In the past personality disorder was considered untreatable, while this should be considered untrue, treatment is still hampered by inconsistent research methodology. RCTs are considered the ‘gold standard’ of evidence in medicine, usually because it strives to identify what intervention is better than another for a specific disorder and in its absence, treatment efficacy cannot be definitive. However, Seligman (1995) argues RCTs strength is understood to be its scientific rigour, yet this could be seen as its weakness because it does not reflect what is done in psychotherapies clinical practice. Furthermore, Slade and Priebe (2001) are critical of RCTs because they often group individuals through a diagnosis or a particular problem (e.g. self-harm) and assume that these people will all be the same or conversely RCTs can have highly selective inclusion criteria and could exclude full representation. Consequently, individuals may have the same disorder but an individual may have a set of different problems and psychological issues from that of another. Therapy tends to focus on the individual’s presenting problems, and it would be unlikely that an individual would enter therapy asking for their personality disorder to be changed.
Available research does demonstrate that no on treatment is considered better than another in treating personality disorder. Therefore, it may be advantageous to
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integrate the diverse models and shape it to the individual’s needs. Nevertheless, research indicates that the treatment of personality disorder can be most positive when it is long-term, intensive, well structured, theoretically coherent, and when follow-up is provided post residential care. It can be seen from the evidence above that dropout rates and satisfactory engagement are problematic with this diagnostic group, which leads Bateman and Fonagy (2000) and Rawlings (2001) to suggest the particular importance that care should be taken to engage personality disordered clients in treatment, and keep them engaged. Consequently, it is argued by Luborsky and Auerbach (1985), that the strongest predictor of outcome in psychotherapy is the therapeutic alliance, which will be explored in the following chapter.
2.4 Conclusion.
It can be seen thus far, from the review above, that there is still much to understand about personality disorder in terms of origin, assessment, treatment efficacy, which can be confounded by inconsistent research methodology and the pejorative and categorical nature of the disorder. Placing this ‘understanding’ within the context of a forensic culture creates yet another level of difficulty in relation to the severity of risk and how this should be managed and treated. Psychiatric nursing and forensic psychiatric nursing roles appear to be ill-defined in relation to the management and treatment of personality disorder. However, despite an emerging improvement in assessment (e.g. dimensional models) and some indications of improvement in treatment efficacy in relation to presenting problems from this diagnostic group, psychiatric nursing does not stand alone in relation to other clinical disciplines in terms of understanding how best to approach their needs. My data collection was initially undertaken at a point in time when it was difficult to identify a clear evidence base to satisfactorily shape the way forward. In fact it was perhaps clearer to say what we didn’t want and utilise available and sometimes unproven resources to this end. Consequently, psychiatric nurses working with people with personality disorder should at the
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most be able to equitably utilise the therapeutic tools reviewed above alongside other clinicians, whilst at least there should be a satisfactory appreciation of these methods to motivate and support their use systemically throughout the 24 hour a day learning opportunities nurses can provide. Forensic psychiatric nurses should equally be able to use the same therapeutic tools alongside those reviewed in the forensic environment below.
Historically, research into treatment modalities for this client group, has been and continues to be fraught with inconsistency regarding diagnosis, research methodology and long term follow up. It is rare to find research which focuses on the same outcome or which uses the same evaluation tool, ensuring that the validity of the intervention remains inconclusive. Even when evidence is available with regard to efficacy, no one therapeutic intervention has demonstrated superiority over another. A considerable amount of confusion exists regarding: research based treatment outcomes, definition and assessment for personality disorder. The interactive processes of individuals are seemingly complex and chaotic but developmental research has begun to demonstrate that it can actually be coherent and follows certain laws. However, it should be recognised that a treatment intervention along one dimension will not necessarily effect change in an individual without intervention along another. No single type of treatment in an institutional setting has been found to be uniformly successful. Convincing evidence does not exist that personality disorder can or cannot be treated successfully. This led Dolan and Coid (1994, p.266), to suggest that in the past ‘nothing works became the accepted wisdom’ but today we should ask, ‘nothing so far tried works but what does work’? For serious and multiple offenders, multi- model treatment programmes are appropriate which are more intensive and the matching of treatment should be improved.
Many of the research difficulties have already been mentioned above but suffice to say there will be limited progress if the underlying nature of the condition is not
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more fully understood. Chiswick (1992), stated that it is unsurprising that an experimental model based upon the concept of the treatment of mental illness has failed to be extrapolated successfully to the treatment of psychopathy, a concept which does not readily fit the illness model. This is a condition which is partially socially defined. It is a condition which requires continued but varied, treatment interventions over the course of life. When research has been evaluated it often appears to appraise the institution e.g. prisons with focus on recidivism, and High Secure Hospitals with focus on risk involved on the decision to discharge. Care providers should not subscribe to failure if we have not tried all the options.
It is with this in mind that following the forensic review below I will explore why an integrated approach may provide further opportunities for Mental Health Nurses to contribute and improve understanding.
Leichsenring and Leibing (2003) report that treatment outcome for personality disorder seems similar across treatments, resulting in the general recognition that no one therapy is better than another. In addition, as discussed above, the diagnosis of personality disorder has been contentious; nevertheless this has been gradually recognised within the new DSM-V to the point that a dimensional model of personality disorder has been included as an emerging model within the system. Leading Livesley to state,
The theoretical models underlying current therapies do not fully explain either the range of psychopathology of PD or the multiple biological and psychosocial factors implicated in its development. (2012, p.18)
Livesley (2012) has not only argued for a more meaningful way of describing personality disorder (e.g. a dimensional model) but in recognition of an absence of a dominant efficacious therapeutic intervention, he suggests that a more integrated therapy is utilised drawing upon the best components of what works from each intervention.
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He proposes a framework that comprising of two main components:
(1) A system for conceptualising personality disorder utilising empirical knowledge; and
(2) A model of therapeutic change founded on specific outcome studies in the treatment of personality disorder.
As highlighted above, treatment is dominated by a few treatments alongside the introduction of a variety of manualised interventions, with the implication that one intervention should be chosen to address PD. To exemplify the utility of an eclectic model, a borderline PD may experience emotional dysregulation, poor impulse control, maladaptive object relationships and cognitions, and impaired mentalising. Utilising DBT Linehan (1993) would address emotional dysregulation by building upon appropriate skills. However, mentalising4 based therapy (MBT; Bateman and Fonagy, 2004) by utilising mentalising techniques would enhance the functioning of meta-cognitions which in turn would impact upon emotional regulation. Thus by amalgamating DBT skills with MBT processing a more effective intervention could be provided. However, if this also involved self-harm, further approaches could involve cognitive therapy to address maladaptive cognitions and schema therapy (Young et al., 2003), a method of cognitive restructuring and even psychodynamic interventions for interpersonal aspects and avoidance behaviour.
Castonguay and Beutler (2006) and Critchfield and Benjamin, 2006 have identified from the analysis of empirical literature that effective generic principles for therapeutic change include a strong working alliance, an empathetically flexible approach to repairing ruptures in the alliance, a caring attitude, warmth, empathy, positive regard, congruence and authenticity, patient-therapist agreement on treatment goals, strong collaboration between patient and therapist in working
4
Mentalization refers to your ability to recognize your own and others’ mental states, and to see these mental states as separate from behavior. Mentalization includes being able to think about thoughts, emotions, wishes, desires, and needs in yourself and other people, and to see that these internal events may have an impact on the actions that you and others take, but are separate from those actions.
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towards goals, and a high level of therapist activity. They further suggest that treatment should be organised in relation to change mechanisms universal to all therapies. Consequently, the five principles common to all treatment and are potential transferable to all clinicians include:
(1) Therapy factors (principles for organizing an evidence-based integrated treatment).
Critchfield and Benjamin (2006) highlight that effective PD treatments comprise of a well-defined structure which in turn provides consistency required for a positive outcome. However, Livesley (2012, p.20) argues that an, ‘integrated treatment cannot be based simply on eclecticism’ and in the absence of an evidence-based personality disorder theory that the clinician should demonstrate a conceptualisation of the personality disordered individual’s psychopathology alongside therapeutic principles of change.
(2) Relationship factors (especially alliance factors).
Smith et al. (2006) have identified that from psychotherapy research that the quality of the therapeutic relationship/alliance is key to outcome, particularly because relationship difficulties are a defining characteristic of PD (Cloninger, 2000). Consequently, it is imperative that strategies are developed to enhance collaboration, to manage and model adaptive approaches to resolve deep-seated interpersonal difficulties related to rejection, abandonment, trust and intimacy. Livesley (2012) believe that the alliance can be enhanced by having agreed goals with an understanding of how they will be achieved, which ultimately enhances motivation.
3) Therapist factors.
Important ingredients in supporting the therapeutic relationship and positive outcome involves the therapists’ ability to utilise empathy, support and validation, which represent the cornerstone of a Rogerian (Rogers, 1957) ‘person centred’
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approach and considered a major predictor of outcome. However, there is a sparsity of supporting research directly linking empathy approaches with personality disorder, with the exception of a study of a PD comorbid addictions group indicated by Miller and Rollnick (2002) who linked the significance of empathy with outcome. Nevertheless, the above Rogerian principles are akin to open-mindedness, flexibility and creativity reported by Fernandez-Alvarez et al. (2006) as significant therapist attributes in terms of patient outcome. Providing support, validation, containing limit setting and repairs to ruptures in the relationship (Safran et al.2002) are also key to this relationship, in light of the replication of inconsistent traumatic attachments in childhood. Therapist factors associated with outcome also involve the ability to cope/tolerate with intense psychopathological positive and negative feelings, particularly in relation to counter/transference responses.
(4) Patient factors (variables associated with outcome).
There are a broad array of characteristics that PD patient may display that will potentially hamper the creation of a therapeutic alliance e.g. impaired object relationships, pessimism and hopelessness, poor social skills, poor family relationships, powerful defensive behaviour, hostility, perfectionism, and limited psychological mindedness. Providing initial and ongoing motivational strategies alongside supportive and empathetic approaches are imperative due to high dropout rates in therapy by PD patients (Cottraux et al., 2009), often due to feelings of helplessness, hopelessness, passivity due to adverse developmental experiences.
(5) Technique Factors.
With regard to the integration of effective strategies for the treatment of PD Critchfield and Benjamin (2006) reported on the importance of maintaining, a goal orientated approach, the identification of maladaptive patterns of thinking and feeling and acting, and dealing with presenting problems. This provides an
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opportunity to reinforce why therapeutic interventions may be helpful. Maintaining a focus on change is important in effecting outcome, whilst Linehan (1993) promotes this approach within DBT but balances this with acceptance and support as part of the integral dialectical approach.
Any effective model for the treatment of personality disorder should be coherent and include a distinction between common and individual factors related to the perceived disorder, where the disorder is in relation to normal personality functioning, and utilise a social cognitive model to provide structures of cognition and affect derived from adaptive mechanisms.
2.5 Summary.
The above review of the understanding of PD indicates that the construct of PD including psychopathy has considerable relevance for forensic psychiatric nurses. Revisions of diagnostic tools have not resulted in an agreed consensus, however new and hopefully illuminating diagnostic and treatment options which describe origins of PD are being postulated and gradually gaining a degree of acceptance, which will need to be evidenced by future research. However, despite disagreements about assessment, manifestation and treatability of psychopathy, Melia, et al. (1998) comments can be considered equally relevant today (Kirkman, 2008), in that PD causes significant challenges to forensic nurses in terms of high levels of stress, anxiety, and the dilemma arising between care and containment. These difficulties are compounded by assumptions associated with PD patients’ level of dangerousness, which potentially could lead forensic nurses to focus on control rather than therapeutic engagement in which the former may seem easier to quantify. In the face of these difficulties nurses need to maintain positive attitudes about their role and contribution to maintain a therapeutic boundaried atmosphere to maximise therapeutic success. Maintaining a contemporary understanding will enable forensic nurses to develop a credible dialogue with other healthcare professionals, thus promoting positive views and attitudes about
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their own role (Kirkman, 2002). Whilst it is imperative that research into the understanding of psychopathy and personality disorder needs to continue not least from a clinical perspective but also for the potential risks posed to society.
A key aspect of personality disorder in terms of origin, manifestation and interface for change is that of their relationships, and for forensic nurses the development and maintenance of the therapeutic alliance, which will be the focus of the following chapter.
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