Effective Strategies for Borderline Personality Disorder Management

Applying the model in practice in NHSGGC Andy Williams Clinical lead for Personality Disorder NHS Greater Glasgow and Clyde

NHSGGC Mental Health Strategy NHSGGC Mental Health Strategy Develop a GG&C-wide system of care for people with a diagnosis of Borderline Personality Disorder Ensure people who have used services influence the strategy Increase staff knowledge and awareness to better support patients (training and materials) Improve equity of access to treatment Reduce inpatient bed days

Ethics of Risk Management throughout pathway CCC (Co-ordinated Clinical Care)Training Concept introduced during training Guidance Documents Crisis Clinical Risk Reference Panel (CRRP) presentations Supported by templates Use principles in panel discussions and feedback In-patient care

CCC Training CCC Training Co Core training for Core training for all Mental Health staff all Mental Health staff Co- -ordinated Clinical Care ordinated Clinical Care Model of care based on good practice guidelines which underpin the pathway Aim to improve staff knowledge and understanding of BPD Promote an empathic and validating stance Co-production of training model (and delivery)

Underpinning Principles of BPD Pathway Co-ordinated Clinical Care or CCC Collaborative and meaningful goal setting Developing clear and relevant goals helps to structure the contact with the service, and to monitor progress. Thoughtful ? Thoughtful approach to risk Risks including self harm, suicide and aggression are common for people with a diagnosis of BPD. Team decisions about thoughtful risk taking may be an important step towards the patient developing self- regulation in the longer term. Development of shared crisis plan Crisis planning is an ongoing collaborative process, which helps the patient and the team to know what a crisis looks like, and what the patient finds helpful and unhelpful when distressed.

In September 2022 NICE published an update to its guideline on Self harm: assessment, management and preventing recurrence . This states: Do not use aversive treatment, punitive approaches or criminal justice approaches such as community protection notices, criminal behaviour orders or prosecution for high service use as an intervention for frequent self-harm episodes. NICE states that this amounts to malpractice. Examples that have emerged and must stop include: 1.behavioural contracts or similar: making patients sign contracts about how they will behave 2.threat of withholding or withdrawing services as a deterrent, or more broadly to elicit desired behaviour 3.anticipatory care plans which instruct mental health staff or other agencies not to see a patient during psychiatric or medical emergencies 4.criminal sanctions (for example, community protection orders, behaviour orders, bail conditions, arrests, charges, cautions, prosecutions or imprisonment) applied in response to people presenting to health services, or deemed to be doing so, regularly. Thoughtful approach to risk, NOT Unthinking/ blaming positive risk taking The use of sanctions (criminal or otherwise), withholding care and otherwise punitive approaches. See NHS England response To SIM Discriminatory practices and attitudes towards patients who express self harm behaviours, suicidality and/or those who are deemed high intensity users . Discriminatory and un-evidenced beliefs regarding people with complex mental illnesses and high intensity needs must be challenged. Examples of practices that need to end include: Labelling of patients by professionals as manipulative and attention seeking . Telling patients that they have capacity to take their own life. Serenity Integrated Mentoring

Good Practice Guidance Documents Assessment, Diagnosis and Formulation Managing Crisis In-Patient Care Complex/ extended in-patient situations

Template for considering any difficult care decision around risk: Template for considering any difficult care decision around risk: Action/ Consequence Action/ Consequence Model ( Model (Warrender Warrender) ) CONSEQUENCES Potential Short Term Impact Short Term Risks increase Long Term Autonomy Potential Benefit Potential Danger Potential Long Term Impact Potential Interpretation of Clinician Motive Can be seen as Neglect of Patient ACTION Tolerating Risk (e.g. reducing observations) Increase Patient Autonomy Clinician Complacency/ Patient suicide Containing risk (e.g. increasing observations) Ensure Patient Safety Increase Patient Dependence Short Term Safety Long Term Dependency Can be seen as Care and Compassion

The Clinical Risk Reference Panel The Clinical Risk Reference Panel An organisational response to risk and complexity In everyday clinical practice, issues around risk are managed effectively using existing multi-disciplinary processes, e.g. complex case discussions and second opinions. In a small number of cases, existing structures are insufficient to help manage complex and ethically challenging situations. We developed the CRRP, as part of the development of our pathway, based on published accounts of similar models, which were adapted with reference to the action/consequences model.

The CRRP allows for: Adoption of an organisational approach to risk management and shared decision making Panels include clinicians and senior managers Embedded in Board Governance structures Provision of externality and capacity for reflection in complex and ethically changing scenarios Greater objectivity in viewing current practice especially where there is disagreement within the clinical team

Small study of 8 cases explores how we used the Action/Consequences model as a tool to prompt discussion about the ethical dilemmas teams faced in complex, risky situations. Alongside this we utilised a mentalizing stance which provided a framework to help promote curiousity, empathy and shared understanding of the situation. Feedback I didn t think about it this much before. We need to be doing the same thing, it is good we are talking like this. I never thought about how other teams felt What we did We have to do something. Facilitated discussion with teams using the action/consequences model and a mentalizing frame to facilitate thinking in the team: Interested and curious Different perspectives Knowledge and feelings Reactions and reflections I'm exhausted I can feel so confused . Actions/ Consequences model + mentalizing = Will they complete suicide? Do they want to die? An agreed way of working Whose responsibility, is it? The Action/ Consequences tool prompts discussion around the impact of ethical dilemmas on how we deliver care, and works well alongside assisting teams engage in reflection. Mentalizing is a valuable stance for helping staff to be reflective and question their practice, explore anxiety and understand the factors influencing the ethical dilemma from various perspectives. By promoting curiosity, empathy, self-awareness and reflection, mentalizing can create a more compassionate and effective working environment and help lead to cohesive approaches that could benefit the care that is provided to our patients. Warrander,D.2018.Borderlinepersonalitydisorderand the ethics of risk management: The action/consequences model .Nursing Ethics.25(7),pp.918-927. Bateman,A & Fonagy,P. (2016). Mentalization-based treatment. Psychoanalytic enquiry, 36(6), pp.438-447.

Ethics of Risk Management Model What does it offer? It is not a simple solution to complex situations But it is a versatile framework to promote thinking and reflection in ourselves our teams and our systems Future plans: Share practice and applications across a mini network of clinicians across UK