Mental health articles

OF mental health care and mentally ill

Psychological interventions for personality disorder

From the relatively limited evidence to date (referring largely to borderline personality disorder), psychological approaches are preferable to drug treatments which are seen largely as adjunctive. Specialist services have been described involving focused psychodynamic psychotherapy following brief inpatient  admission, supported by attendance at a structured day programme. Whilst benefi ts in mood and reduction in self-harm may not be apparent immediately, the gains appear to be made after the first six months of the intervention. Dialectical behaviour therapy (DBT) involves a combination of practical support, help in coping with stress without self-harm, emotional support to address early traumatic life experiences and help in changing the ‘black and white’ polarised views that might have become habitual ways of thinking. Early gains in reduced self-harm have been reported although the effects may wane by 12 months.

General principles of intervention of personality disorder

Be realistic about what can be delivered, by whom and in what period

Avoid being cast as angel or tyrant

Communicate clearly with the patient and other professionals involved

Aim for a stable, long-term therapeutic relationship: this can be achieved with a fairly low level of contact

Aim to improve the patient’s self-worth problem-solving abilities in the short run motivation for change in the long run

Inpatient admission for personality disorder Ideally admissions should be

Planned with the patient, the inpatient unit and community team

For a mutually agreed purpose

For a mutually agreed brief period

On a voluntary basis

With an agreed plan of discharge to specifi ed follow-up

Therapeutic communities are available within and outside NHS provision: they share the aim of enabling the patient to address problems and change behaviour through living in an environment shared with others with broadly similar problems, and participating in groups to share and confront problems as they arise. The emphasis is on community rather than hospital, with residents taking responsibility at all levels of managing each other’s difficulties and the environment itself. It appears that better outcome is associated with longer stay, residents expecting to stay for around 12 months. Cognitive analytic and cognitive behavioural therapy have also been reported to be of benefit although the indicators of benefit are less clear. Overall, psychotherapy may well be the preferred intervention but is probably best delivered in the context of a structured care plan.

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