Closed Cultures and "Specialist" personality Disorder Units

The Care Quality Commission has recently published its annual State of Care report looking at how health and social care services are functioning.  It’s interesting to see their concern about Closed Cultures – “a poor culture that can lead to harm, including human rights breaches such as abuse”

 

It begins by a quote from someone saying :

 

“It felt like all my experiences, past education, training and work counted for nothing because I was the one who was mentally ill and they were the ‘professionals” 

 

highlighting how dissent can be pathologized in such cultures.

 

It goes on to highlight particular features

 

  • incidents of abuse and restrictive practice

  • issues with staff competence and training

  • cover-up culture

  • lack of leadership and management oversight

  • poor-quality care generally

  • poor-quality reporting.

 

It might not surprise anyone who has read anything I’ve ever written to hear that the above criteria are to be found in almost every private unit I have ever experienced that claims to specialise in working with Personality Disorder. Lets have a look through them…

 

 Incidents of abuse and restrictive practice

 

The practice is rife.  Whether it was someone who only self-harmed in a particular location being confined to that location due to a feared risk of self-harm or 3 person restraints for incidents that would have passed without comment in the community, restriction is what the “specialist” units provide in abundance.  It’s harder to witness incidents of outright abuse on such units, but when reports and note entries refer to people as being manipulative, calculating or attention seeking, it gives an indication of the level of esteem people are held in and how they might be treated.  

 

Issues with staff competence and training 

 

In almost every tribunal and visit I do, a consistent theme is that the people delivering psychological interventions are generally not qualified to deliver them.  There is much use of assistant and trainee psychologists with a clinical psychologist rarely to be seen.  In the general staff team there never seems to be any specialist understanding of what they claim to specialise in, with the mantra “they do the dangerous things because they have a disordered personality” being the predominant way of interpreting everything. 

Our recent experience of going to a new “specialist” unit, meeting a senior clinician and hearing “we’re glad you’re here, we don’t know anything about personality disorder” is unlikely to be beaten but is more notable for the level of candour rather than the situation being unusual. 

 

Cover-up culture

 

I never see an admission that something has gone wrong and the patients fulfil vital roles here because they can be blamed for everything.  An escalation in risk is due to them, never the inadequacy of the environment.  An interpersonal difficulty is down to them rather than restrictive staff being people who might be hard to trust.  

 

Poor-quality reporting

 

This probably means something different but the reports and case notes I see convey very little understanding of why people do what they do.  Incidents are listed, the reasons why people do what they do are not.  

 

Poor-quality care generally

 

This is the most frequent experience.  The care on offer deviates, often quite markedly, from what NICE recommend.  The reasoning behind this is often that the guidelines written for people who self-harm and are suicidal can be ditched when people self-harm and are suicidal.  There is never any acknowledgement regarding how far care has moved from what is seen as quality provision, only that the person is still dangerous and needs to receive more of the compulsory poor quality care until they get better.  

 

 

Something the CQC doesn’t comment on is the relationship these units have with relatives.  My general experience is that if the relative thinks of the person they care for as being disordered and needing restriction then the relationship will be great.  If the relative raises any questions regarding the issues above then they become pathologized themselves.  Criticism of the system is seen as a manifestation of a disorder in itself. Quickly they are attributed all the blame for the problems that led to the person they care about being there.  They will be slowly ostracised and if they become distressed as the person they care about sinks deeper into their environment of poor care…well that can be pathologized even more.  

 

Now obviously I am very anti “specialist” private placement so you should take all the above with a huge bucket of salt.  What really struck me reading this today was just how the concerns of the CQC dovetail with what I’ve witnessed on almost every ‘specialist’ private unit I’ve been party to.  Much as I would like to be, I am not an RCT study and I haven’t seen every unit, but I wonder if there is something about a “specialist” personality disorder unit that makes it especially vulnerable to developing the closed cultures that worry the CQC.  I’ve previously argued such units are simply places for dangerous people to be warehoused rather than there being any optimism.  I’ve taken a bit of flack for suggesting these units are places who accept those that the NHS doesn’t want to work with.  If we combine a client group that raise anxiety in staff with a system that places people out of sight, out of mind, there’s some pretty good ingredients there for things to go wrong (and when they go wrong, unless a journalist has sneaked in with a bodycam, then the patients can be blamed). 

 

I’d really like the CQC to look at these “specialist” units more as even the ones I see with decent CQC ratings tick a lot of the boxes above.  I’d certainly like the claims of specialism to be interrogated a bit more as at the moment, you’re a specialist unit just because you say you are. 

 

At present inpatient treatment for those who receive a personality disorder diagnosis has been almost entirely privatised.  We spend hundreds of millions of pounds on this inpatient care while claiming there isn’t enough money for decent community services that at least carry some evidence base for being effective and bear some relation to what NICE recommend (Could there possibly be a link???) 

 

Everyone hates being invalidated.  We owe people who have survived neglect, abandonment and abuse more than confining them to these closed cultures.  We can do better than this.  

 

You can decide if this is shameless profiteering or a plea from someone who wants to effect change – Last week we did some training about “specialist” placements and 100% of the attendees said they would be less likely to use them at the end.  Let us help you avoid this.  

Keir helps people work with complex mental health difficulties through beamconsultancy.co.uk