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Personality Disorders: No Longer a Diagnosis of Exclusion?

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A note of thanks

• This presentation has been somewhat modified in the light of a number of very helpful comments.

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Caveat

• All findings are provisional.

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Rationale

• Previous experiences working in:

• Substance misuse

• Criminal justice

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Preparatory Research

• DSPD reform agenda of the UK government.

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Current Research

• PhD

• Social work orientation

• Advisory group

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Design and Implementation

• Extensive literature review

• Semi-structured interviews

• Front-line workers

• Key informants

• Service users

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Relevant Recent Reports and Inquiries

MWCS reports re: the care and treatment of Mr L and Mr M (2006) followed by Mr G (2007).

The report into the early impact of the legislation by (Atkinson et al, 2007).

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Possible Titles for This Presentation

• Personality Disorders – no longer a diagnosis of exclusion?

• Or more controversially:

• Personality Disorders – still not my problem?

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Service Planning

• Limited response based upon specialised services.

• This appears to have been largely confined to the health service.

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Staff Support and Training

• Where available also largely confined to health service staff.

• Exception – MHO additional training following the report into the care and treatment of Mr L. and Mr M.

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Policies and Procedures

• These are a necessary but not sufficient criterion for change.

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Service Provision and Delivery

• The continued absence of appropriate psychological interventions appears to be an ongoing problem.

• Future resource planning does not appear to anticipate an expansion in the provision of these services.

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What Else Would You Really Expect?

• All change or status quo?

• The Report of the Millan Committee has quite rightly been heralded as providing the basis for one of the most progressive examples of mental health legislation to be found anywhere: namely the Mental Health (Care and Treatment) (Scotland) Act 2003.

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Cont…

• The report of the Millan Committee reflected the breadth of views received during the extensive consultation process. The following few slides are intended to highlight the balanced and realistic view, which characterised the Committee’s recommendations concerning personality disorders.

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Cont..

• “there are attractions in reverting to the position prior to 1999, when personality disorder was not mentioned in the Act. However, it would not be realistic to ignore the fact that the 1999 Act has given a new emphasis to the question of personality disorder” (pg 44).

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Cont…

• The report then states that:

• “we are of the view that people with personality disorder require and deserve appropriate services, and so should be included within the scope of mental disorder” (pg 44).

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Cont..

• The Millan Committee expressed the view that in general, the effective treatment of personality disorders “normally require the co-operation of the patient” (pg 39).

• Furthermore that in most cases compulsion would not be appropriate because of the presence, rather than absence of capacity or absence of impaired judgement.

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Cont…

• The Committee recognised that the most likely outcome of the continued inclusion of personality disorders within mental health legislation would therefore be that in the vast majority of instances services would be provided on an informal basis.

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Cont…

• Within its report, the Millan Committee acknowledged considerable concerns regarding the quality and availability of mental health services (pg 179); the Committee also however took the view that mental health legislation itself was not an appropriate vehicle to remedy this, largely because the majority of people receiving services will not be subject to compulsory measures (pg 179).

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Cont…

• The report of the Millan Committee therefore contains the clear aspiration that people with a diagnosis of personality disorders, should not simply be included within the scope of mental health law; but rather that they should receive appropriate services.

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Cont…

• The fact however that the vast majority of people with personality disorders are likely to continue to receive services on an informal basis, means that the status quo may prove difficult to change.

Considerable investment and the use of

specific delivery mechanisms will be necessary.

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Law of Unintended Consequences

• Emergence of a two-tier system Formal v Informal care and treatment.

• Driven by the requirements and obligations contained within the current Act in respect of formal care and treatment.

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Filtering Out

• Filtering out is a predictable consequence of the Significantly Impaired Decision-Making Criterion.

• N= 133 i.e. 4% STDOs – PD (MWCS, 2008).

• N= 50 of these PD sole diagnosis.

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Unintended Consequences – again!

• The profile of people with personality disorders receiving services on a formal basis is therefore likely to be skewed by a focus upon risk and dangerousness.

• This may serve to reinforce existing stereotypes.

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The Forensic and General Divide

• Despite the rejection of the DSPD agenda a growing divide based upon assumptions concerning risk and dangerousness is apparent.

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Another Tier

• In terms of the civil provisions of the Act those perceived as risky or dangerous are more likely to receive a formal service response.

• MDOs with personality disorders are receiving an increasingly formal and robust service response.

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Champagne and White Cider

• “the detained population gets the champagne service and the non-detained population gets the white cider service”

• (Atkinson et al, 2007)

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Reaction and Progress

• PD was included explicitly in Scots law as a reactive measure; rather than as a genuinely progressive and inclusive one.

• This was implicitly acknowledged within the report of the Millan Committee, who then advanced a positive case for inclusion.

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Inclusion a Utopian Aspiration?

• The inclusion of people diagnosed with personality disorders based upon their needs appears to remain substantially aspirational.

• This is despite legislation that has been rightly heralded as highly progressive.

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Rights and Obligations

• As long as personality disorders remain part of the diagnostic lexicon, the reciprocal right to services will continue.

• The issue of the right to treatment has been defined as a basic human right

• cont……..

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United Nations Resolution 46/119

• Fundamental freedoms and basic rights

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• 1. All persons have the right to the best available mental health care, which shall be part of the health and social care system.

• (emphasis added)