Working with clients with a personality disorder in a drug and alcohol setting. Heidi Jarman hjarman@uow.edu.au

Transcription

1 Working with clients with a personality disorder in a drug and alcohol setting Heidi Jarman hjarman@uow.edu.au

2 NSW Health Priority 1. Improve the capacity of mainstream mental health services to manage and treat personality disorders 2. Expand specialist treatment options including improved referral pathways between generic and specialist treatment 3. Deliver well constructed and supported education 4. Evaluate expert intervention models to provide guidance for future service development Announcement by Barbara Perry, MP (Auburn) 2010 NSW Minister for Mental Health

3 1. Project Air is a relational model developed to operationalise good clinical care, grounded in treatment guidelines 2. The guidelines provide a pathway through the health service from inpatient, outpatient, justice and community services 3. The model emphasises the importance of the relationship between the health service and the person and their wider social network

4 WHAT IS PERSONALITY DISORDER?

5 What is Personality? An individual s unique pattern of thinking, feeling and behaving Each individual possesses a small and distinct group of characteristics (traits) which are relatively: Persistent and enduring across lifespan Consistent across situations

6 What is Personality Disorder? Personality disorder occurs when characteristics (traits) are: Inflexible, inappropriate and cause distress or impairment in social, occupational, or other areas of functioning Look for an enduring pattern of: inner experience behaviour that deviates markedly from the expectations of the individual's culture

7 What is a Personality Disorder? Characterised by difficulties with: Sense-of-self and identity Interpersonal relationships Occupational and social functioning is impaired Problems not better accounted for by medical condition, direct effects of substance use/abuse, or cultural context Relative stability over time and across situations

8 3 clusters of PD in DSM-IV Cluster A Odd and eccentric - Paranoid, schizoid, schizotypal Cluster B Dramatic - Antisocial, borderline, histrionic, narcissistic Cluster C Anxious and fearful - Avoidant, dependent, obsessive-compulsive * Cluster B & C most likely seen in D&A setting

9 Frequently diagnosed PDs in D&A Antisocial a pattern of disregard for and violation of the rights of others, with lack of remorse for impact of their behaviour on others Avoidant pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation. Tends to avoid interaction w others despite longing for it Borderline instability in interpersonal relations, self-image, affect and marked impulsivity. Selfharm may also be evident

10 Frequently diagnosed PDs in D&A Narcissistic pattern of grandiosity, need for admiration, empathic failure and sense of specialness and entitlement that masks an underlying sense of shame and humiliation (inferiority) Obsessive compulsive pattern of preoccupation w orderliness, perfectionism, and control. May display rigid attention to detail, rules and procedures

11 Example beliefs / feelings Borderline Antisocial Obsessive Avoidant Anxious Schizoid Narcissistic "I go to extremes to stop people leaving me" "I will lie and con someone if it serves my purpose" "People think I'm too strict about rules and regulations" "I won't get involved with people unless I'm certain they will like me" "People think I'm odd and detached" I am entitled to special rights and privileges because I am special and unique Problems range from normal to pathological i.e. most people can identify some symptoms in themselves!

12 The Need Approx. 11% of the general population: 2 million Australians have a diagnosable personality disorder at any given point in time 1.1% of the population have schizophrenia (i.e. 285,000 people in Australia)

13 Prevalence of PD and D&A Among ppl with a PD, up to 22% of people have co-occurring substance use disorder (among BPD co-occurrence is 60%) Among ppl with SUD, up to 50% have cooccurring PD Prevalence of people with sub-threshold problematic personality traits is much higher again

14 Presenting problems Often occur with social and other problems Learning disability Cognitive impairment Low rate of school completion Vocational problems Family conflict and problems Family mental illness Abuse, neglect & victimisation Other mental illness

15 Co-occurring PD and D&A Dually diagnosed individuals enter treatment at higher rates than do individuals with a single diagnosis This impacts upon provision of treatment, with growing recognition that each disorder cannot be treated in isolation

16 Biopsychosocial Model Individuals with a sensitive genotype (genetic predisposition) are at greater risk of PD in presence of a predisposing environment Environmental risk factors include: Child abuse and neglect Maladaptive parenting Maladaptive school-experiences Childhood and parental demographic characteristics Insecure attachment

17 Experiences as an adult Also characterised trauma & abuse (physical, sexual, domestic violence, rape etc ) Removal of children into care, family breakdown

18 Challenges Misdiagnosis bipolar disorder, PTSD, substance dependence, psychosis, depression Pharmacotherapy not recommended as primary treatment but often over-medicated Relationship deficits swing between interpersonal neediness, idealisation, devaluation, hypersensitivity, anger, avoidance Health service deficits reactive, limited, punitive, inconsistent, overwhelmed & under resourced Stigma amongst health professionals (not wanting to use the term personality disorder - increases stigma)

19 Potential risks for not diagnosing Well-intentioned clinicians deliberately avoid the label Perpetuate negative stereotypes Reduces prospect of applying specific evidencebased interventions Increasing likelihood of inappropriate interventions and iatrogenic harm (polypharmacy)

20 What 25 RCTs tell us (for BPD) DBT Dialectical Behaviour Therapy CBT plus treatment as usual SFT Schema-Focused Therapy TFP Transference-Focused Psychotherapy MBT Mentalisation Based Therapy TEC Therapy by experts in the community GPM General Psychiatric Management CAT Cognitive Analytic Therapy for Youth All treatment types work! Treatments are available to help! People improve! BUT: No treatment types are superior RCTs are all specialist interventions No research on whole of service approaches "However, the available forms of psychotherapy do not yet lead to remission of BPD for most patients (ie. no longer fulfilling the criteria of a diagnosis of BPD). Thus, further research is needed"

21 Guideline-based treatment 1. Once a week individual meetings 2. Focus on person's priorities (not specifically targeting self-harm and suicidal thinking) 3. Psychoeducation about problems 4. Here and now focus 5. Emotion focus 6. Relationship focus 7. Hospitalisation if helpful Research not done by Linehan or Gunderson, but both support its validity and findings.

22 General Psychiatric Management Professor John Gunderson, Harvard Professor of Psychiatry Chaired the DSM-IV Personality Disorders Workgroup Developed the diagnosis of BPD Gunderson & Links, A Clinical Guide (2008)

23 Gunderson: Future Developments Need treatments that are simpler to teach and disseminate Need to focus on social rehabilitation work, family, relationships, not just symptoms Following a few basic principles leads to good enough treatment in most cases Many health professionals miss that education Recognise some modes of therapy (e.g.dbt) may not be suitable for cognitive impairment

24 TRADITIONAL APPROACHES TO PD & SUD TREATMENT

25 Traditional Approaches Historical divide between mental health and substance abuse treatment services for many years Two different systems oversee and provide separate services for each type of disorder Treatment is either delivered sequentially or concurrently (in parallel) Sequential treat one disorder first then another Parallel different providers treat at same time

26 Sequential Approaches Common clinical justification for excluding ppl from treatment Person w dual disorder is not eligible for Rx in one part of system until other part is resolved or stabilised Untreated disorder worsens treated disorder, making it impossible to stabilise one w/out attending to other Ignores interactive & cyclical nature of dual disorders Lack of agreement re which disorder to treat first Unclear when one disorder has been successfully treated so that Rx of other disorder can begin Client is not referred for further Rx, or when they are fail to follow-through

27 Parallel Approaches PD & SUD Rx not integrated into cohesive Rx package Rx providers fail to communicate Burden of integration falls on client, who is often illequipped to cope w this responsibility Funding & eligibility barriers to access both treatments exist Different Rx providers have different Rx philosophies, methodologies and lack a common language Client slips b/w cracks and receives no services as no service accepts final responsibility for client

28 Problems w Traditional Approaches Research has shown poor prognosis for ppl w dual diagnoses who are treated w traditional sequential and parallel approaches

29 Integrated Treatment Approaches Both disorders are considered primary and are targeted for treatment concurrently Although different members of treating team may have different philosophies, the need to work collaboratively w/in team and provide consistent message to clients leads to compromises and gradual shifts to shared perspectives and a unified Rx approach Flexible approach that is individualised for each person s unique needs

30 Core Value of Integrated Treatments Shared decision making Between client, family members & clinicians Families provide support Clinicians provide specific consultations & treatment

31 Requirements Residential treatment programs are needed that do not: Exclude clients with ongoing substance abuse, particularly if they relapse continually (often PD can relapse more readily esp. w features of impulsivity) Integrated treatment programs are needed that: Attend to housing needs of people Provide long-term residential treatment for clients, which provide better outcomes than short-term programs

32 ESSENTIAL SKILLS FOR WORKING WITH PERSONALITY DISORDER

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35 Guidelines The Relational Model of Treatment Working w ppl in crisis and conducting risk Ax Developing a Care Plan Working in forensic setting Working w ppl w intellectual disability Working w specific PDs and traits Working with Indigenous and CALD populations Working w young people Working w older persons

36 Guidelines cont... Brief interventions Ongoing community treatment Clinical supervision and consultation for medical practitioners for working in a hospital setting Working with comorbid conditions (in development)

37 WHAT WORKS

38 Engagement What works Retention is the most critical factor in treatment Drop-out with BPD ranges from 40-60% - particularly early in contact with client Barriers to engagement Psychological: offered close relationship with therapist - intensity threatening Practical: Housing, transport, childcare, cost

39 What works Working Alliance Capacity of client to feel understood & supported Bond: can I trust therapist ( does therapist likes me ) Goal: therapy has an agreed direction Task: therapy activities are helpful Clinician belief they can help sets the foundation Alliance of organization and staff critical

40 What works Consistent and stable frame Reliable treatment conditions environment, availability, frequency, duration, treatment set-up (e.g. individual, group or both) Relationship boundaries Staff approach and attitude consistent Understand difficulties with these conditions for both clients and therapists

41 Attitude and approach What works View behaviour as meaningful Self-harm, substance abuse, impulsivity, anger & suicidal gestures may be meaningful attempts to communicate, manage symptoms and relationships DBT: 'find kernel of truth in behaviour' Dynamic: 'symptoms and defenses are attempts to master problems'

42 What works Consultation & Supervision Efficacy of therapist that they can help Analysis of repetitive relationship conflicts Remoralisation of therapist in terms of expected gains and frequency of setbacks Maintain therapeutic focus on psychological despite multiple needs - presenting issues

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44 Resources for Clinicians Guidelines for working w ppl w PD Fact Sheets for clients, family members and carers Therapy Cards Training for staff Workshops for partners, families and carers Personal stories Annual Conference UOW, 9 November Keynote speaker Roger Mulder from NZ Opening a clinic Research

45 Fact Sheets for Clients What is a personality disorder? What Rx is available to me? Relationship difficulties, conflicts and arguments Self-harm: What is it? The importance of self-care Managing anger Managing distress Managing emotions

46 Fact Sheets for Partners, Families & Carers Personality disorder: The basics Helpful tips for challenging relationships Managing anger Looking after yourself Strategies for effective communication and healthy relationships Navigating the system

47 NADA Training: Wed, 29 th August Wed, 29 th August 2012 Theme Content 9.00am 10.30am Introduction to Personality Disorders 11am 12.30pm Managing Risk & Care Planning Risk assessment, care planning, psychoeducation 1.30pm 3pm Integrated & Relational Treatment Approaches Specific treatment skills, relationship management, challenges 3.30pm 5pm Involving Families & Carers, Working Collaboratively with a Multidisciplinary Team Involving families and carers, working in a multidisciplinary team, supervision and expert consultation

48 Training Team Simon Milton Clinical Psychologist, Consultant to Project Air Strategy for Personality Disorders. Professional Officer, Psychology Board of Australia. Professor Brin Grenyer Clinical Psychologist & Director, Neuroscience and Mental Health Theme, Illawarra Health and Medical Research Institute. Professor of Clinical Psychology, University of Wollongong.