terrified and out of control, showing risk-taking behaviour by, for example, standing semi-naked in a main road. This woman might be Sectioned and often forcibly medicated [1]. At this point she will become enraged and abscond from the hospital [2], coming-and-going in a teasing way so that staff are unable to carry out any form of care plan or medical treatment. They feel impotent and inadequate! [3] The client is once again frightened,[4] and psychotic experiences increase as she becomes more anxious and feels less and less safe. Out intention is to use this kind of formulation to devise a way of her care team interrupting the cycle and experimenting with alternatives. These clients are usually judged unsuitable for any kind of formal, exploratory therapy due to the fragility of personality structure. But the mental health service will always be looking after her, and will be contributing to her long-term pathology as long as it blindly re-enacts her early object relations. We expect there to be a therapeutic value in adjusting the ways in which the service relates to her. Our aim is to provide her with access to the care and safety of the hospital without the need for escalated dangerous behaviour. She is enraged by forced medication and there is little evidence that it achieves a therapeutic effect. We can negotiate with her to provide short-term 'respite' care which we will monitor to see whether this improves the rate of risk-taking behaviour over a long period of time. It is too early to evaluate the success of this approach, but early signs are encouraging in that mental health staff are increasingly accessing the CAT consultation service, and are feeling supported with the strength of a model which values their skills. A formulation for such a client shows her attempts to be rescued and cared for and the ways in which they inevitably result in inviting rejection or feelings of being inadequately cared for, which then result in self-blame and self-harm, thereby producing anger and deskilled responses in the staff. These feelings on a ward result in the 'splitting' of staff, some of whom are closely involved with the client and feel that she is misunderstood and persecuted, while others feel that their best efforts have been thrown back at them. They feel personally hurt and powerless to know which is the best course of action, whether to be 'firm' or whether to be 'gentle', whether to be caring or whether to defend themselves. This is a familiar dynamic which places the staff in a dilemma between being abused or being abusive. When the 'borderline' client is unable to accept caring but demands more and more, staff find themselves being more and more giving, then accused of not caring enough. With the best will in the world, they seem to end up in the role of the abuser, and can easily feel as though they want to defend themselves angrily. The clients are devastated if this happens, and often injure themselves, resulting in an even more desperately deskilled and hopeless feeling on the part of the staff. It can be argued that the most important issue for this staff group is to be safely held by skilled group supervision, so that they are supported and given a safe space for thinking about their experience. The powerful transference (or reciprocal role enactment) which affects them all will feel undermining, both as a staff group and as therapeutic individuals. With a diagrammed formulation they are able to identify the 'problem procedure', and keep their understanding at that psychological rather than the personal level. They can maintain staff cohesion by using the same vocabulary to understand the procedures at any given stage, and can be alerted to splitting or rejecting behaviours as they occur. They will be greatly strengthened by agreeing on their responses beforehand, and the client will be held by a secure staff group. People with 'borderline' problems who feel out of control can more easily settle when they are not terrified by their own dangerous omnipotence. Until this happens, the capacity of the client to tolerate their emotions, reflect on their self-experience and change their self-destructive behaviour is repetitively undermined. SUMMARY This example of cognitive analytic formulation has illustrated the potential value of using a psychotherapeutic approach to the management of the mental health problems of people for whom formal exploratory therapy may be inappropriate. Their neediness is self-evident, and the difficulties faced by the staff who care for them are enormous. We hope to show the relevance of a psychotherapeutically informed care programme, so that both client and staff can benefit. REFERENCES Dawson, D. F. - 1988 - Treatment of the Borderline Patient: Relationship Management. Canadian Journal of Psychiatry, 33, 370-74 Linehan, M. M. - 1993 - The Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press Linehan, M ., Heard, H. L. & Armstrong, H. E. - 1993 - Naturalistic Follow-up of a Behavioural Treatment for Chronically Parasuicidal Borderline Patients. Archives of General Psychiatry, 50, 971-74 Maroda, K. - 1991 - Inpatient Management of Borderline Personality Disorder: a Review and Update. Journal of Personality Disorders O'Brien, P., Caldwell, C. & Transeau, G. - 1985 - Destroyers: Written treatment contracts can help cure self-destructive behaviours of the borderline patient. Journal of Psychosocial Nursing 23, 19-23 Rosenbluth, M. - 1991 - New Uses of Countertransference for the Inpatient Treatment of Borderline Personality Disorder. Canadian Journal of Psychiatry, 36, 280-84 Roth, A. D. & Fonagy, P. - 1996 - What Works for Whom?: A Critical Review of Psychotherapy Research. New York: Guilford Press Ryle, A. - 1990 - Cognitive Analytic Therapy: Active Participation in Change. Chichester: Wiley The Quality Assurance Project - 1991 - Treatment Outlines for Borderline, Narcissistic and Histrionic Personality Disorders. Australian and New Zealand Journal of Psychiatry, 25, 392-403
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