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Personality Disorder and People with Learning Disabilities
Dr Simon Crowther
Overview• Personality Disorder (PD) and people with Learning Disabilities
(LD)
• A model for PD and LD
• Case examples
• Challenges
Personality Disorder (PD)
Definition of PD“Deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations.” World Health Organisation
3 P’s model- Persistent, Pervasive and Problematic (DoH, 2012).
Prevalence of PD in LD (Alexander et al, 2002)-Community teams- 7%-Secure settings- 50/60%
Personality Disorder Clusters
Personality Functioning Continuum
Offenders
General Public
Diagnostic Cut-off
PD and LDDiagnosing PD in people with LD is a contentious issue…-Assessment problems-Validity problems-More stigma
But PD is a clinically important issue…
Tor (2008)- diagnosis of ASPD associated with placements in higher security, serious and repeat offending and poorer long term outcomes
Alexander et al (2006)- LD offenders with PD discharged from MSU were x9 times more likely to re-offend
PD and LD
Diagnosis solutions?
Only diagnose people with LD in the mild/moderate range (Lindsay et al, 2005).
Only diagnose those with ‘cluster B’ Personality Disorder (Naik et al, 2002).
PD and LD
The initial evidence suggests that interventions beneficial for people without LD can also be helpful for people with LD…
•Cognitive Analytic Therapy (CAT)- Lloyd & Clayton (2013)•Dialectical Behaviour Therapy (DBT)- Morrissey & Ingamells (2012), Brown et al (2014).•Therapeutic Communities (TCs)- Taylor & Morrissey (2012), Taylor et al (submitted).
PD and LD
In the literature on working with people with PD two themes are prominent:
1.That the environment around the person is supportive, healthy and enabling (MoJ)
2.The importance of delivering treatment in an integrated and coordinated manner- John Livesley (2003)
What works with PD
For people with a diagnosis of PD their difficulties exist in their relationships with others.
Healthy and supportive relationships are crucial to treatment- but this is easier said than done!
Current relationships and interactions are a focus of the treatment approach.
Every interaction, from the mundane to the emotionally charged, is an important opportunity for reflection and learning.
What works with PD? (Livesley, 2003)
PD treatment framework
Engagement and Assessment
Engagement and Assessment
Formulation and Goal setting
Formulation and Goal setting
TreatmentTreatment
First 3-6 months in the PD care
pathway
Moving onMoving on
12-18 months in the care pathway
Principles
All members of the team have a
role
‘Team’ approach
Formulation and goal setting as
central
Enabling Environment
Principles of the approach
• An ‘enabling environment’
• Use of psychological formulation to understand complex behaviour and risk.
• Whole team philosophy
• Training and support for the staff team
An ‘Enabling Environment’
Psychologically Informed Planned Environments (PIPEs). (NOMS & DoH, 2012).
•An emphasis is placed on the importance and quality of relationships.•Staff are provided with further training to have an increased psychological understanding of their work and of complex behaviour.•Service structures aim to promote healthy relationships and offer opportunities to work through relationship difficulties.
An ‘Enabling Environment’
Development of psychological thinking through psychological formulations
‘Every interaction matters’
Occupational therapy sessions structure the day.
Social participation and group activities .
Personal responsibility and self-efficacy
Psychological Formulation
All clients are offered a formulation as part of the assessment process.
Two types of formulation are used in this service…
Case formulation- to develop an understanding of the key relationship problems that we need to support the person with.
Risk formulation-to develop an understanding of key risk behaviours, how this might play out with others and what support is needed to minimise this.
Psychological Formulation
Case formulations
PD as PTSD- re-enacted in current relationships
Formulations aim to make sense of overwhelming and confusing behaviour.
Formulation as a support guide for staff team and to suggest most appropriate interventions.
Formulations should predict difficulties in engagement.
Psychological Formulation
Risk Formulations
The key risk areas assessed using a structured professional judgement assessment. (SPJ)- HCR 20 v3, RSVP, etc.
Service user involvement in the process.
Should identify strengths and protective factors.
Should lead to prediction of how the behaviour could happen in current context and a mitigation plan.
Whole team philosophy
A ‘core team’ for each service user- i.e. service user-key worker-case manager-MDT.
Shared goals that everyone works towards achieving.
A shared understanding of the service user that everyone uses.
A belief in the team approach, including an ability to work democratically and consistently.
The use the communication forums to resolve conflict and disagreements.
The staff team
A different role from what they may be used to.
Helping the staff team develop a psychological understanding of their work.
The importance of regular and consistent support sessions.
A ‘culture of curiosity’ and reflective practice.
‘Ad hoc’ supervision.
PD- integrating treatment
PD- integrating treatment
MSUMSU
LSULSU
Case examples…
‘Mark’
‘John’
AngryAbused
Hurt Child
AngryAbused
Hurt Child
Controlling
Controlled
Controlling
Controlled
“I have to be in control.”
Using anger to get what I want
“I have to be in control.”
Using anger to get what I want
Abusing
Abused/Damaged
Abusing
Abused/Damaged
Rage against women and ‘the system’
e.g. offending, rule breaking, challenging
authority
Rage against women and ‘the system’
e.g. offending, rule breaking, challenging
authority
Admiring
Admired
Admiring
Admired
Overwhelming feelings- Using drugs, alcohol and
pornography and self harm
Overwhelming feelings- Using drugs, alcohol and
pornography and self harm
RejectingCut off
Rejected
RejectingCut off
Rejected
No-one cares about me. Can’t trust anyone. Push
others away. Blame others
No-one cares about me. Can’t trust anyone. Push
others away. Blame others
Minimizing any problems
Just focusing on the positives
Minimizing any problems
Just focusing on the positives
‘Mark’- working with the staff teamGoal 1- Acknowledging my risk e.g. being able to talk about the risk I could present in the future and how I am going to manage this. I find it hard to talk about my risk of reoffending. I don’t like thinking about it because it makes me feel bad, and instead I try and focus on the positives. I also worry that talking about my risk of reoffending will make others feel worried and that they might keep me here longer. However, I will need to be able to talk about risk so that people feel confident that I can manage this in the future. Rating- 5/10
‘Mark’- working with staff teamPlan for Goal 1
1. Engage in therapy work regarding sexual feelings. 2. To start to talk to trusted others about my risk of reoffending. 3. To try and not be defensive when others talk about my risk. Evidence of progress….
Weak, VulnerablePunished
Weak, VulnerablePunished
Punishing, Attacking
Punished, Hurt, Angry
Punishing, Attacking
Punished, Hurt, Angry
Look out for people taking the
‘p*ss’
Look out for people taking the
‘p*ss’
Signs that I am in this place
I put my needs first
I keep other people at a distance
Signs that I am in this place
I put my needs first
I keep other people at a distance
Controlling
Controlled
Controlling
Controlled
Painful feelings from childhood-
Painful feelings from childhood-
Abusing/Rule
breaking
Abused
Abusing/Rule
breaking
Abused
I start to feel fed up and
unfairly treated and think- F*ck it! I should be able to have whatever I
want!”
I start to feel fed up and
unfairly treated and think- F*ck it! I should be able to have whatever I
want!”
BATTLINGBATTLING GETTING A BUZZGETTING A BUZZ
Others ‘punish and control me’Which make
me think I need to be in
control of myself and
others
Others ‘punish and control me’Which make
me think I need to be in
control of myself and
others
Others get worried, and
punish/ control me’
which makes me think I
need to be in control of myself and
others
Others get worried, and
punish/ control me’
which makes me think I
need to be in control of myself and
others
“ALTER EGO”“ALTER EGO”
Signs that I am in this place
I shout, threaten and pace up and down.
I make complaints and threaten to get people sacked
I refuse to ‘back down’
Signs that I am in this place
I shout, threaten and pace up and down.
I make complaints and threaten to get people sacked
I refuse to ‘back down’
Signs that I am in this place
‘Sneaking around’/changes to
my usual routine
Asking for things that I won’t get/are
unrealistic
Not being open about my feelings
Becoming defensive when talking about
risk
Signs that I am in this place
‘Sneaking around’/changes to
my usual routine
Asking for things that I won’t get/are
unrealistic
Not being open about my feelings
Becoming defensive when talking about
risk
Signs that I am in this place
I use intimidation and threats to get what I want
I ‘look out’ for people ‘taking thep*ss’
Signs that I am in this place
I use intimidation and threats to get what I want
I ‘look out’ for people ‘taking thep*ss’
John- working with the staff team
Goal 2
To cope with feeling frustrated, disappointed or let down
When I feel frustrated, disappointed or let down I can ‘go off on one’, becoming angry very quickly and making threats towards others.
Rating- 2/10
John- working with the staff team
Plan for Goal 2
(a) To practice coping strategies when I feel like this- and to learn coping strategies for this if I don’t have any(b) To stop myself from ‘punishing’ people when I have these feelings.(c) To repair relationships when I have punished or threatened others.
Evidence of progress….
John- working with the staff team
Goal 4
To show care and support to others
I find it hard to think about others, and put my needs first. When my behaviour has an impact on others I can say things like, “I don’t care about anyone others than myself”.
Rating- 1/10
John- working with the staff team
Plan
(a) To put other people first sometimes(b) To make compromises with others(c) To show support for people I live with(d) To think about how other people feel
Evidence of progress…
Challenges
It can be emotionally intense.
Low motivation, hopelessness and despair is common.
Training and supervision is vital.
It takes time to set up services and for people to feel comfortable working this way.
The treatment pathway through services for people with LD and PD needs further development (and funding!)…
Working with people with PD
“Providing effective care and treatment for people with personality disorder is one the most challenging in the field of mental health…but…working with this client group can provide staff with a tremendous sense of job satisfaction and growth”
(Murphy and McVey, 2010)
ReferencesAlexander, R., T., Piachaud, J. Odebiyi, L. & Gangadharan, S., K. (2002). Referrals to a forensic learning disability, British Journal of Forensic Practice, 4, 29-33.Alexander, R. T., Crouch, K., Halstead, S. & Piachaud, J. (2006). Long-term outcomes from a medium secure unit for people with intellectual disability, Journal of Intellectual Disability Research, 50, 305-15.Alexander, R. T., Green, F., N., O’Mahony, B., Gunarantna, J., I., Gangadharan, S., K. & Hoare, S. (2010). Personality disorders in offenders with intellectual disability: a comparison of clinical, forensic and outcome variables and implications for service provision, Journal of Intellectual Disability Research, 54. 650-658.Lindsay, W.R., Gabriel, S., Dana L., Young, S. & Dosen, A. (2005). Personality Disorders. In: Diagnostic Manual of Psychiatric Disorders for Individuals with Mental Retardation, National Association for Dual Diagnosis, Kingston, NY.
ReferencesLivesley, J. (2003). Practical Management of Personality Disorder, Guilford Press. Lloyd, J. & Clayton, P. (2013) .Cognitive Analytic Therapy for People with Intellectual Disabilities and their Carers, Jessica Kingsley. Murphy, N. & McVey, D. (2010). Treating Personality Disorder: Creating Robust Services for People with Complex Mental Health Needs.Morrissey, C. Taylor, J. & Bennett, C. (2012). Evaluation of a therapeutic community intervention for men with intellectual disability and personality disorder, Journal of Learning Disability and Offending Behaviour, 3, 52-60.Morrissey, C. & Ingamells, B. (2011). Adapted dialectical behaviour therapy for male offenders with intellectual disability in a high secure environment: six years on, Journal of Learning Disabilities and Offending Behaviour, 2, 10-17.
References
Naik, B., I., Gangadharan, S., K. & Alexander, R., T. (2002). Personality disorders in learning disability- the clinical experience. British Journal of Developmental Disabilities, 48, 95-100.Taylor, J. & Morrissey, C. (2012). Integrating treatment for offenders with an intellectual disability and personality disorder, The British Journal of Forensic Practice, 14. 302-315.Taylor, J., Crowther, S., Sothern, C., & Stronach, C. (submitted). Therapeutic Communities for People with Intellectual Disability and Complex Needs, Advances in Mental Health and Intellectual Disabilities.