Search

In psychiatric practice, professionals tend to split patients into those who are responsible for their actions, and those who are not. This approach does a disservice to both groups. Patients assumed to retain agency may be blamed, and those assumed to lack agency are disempowered. Professionals should adopt a more nuanced approach to agency and control, recognising that it is impaired in most psychiatric disorders, but absent in very few. This is possible without making stigma worse.

Background People with personality disorder experience long waiting times for access to psychological treatments, resulting from a limited availability of long-term psychotherapies and a paucity of evidence-based brief interventions. Mentalisation-based treatment (MBT) is an efficacious therapeutic modality for personality disorder, but little is known about its viability as a short-term treatment. Aims We aimed to evaluate mental health, client satisfaction and psychological functioning outcomes before and after a 10-week group MBT programme as part of a stepped-care out-patient personality disorder service. Method We examined routinely collected pre–post treatment outcomes from 176 individuals (73% female) aged 20–63 years, attending a dedicated out-patient personality disorder service, who completed MBT treatment. Participants completed assessments examining mentalising capacity, client satisfaction, emotional reactivity, psychiatric symptom distress and social functioning. Results Post-MBT outcomes suggested increased mentalising capacity (mean difference 5.1, 95% CI 3.4–6.8, P < 0.001) and increased client satisfaction with care (mean difference 4.3, 95% CI 3.3–5.2, P < 0.001). Post-MBT emotional reactivity (mean difference −6.3, 95% CI −8.4 to −4.3, P < 0.001), psychiatric symptom distress (mean difference −5.2, 95% CI −6.8 to −3.7, P < 0.001) and impaired social functioning (mean difference −0.7, 95% CI −1.2 to −0.3, P = 0.002) were significantly lower than pre-treatment. Improved mentalising capacity predicted improvements in emotional reactivity (β = −0.56, P < 0.001) and social functioning (β = −0.35, P < 0.001). Conclusions Short-term MBT as a low-intensity treatment for personality disorder was associated with positive pre–post treatment changes in social and psychological functioning. MBT as deployed in this out-patient service expands access to personality disorder treatment.

Introduction: Over time, there have been different views regarding the verbal auditory hallucinations (VAHs) reported by borderline personality disorder (BPD) and schizophrenia patients. More recently, their similarity has been emphasized, a view that undoubtedly has significant implications in terms of differential diagnosis and management. To explore this important issue, we undertook a detailed phenomenological assessment of persistent VAH reported by BPD and schizophrenia DSM-IV participants. Methods: The Psychotic Symptoms Rating Scale (PSYRATS), the Revised Beliefs About Voices Questionnaire (BAVQ-R), the Multidimensional Scale for Hallucinations (MSH), and a detailed clinical interview were administered to 11 BPD and 10 schizophrenia DSM-IV participants. Results: The VAHs of both groups were similar regarding intensity, reported as located inside or outside the head, and frequency in which they were described as a third-person phenomenon. However, the patients’ stance towards their VAH was clearly different. Whilst BPD patients identified them in a clear way in terms of gender and age and disliked them, schizophrenia patients identified them more vaguely, reported them both as more disruptive but at the same time engaged with them more positively; schizophrenia patients also integrated their VAH more into delusions. Discussion: Whilst reporting similar intensity of their VAH, the 2 groups’ stance towards them were strikingly different in that BPD participants regarded them as identifiable and unequivocally unpleasant whilst schizophrenia participants regarded them in a rather vague and ambiguous manner. Methodologically, this preliminary study suggests that in-depth phenomenological assessment can help to elucidate the differential diagnosis of VAH in these, possibly other, clinical groups. Further research is warranted to establish whether these preliminary findings are replicated on a bigger clinical sample.

Background Borderline Personality Disorder (BPD) is a serious mental disorder characterized by marked interpersonal disturbances, including difficulties trusting others and volatile impressions of others’ moral character, often resulting in premature relationship termination. We tested a hypothesis that moral character inference is disrupted in BPD and sensitive to Democratic Therapeutic Community (DTC) treatment. Methods BPD participants (20 treated and 23 DTC-treated) and non-BPD control participants (N=106) completed a moral inference task where they predicted the decisions of two agents with distinct moral preferences: the “bad” agent was more willing to harm others for money than the “good” agent. Periodically, participants rated their subjective impressions of the agent’s moral character, and the certainty of those impressions. We fit a hierarchical Bayesian learning model to participants’ trial-wise predictions to describe how beliefs about the morality of the agents were updated by new information. Results The computational mechanisms of moral inference differed for untreated BPD patients relative to matched non-BPD control participants and DTC-treated BPD patients. In BPD patients, beliefs about harmful agents were more certain and less amenable to updating relative to both non-BPD control participants and DTC-treated participants. Conclusions The findings suggest that DTC may help the maintenance of social relationships in BPD by increasing patients’ openness to learning about adverse interaction partners. The results provide mechanistic insights into social deficits in BPD and demonstrate the potential for combining objective behavioral paradigms with computational modelling as a tool for assessing BPD pathology and treatment outcomes.

Personality disorders are a divergent group of diagnoses which are pervasive in nature and, until recent years, were thought to be treatment-resistant. While the majority of current treatments have evolved on the basis of psychoanalytic and behavioural theories of personality development, there is an emerging understanding of the underlying neurobiology. Current neuroscientific evidence, supported by the theoretical underpinnings of successful psychotherapeutic interventions, converges on social functioning and mood regulation as key treatment targets in personality disorder, and specifically in borderline personality disorder.

Purpose Training in therapeutic community and related approaches has not been widely available, and there is debate about the form this should take. This has had a negative impact on the field. The paper aims to discuss this issue. Design/methodology/approach The authors consider the history of training in democratic therapeutic community methods in the UK in particular, and trace some of the reasons for its lack of development. Findings With the expansion of TC methodology into new areas, such as therapeutic and enabling environments, the ability to provide training in DTC approaches and techniques is increasingly important. The developing evidence base, and the increasing detail in which the method has been described, make dedicated TC training increasingly important. Originality/value Training in therapeutic community methods, and enabling and therapeutic environment approaches, provides a grounding in technique and theory that would otherwise be impossible to acquire for most workers, and can lead to a general increase in the level of competence and confidence in the way these environments operate.

Purpose The purpose of this paper is to provide an overview of the application of therapeutic community (TC) method in non-TC environments. Design/methodology/approach Milieu treatment is defined and differentiated from TC “proper”. Literature is reviewed covering attempts to use TC methods in inpatient wards, across hospitals, and more recently in the criminal justice system and more widely through the enabling environments initiative. Findings It is unclear whether TC milieu treatments proved helpful in acute ward environments in their heyday in the 1950s, 1960s and 1970s, in particular those involving people suffering from acute psychosis, and the changing landscape of psychiatric provision may make further investigation difficult. The reasons for this, and for the difficulties reaching a firm conclusion, are outlined. In contrast, TC milieu interventions appear to be demonstrating usefulness more recently in less mixed populations without the implementation of full TC “proper”. Research limitations/implications Much of the research is old and the methodology poor, which limits the conclusions that can be drawn. Practical implications Recent innovations pick up in a more accessible way principles of therapeutic communities that can inform and improve care in a variety of contexts. They are sufficiently well defined to lend themselves to research, which should now be a priority. Originality/value After a gap in developments in the field, recent innovations are reintroducing elements of TC functioning to new contexts including criminal justice settings, inpatient wards, homeless shelters and city communities.

BackgroundDemocratic therapeutic community (DTC) treatment has been used for many years in an effort to help people with personality disorder. High-quality evidence from randomised controlled trials (RCTs) is absent.AimsTo test whether DTC treatment reduces use of in-patient services and improves the mental health of people with personality disorder.MethodAn RCT of 70 people meeting DSM-IV criteria for personality disorder (trial registration: ISRCTN57363317). The intervention was DTC and the control condition was crisis planning plus treatment as usual (TAU). The primary outcome was days of in-patient psychiatric treatment. Secondary outcomes were social function, mental health status, self-harm and aggression, attendance at emergency departments and primary care, and satisfaction with care. All outcomes were measured at 12 and 24 months after randomisation.ResultsNumber of in-patient days at follow-up was low among all participants and there was no difference between groups. At 24 months, self- and other directed aggression and satisfaction with care were significantly improved in the DTC compared with the TAU group.ConclusionsDTC is more effective than TAU in improving outcomes in personality disorder. Further studies are required to confirm this conclusion.

This chapter reviews research and expert guidelines on inpatient management of personality disorder, autism spectrum disorder, and adult attention deficit hyperactivity disorder. It covers use of medication, milieu approaches, other psychosocial interventions, the impact of the ward environment, quality assurance mechanisms, and the impact of institutionalization. Ways in which formal therapeutic approaches can be implemented on inpatient wards are also addressed. The effect of risky and challenging behaviours on defensive practice and staff burnout is covered, and detailed advice on managing suicidal and high-risk patients who are difficult to discharge safely is included. The chapter details specific approaches to milieu management, use of observations, personalized care plans, and communication styles in borderline personality disorder, autism spectrum disorder, and attention deficit hyperactivity disorder. Patients with these diagnoses constitute an important group of inpatients, and with careful management, iatrogenic harms can be avoided.

SummaryPatients with severe and enduring somatoform disorders (SESD) characteristically present with multiple, recurrent and frequently changing physical symptoms that have usually been present for several years before referral to a psychiatrist/psychologist. Many patients report long histories of contact with both primary and tertiary care services, have undergone repeated fruitless investigations and have high levels of disability. SESD are responsible for disproportionately high healthcare costs and are the third most common cause of workplace absence. Identification of patients with SESD by psychiatrists requires particular skills: collaboration with colleagues is vital and there are risks of iatrogenic harm. We describe the obstacles encountered in identifying these patients as well as methods of assessment and management. Treatment pathways best suited to managing this large and as yet untended group of patients are described.

Patrick Sullivan's emphasis on the importance of supporting autonomy and independence among vulnerable people who self-injure is fundamental to good clinical practice. Although people who self-injure typically experience overwhelming emotions and may be prone to impulsive behaviour, self-injury is nonetheless a choice and must accordingly be treated as such.1 In addition, patients who self-injure when not acutely mentally ill typically retain decision-making capacity in relation to self-injury.2 This is why some forms of harm minimisation, such as encouraging reflection, responsibility, safe cutting and where appropriate self-aftercare, are uncontroversial and already widely practised within community settings. The situation is different, however, with respect to both secure and non-secure inpatient settings. It is also different when we consider some of the other forms of harm minimisation that Sullivan advocates, namely the provision of self-harming instruments alongside education about anatomy and physiology. Sullivan does not distinguish secure and non-secure settings, but it is crucial to do so. In secure (forensic) inpatient settings, it is neither practical nor ethical to provide implements that can be used as weapons to any patient, for any reason. This would be to severely compromise staff and patient safety. In non-secure inpatient settings, patients are likely to be detained under the Mental Health Act. This raises the question of the grounds of detention. Typically, patients who self-injure are detained because they are judged to be currently at risk of life-endangering or life-changing injury. As Sullivan notes, it is not clinically or ethically appropriate to provide patients with the means to self-injure when they are in this state of mind. This means that the relevant inpatient population for which a harm minimisation approach could even be considered is relatively small: those who have a standing pattern of self-injury and who are detained on non-secure units for reasons other …

Purpose – The purpose of this paper is to investigate the possible impact of a randomised controlled trial on the therapeutic environment of participating therapeutic communities (TCs). Design/methodology/approach – The authors compared the environment in four democratic day TCs involved in a randomised trial (experimental TCs) with a similar democratic day TC not involved in the trial (the control TC) by administering the Community Oriented Environment Scale (COPES) to 28 TC members. Findings – TC members’ views of the real psychosocial environment at the experimental TC and control TC showed similar high levels for spontaneity, autonomy and personal problem orientation and similar intermediate levels for practical orientation and staff control. The TC members at the experimental TC rated significantly higher levels for order and organisation and clarity, while members at the control TC rated a significantly higher level for involvement. Originality/value – The study provided no evidence of a significant adverse impact on the culture of democratic day TCs due to participation in a randomised trial. This finding answers one of the most common arguments in the debate on the ethics of RCTs in TCs.

Purpose The mentalisation based therapeutic community (MBTC) is a group experience which promotes the acquisition of the capacity to mentalise. Members of the community gain greater emotional stability and psychological robustness. The paper aims to discuss these issues. Design/methodology/approach MBTC works with three theoretical principles: the intrapsychic, interpersonal and social. It is a slow open group where each member completes a ten-week course. The approach is deliberately non-interpretive with an emphasis on personal responsibility and accountability in order to promote clarity of mind. Findings The authors’ experience is that the model engages group members with few drop outs. Originality/value The combination of mentalising and the use of therapeutic community principles within in MBTC has enhanced outcomes for group members.

Therapeutic communities (TCs) for addictions are drug-free environments in which people with addictive problems live together in an organized and structured way to promote change toward recovery and reinsertion in society. Despite a long research tradition in TCs, the evidence base for the effectiveness of TCs is limited according to available reviews. Since most of these studies applied a selective focus, we made a comprehensive systematic review of all controlled studies that compared the effectiveness of TCs for addictions with that of a control condition. The focus of this paper is on recovery, including attention for various life domains and a longitudinal scope. We searched the following databases: ISI Web of Knowledge (WoS), PubMed, and DrugScope. Our search strategy revealed 997 hits. Eventually, 30 publications were selected for this paper, which were based on 16 original studies. Two out of three studies showed significantly better substance use and legal outcomes among TC participants, and five studies found superior employment and psychological functioning. Length of stay in treatment and participation in subsequent aftercare were consistent predictors of recovery status. We conclude that TCs can promote change regarding various outcome categories. Since recovering addicts often cycle between abstinence and relapse, a continuing care approach is advisable, including assessment of multiple and subjective outcome indicators.

Background Therapeutic communities (TCs) could reduce the health care use of people with personality disorder (Davies S, Campling P and Ryan K, Psychiatrist 23:79–83, 1999; Barr W, Kirkcaldy A, Horne A, Hodge S, Hellin K and Göpfert M, J Ment Health 19:412–421, 2010) and in turn reduce the financial and environmental costs of services. Our hypothesis is that 3 years following entry to a TC service, patients have reduced subsequent health care use and associated reductions in financial costs and carbon footprint.MethodsA retrospective 4-year cohort study examined changes in health care use following entry to the Oxfordshire TC service. Comparative analysis was undertaken on a treated (n = 40) and a control group (referred but who declined treatment; n = 45). Financial costs and carbon footprint of health care use were calculated using national tariffs and standard carbon conversion factors. Mean changes in these outcomes were compared over 1, 2 and 3 years and adjusted for costs and carbon footprints in the year prior to joining the TC service.ResultsCompared to baseline, the group receiving TC care had greater reductions in financial costs and carbon footprint associated with A&E attendances (p = 0.04) and crisis mental health appointments (p = 0.04) than the control group. There were significantly greater reductions in carbon footprint for all secondary health care use, both physical and mental health care, after 3 years (p = 0.04) in the TC group.ConclusionsTC services may have the potential to reduce the financial cost and carbon footprint of health care.Keywords: Sustainability, Personality disorders, Carbon footprint, Economic evaluation

Background The concept of ‘unbearable suffering’ is central to legislation governing whether euthanasia requests may be granted, but remains insufficiently understood, especially in relation to psychiatric patients. Aims To provide insights into the suffering experiences of psychiatric patients who have made a request for euthanasia. Method Testimonials from 26 psychiatric patients who requested euthanasia were analysed using QualiCoder software. Results Five domains of suffering were identified: medical, intrapersonal, interpersonal, societal and existential. Hopelessness was confirmed to be an important contributor. The lengthy process of applying for euthanasia was a cause of suffering and added to experienced hopelessness, whereas encountering physicians who took requests seriously could offer new perspectives on treatment. Conclusions The development of measurement instruments to assess the nature and extent of suffering as experienced by psychiatric patients could help both patients and physicians to better navigate the complicated and sensitive process of evaluating requests in a humane and competent way. Some correlates of suffering (such as low income) indicate the need for a broad medical, societal and political debate on how to reduce the burden of financial and socioeconomic difficulties and inequalities in order to reduce patients' desire for euthanasia. Euthanasia should never be seen (or used) as a means of resolving societal failures.

The Oxford Friends and Family Empowerment (OFAFE) service is a carer support service that originated in a collaboration between the Oxfordshire Complex Needs Service and the national mental health charity Rethink. OFAFE provides support and education for adults supporting an individual with a personality disorder. This paper describes the background and operation of the OFAFE service, along with the early stages of the development of a similar service for young carers, the Young Friends and Family Empowerment (YFAFE) service.

The development and publication of Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) produced a peak in mainstream media interest in psychiatry, and a large and generally critical set of scientific commentaries. The coverage has focused mainly on the expansion of some categories, and loosening of some criteria, which together may lead to more people receiving diagnoses, and accompanying accusations of the medicalisation of normal living. Instructions given to members of DSM-5 work groups appear to have encouraged this.1 This has not been the only source of disquiet. The influence of the pharmaceutical industry on the members of the appointees to DSM diagnostic work groups, which constructed the new rubrics, has caused concern,2 as remuneration and insurance coverage in the USA depends partly on DSM diagnosis, and the pharmaceutical industry has been accused of encouraging the development of new diagnoses as a way to increase profitability.3 Societal impact has been an explicit part of the development of DSM-5, as outlined in the article in this issue.4 Reasons for decisions by DSM-5 workgroups have included enabling sufferers to receive treatment which would not be available without a DSM diagnosis (a local US concern), or …

Recovery from a range of common medical conditions requires patients to have the will to change their behaviour. The authors argue that the proper recognition of the role of willpower in recovery is necessary for effective treatment.

The need to change the way any business operates quickly is essential for remaining competitive, understanding what you key competencies and capabilities are is a key prerequisite before initiating a change programme. The restructuring of the UK gas industry presents an additional complication to transforming the business, the market changes, regulatory pressures and an inherited culture all serve to make the journey move complicated. Ensuring the destination is reached requires a full understanding of the environment, a radical change planning process which highlights key competencies and an implementation plan capable of measuring achievements in all aspects of the change. The business competency developed during the change process will ensure the company will remain the leading player in the emerging energy business. © 1997 John Wiley & Sons Ltd and Cornwallis Emmanuel Ltd.

SummaryPsychiatric treatment can enhance human morality. It can promote the emergence of moral motives and intentions, aid in the acquisition of skills essential to moral action, and help to develop the ability to apply moral understanding and skills in particular circumstances. Good psychiatric practice demands an honest appraisal of its moral dimension.

A Web-based coding application was designed to improve coding efficiency and to provide a systematic means of evaluating responses to open-ended assessments. The system was developed for use by multiple raters to assign open-ended responses to predetermined categories. The application provides a software environment for efficiently supervising the work of coders and evaluating the quality of the coding by (1) systematically presenting open-ended responses to coders, (2) tracking each coder’s categorized responses, and (3) assessing interrater consistency at any time in order to identify coders in need of further training. In addition, the application can be set to automatically assign repeated responses to categories previously identified as appropriate for those responses. To evaluate the efficacy of the coding application and to determine the statistical reliability of coding open-ended data within this application, we examined data from two empirical studies. The results demonstrated substantial interrater agreement on items assigned to various categories across free and controlled association tasks. Overall, this new coding application provides a feasible method of reliably coding open-ended data and makes the task of coding these data more manageable.

Treating personality disorder: Creating robust services for people with complex mental health needs, edited by Naomi Murphy and Des McVey, London, New York, Routledge, 2010, 308 pp. £32.95 (Hbk), I...

Gask and colleagues state that there is no evidence for the effectiveness of therapeutic communities in the treatment of personality disorder.1 This is misleading. As the authors note, therapeutic communities have been …

Zero Degrees of Empathy: A New Theory of Human Cruelty By Simon Baron-Cohen. Allen Lane Publishing. 2011. £20.00 (hb). 208pp. ISBN: 9780713997910 The Director of the Autism Research Centre at Cambridge University, Simon Baron-Cohen is a well-known expert on autism. He has appeared in the media