"Borderline Personality Disorder" and "Being ill"

In my day to day work I meet a lot of people who get the diagnosis of Borderline Personality Disorder.  While few of them had ever been party to an in depth discussion about what this diagnosis means, many find that their thoughts and opinions suddenly lose value because they are ill.  Now I don’t want to tell anybody how to describe or understand their experiences but if you find that having this diagnosis and being seen as ill causes problems for you (the testimonial injustice that Jay Watts writes about) this might be a useful way to think about how this diagnosis has come about.  

Lets start by saying that experiences of neglect, abandonment and abuse are very common amongst people who are given this diagnosis.  It would make sense that our minds and bodies adapt to these experiences.  Some people with a BPD diagnosis don’t identify with trauma as a part of their lives.  Here it might be useful to think about the life of Marsha Linehan, the creator of Dialectical Behaviour Therapy.  While she didn’t identify one big event in her life, she did recognise that she was different to how her mum wanted her to be.  This meant that she had a lifetime of getting a clear message that she was wrong about who she thought she was, that her achievements were of little value and that praise could only be obtained by denying who you were.  Years of this combined with stress around exams and a desire to achieve led to headaches that would not go.  When this led to a hospital admission where restrictions were placed on her she became someone who ticked every criteria for BPD in the book.  Not everyone I work with has an obvious traumatic event in their lives, but I’ve never met anyone whose difficulties couldn’t be explained in terms of what they had lived through and how they had been shaped to think and behave. 

With all this in mind, lets take a look at the BPD criteria.  In theory, you will need 5 of these to get the diagnosis. 

1 -Frantic efforts to avoid real or imagined abandonment.

This basically means that the idea of people you care about not being in your life is frightening and you’ll do a lot to avoid it happening.  This is something most people in the world do.  The difference is often that you’ve probably had experiences of people quickly vanishing from your life.  It might also be that you’ve not met many people you could count on so losing the ones you’ve got is a huge blow.  Equally it could be that you think very badly about yourself and feel that if someone leaves, you’ll be alone forever.   For all the above it makes sense that you will do more than the average person to keep people in your life.  The reality is that no one wants to be abandoned so there’s nothing odd about wanting to keep people around. 

2 - A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 

Everyone in the world likes some people more than others.  It’s not odd for this to be your experience too.  You have probably had people in your life who have really let you down and it would make sense that if they did, others will too.  Sometimes people will seem alright, but they can do things that remind you of those who have let you down in the past.  If you’ve had poor experiences of people in the past, it makes sense that you’ll want to make the most of those who are kind to you.  Again, there’s nothing odd about this.  We can be pushed into seeing people as absolutes, or that in life there is a binary right and wrong.  If these were oure early experiences it makes sense we carry them throughout orur lives. 

3- Identity disturbance: markedly and persistently unstable self image or sense of self. 

I meet a lot of people who experience this.  They tend to have had long periods in their lives where they couldn’t be themselves.  They might have been punished for it or not rewarded or accepted for it.  Because most of us want to be accepted, we will normally adapt aspects of ourselves to the people we are with.  How quickly do we start picking up accents in another part of the country?  

If we’ve had prolonged experiences of having to be someone else to avoid pain or to be accepted, then it makes sense that we might not know who we are.  We might be extremely different for different people and never feel ‘right’ – like we are always wearing a mask or putting on a performance.  It can be exhausting but again, based on previous experiences this isn’t odd. 

4 - Impulsivity in at least two areas that are potentially self- damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). 

Pretty much everyone I meet who has been given this diagnosis thinks of themselves in a very negative way.  People have generally encouraged them to do this and their worst thoughts about themselves often echo what abusive people have said in the past.  This often leads people to feel that they are worthless and that life is not worth living.  When you feel either or both of these things it makes sense that doing things that make the moment better are worth doing.  If you can’t see a future it makes perfect sense to do whatever makes the now more bearable.  When people are given months left to live their lives often change radically.  It makes sense that people who don’t see a future live more for the now.  It makes sense that people who think they are worthless don’t value themselves enough to take more care of their lives. 

5 - Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior. 

This relates to the above.  If you are convinced that life is not worth living, it makes sense that you would do things that might bring life to an end.  It’s hard to overcome our instinct to stay alive so it makes sense that something dangerous might be done, then help sought.  It might make sense that we do dangerous things again and again and again.  Separate to this, it might be that the world has taught us that asking for help is not enough and that people will only help when the volume is at 11.  Few people think “I will do x to get y” but life will have shown them that people will only show care when danger levels are high, when blood is flowing or poison ingested.  Mental health services are brilliant at giving the message “you’re not bad enough for help” so it makes sense that people respond to that message.  

6 - Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 

If we think about Marsha Linehan again, she would tell us that people who get this diagnosis have 3 features.

1 – They are quicker than the average person to be ‘triggered’.  They will be more sensitive to a stimulus that sets off an emotional reaction

2 – It takes longer for the emotion to come back down than the average person

3 – As its coming down its even easier for something to stimulate the response again

Obviously those who get this diagnosis have not had the average experiences of others.  People might be triggered more easily because there have been a lot more threats and dangers in their life.  If this is the case, it makes sense people would be on extra alert.  Nobody in the world wants to be hurt. 

People have often been in environments that were threatening to them for a long time.  The body had to adapt to danger that didn’t go away, that couldn’t be fought off or run from.  It makes sense that it takes a longer time for emotions to settle down 

Again, when the danger is ever present, it makes sense that to stay safe the body has that response kick in quicker.  

Linehan would also say that because of these early experiences, its harder to keep emotions in check.  Its hard to manage anger if your role models didn’t, or if they just told you to feel something different.  Many people are taught how to identify and respond to emotions but if you come from an environment where that didn’t happen (or people taught the opposite) it would make sense that this is really hard 

7 - Chronic feelings of emptiness. 

This is a bit vague and can mean different things to different people.  When we lose something, we often feel numb, empty.  Nothing.  If life has little meaning for us we again feel numb.  We might have been punished for ‘feeling the wrong things’ in life meaning that all emotion had to be crushed and hidden and we got good at it.  Those I work with can often see the lives of others and understandably compare their own.  They feel they have lost out because of either who they are or what has happened to them.  They also tend to have lives where they can’t be kind to themselves (as they feel worthless) and can’t make long term plans (I cant picture being here in 2 years).  These feelings of emptiness make sense. 

8 - Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 

The people I work with have a lot to be angry about.  Having experienced repeated injustice, they are acutely aware of when it rears its head again.  Their role models often haven’t shown how to control anger and have also shown that anger and violence gets things done.  When confronted with injustice or when our goals are blocked by others, most people feel angry.  Most people when told their anger is inappropriate get angrier. Because most people who get a diagnosis of BPD are women and society does not like seeing women being angry, their anger is often seen as being ‘wrong’.  I frequently meet people where, if I had had the same experiences in my life, I would be intensely angry.  Services are again excellent at replaying scenarios that occurred earlier in life and its understandable that anger is a response.  

9 - Transient, stress-related paranoid ideation or severe dissociative symptoms. 

This is probably the least talked about criteria of BPD, possibly because it comes closest to what Mental health services feel they are set up to deal with.  Paranoid ideas make sense if people have been repeatedly let down by others, if others have hurt them, lied about them or used them to their own advantage all while telling them that they were wrong to feel what they feel.  Paranoia would be a healthy response to these circumstances.  Hearing voices always seems to come under this category.  The voices people hear are separated from what people experience in something like schizophrenia in that they tend to say what the person thinks about themselves or are connected to previous traumatic events.  This doesn’t make them any less terrifying, but it does make sense that trauma embeds itself in many ways.  The severe dissociation is something I see less often but can be a total disconnect with reality.  Again it makes sense that if people have had experiences that cannot be tolerated, slipping out of reality is a way to cope.  If it had to happen a lot in the past it makes sense its likely to happen again.  While these experiences look a lot like someone who is outside of our reality, I do want us to hold on to the idea that they all make sense based on previous experiences. 

So those are all the criteria for BPD.  You need five out of nine to get the diagnosis but if you are female and self-harm, you’ll be lucky to get a different one.  We now come to the reason for writing this piece.  People who have been given this diagnosis say they get dismissed because they are ill.  Their reactions to things are seen as being the result of a disease and thus not valid.  What I would really like people to take from this piece is that all the experiences listed above can make perfect sense based on what people have lived through.  We could see this as an adaptive response to what has gone before. We don’t need to see this as illness and we certainly don’t need to say someones personality is disordered. BPD is definitely something you can write on a benefit, housing or insurance form, but if you don’t like being seen as “ill” then there’s lots above that might challenge that way of people seeing you.  It’s certainly a label that can be used to invoke use of the mental health act, but we might take time to pause before we brand it as an illness. We all experience emotions, our emotions tell us something important about what is going on.  We are never wrong to feel what we feel.  We might want to think about the extent to which we express and react to our emotions, but the feelings themselves make sense.  My preference is always to understand people in terms of how their experiences have shaped them.  Others might feel differently and no one way is right for everything.  If you work with people who get this diagnosis this might help provoke some thought about how to discuss the things they find difficult.

Keir

Why Occupational Therapy Saved Ellie

Keir provides clinical supervision, therapy, consultation and training via www.beamconultancy.co.uk

A weird thing happened the other week.  I’d just been to an Occupational Therapy conference and because I had saturated twitter with posts about what had been going on I ended up in a conversation around how Occupational Therapy had really benefited people.  I encouraged them to write down what had been helpful them.  I thought very little of this until lo and behold this turned up in my inbox.  Most OT’s will find this a fairly interesting read.

Just to introduce Ellie, she is someone I met at the British and Irish Group for the Study of Personality Disorder annul conference in Cardiff last year.  She ended up being highly commended for her poster “The Impact of Activity and Occupation on Borderline Personality Disorder”.  She’s a big advocate for OT and at some point I hope she becomes one.  Enjoy her tale….

3 years ago I was a very lost young woman. I was sectioned in an acute psychiatric ward for the 5th time after years of BPD and an eating disorder slowly dragging my life away from me. My daily routine consisted of spending the nights in A&E getting stitched up after self harm, coming back home in the early hours, sleeping in the day, self harming again in the evening, back to A&E and so the cycle continued…sometimes with the occasional break of an overdose or suicide attempt and sometimes with the addition of multiple trips to A&E in a day. I was admitted to A&E over 200 times in less than a year.

But something about this admission was different to the last. As someone who is pretty dam intelligent (if I do say so myself), acute wards are pretty dangerous for me as I get very bored and spend my hours conjuring up inventive ways to hurt myself. So generally, acute admissions had brought no benefit apart from new self-harm methods. However, the big difference with this admission is that the ward that I was on had double doors at one end that led straight through to the OT department. And this is where the first glimpses of healing began. Here there were things to do, things to keep my mind and my hands occupied, I could make my own meals (which helped with my eating disorder), the staff had more time to chat to me and help me process my situation than the staff on the ward that were rushed off their feed with medications and observations. I was also more willing to talk, its easier to chat to someone whilst you’re doing another task – rather than artificially sitting opposite someone in a chair in a box room with no windows. Entries in the notes from around that time show that I was considered “complex”, “a disruptive influence on the ward” and someone who would be in the system a long time. However when I speak to the staff in that OT department from that time they don’t recall that side of me. I was like a totally different person once I went through those double doors. Here I was celebrated for who I am, staff encouraged me to teach other people to hoop (my favourite hobby), to write poems and explore art, to have a go at yoga and spend time outside. This also coincided with me coming off all my medication which after years on antipsychotics meant that I suddenly had a clearer head and could actually engage with these things rather than just going through the motions. I was starting to FEEL again.

One day, the lead OT asked me if I would like to come and sit on the Therapeutic Activities Development Group as a service user representative. He felt that I had a lot to contribute to ideas for activities in the inpatient areas of the mental health trust. The first meeting was a fortnight after I was discharged from hospital. I hadn’t got out of bed or washed in over a week, I vividly remember turning up still with pyjama bottoms on and steristrips on my face. I didn’t want to go, I was anxious about being the only service user in the room and having nothing to contribute. But to my surprise I had a really positive reception and professionals were turning round to me and asking my opinion and valuing my input. I walked out of that meeting and went home and had a shower and changed my clothes and felt a glimmer of hope that maybe there was something I could do in the world.

I was admitted to a specialist unit in a different city for a year after that, which changed my life, but all through it I worked remotely on tasks for the group and returned to Sheffield for monthly meetings if I was able. Part way through the year I was asked if I would like to start volunteering in the OT department on the ward – gathering service-user feedback about activity provision and just generally helping out. It meant that I had something to work towards and keep well for on my return to Sheffield – a city where I had been living a dysfunctional life for so long previously. 

Fast forward a further 2 years and I can’t believe how far I’ve come since attending a once-monthly meeting in my pyjamas! I spent a year volunteering in OT on the ward, and during that time I learnt so much, got opportunities to present what I was doing to the rest of the trust and this lead to further people being interested in getting me involved. I started to deliver trainings on mental health to police officers, A&E staff, telling my story to people on induction to our trust, running workshops and attending conferences. My life is full of hobbies and activity (I roller skate in skate parks and take part in other circus activities) From one person believing in me and the power of having an occupation on someone’s recovery – even though they are very unwell – I am now employed by the trust, using my lived experience in my role as patient ambassador in medical education and research. I still volunteer and I still speak about my experiences and advocate for the impact of occupation and activity on recovery. I even wrote a poster presentation on the topic which came highly commended at BIGSPD 2018 which was a huge boost to my confidence and also helped me get where I am today.

My 2 years since returning to Sheffield have not been great in my personal life – I have battled with homelessness, fighting for care, a lot of issues with services (some of which have been quite frankly traumatic) not resolving certain unmet needs that are still impacting on my life significantly and it has been incredibly hard to keep going. But one of the reasons I have been able to soldier on is that now I have a purpose and a value in my existence. I’m appreciated for what I bring to the table in mental health in the city and for speaking out about my experiences. I have a future ahead of me and a whole new potential career path I would have never envisaged. And if that doesn’t end up working out then I’d actually love to become an OT. I’ve learnt to put the bad stuff that has happened to me to good use and for the first time I am excited about the future. And I honestly don’t think it would have been possible if it wasn’t for that OT department believing in me and encouraging me when I was in my darkest times. Occupation and activity is my medicine and it is what keeps me alive every day.

You can hear more from Ellie here on this podcast 

Ellie talks lots of sense on twitter @elliewildbore

Keir provides clinical supervision, therapy, consultation and training via www.beamconultancy.co.uk

Diagnosing Borderline Personality Disorder: A 21st Century Witch Hunt

Happy Halloween.  I’ve been reading The Witches by Stacy Schiff, an account of the Salem witch trials held in America in the 17th century.  In this process 150 people were accused of witchcraft with 20 people (14 of whom were women) executed.  While I read the book I was struck by the similarities between the witchcraft of puritan New England and the Borderline Personality disorder of today.  I probably wouldn’t have made this link without listening to Lucy Johnson talking about the validity and reliability of the BPD diagnosis.  While Lucy phrases it better, because BPD is so often diagnosed by gut feeling as opposed to structured assessment, the validity is very poor.  Validity in this case means how ‘true’ criteria are for measuring a specific condition.  The reliability is much better meaning that faced with the same presentation, a high number of people would agree “that is BPD”.  As Lucy points out, in 17th century Salem, most people would be able to identify a witch.  The reliability of the witch diagnosis was pretty good.  Whether there were any witches present is another matter entirely.

As part of the preparation for writing this I did a bit of googling to see how much this idea had been thought about before.  One writer suggested that Salem occurred because a number of girls at the time had BPD.  I want to toss that theory out of the window right now, but let’s have a look at the book The Witches and see if there is any overlap between the occult of 4 centuries ago and the BPD of today.  I’m convinced that in the past someone has already done this better. 

In the 17th century it was certainly accepted that witchcraft was a thing.  People would happily find a supernatural explanation for whatever phenomenon occurred in their lives and if things took a turn for the worse, a witch was often the answer.  Between 1580 and 1680 the UK disposed of (and by that I mean murdered) around 4000 witches.  Arguments at the time would go along the lines of “I cant explain what just happened, therefore it must be sorcery/witchcraft/the devil”.  Absence of anything else was proof of something diabolical at work.  One theologian claimed that witchcraft was so impossible and far fetched that it had to be true.  

In New England, most witchcraft cases focused on women who were overly attentive or begging.  They tended to be less popular people of the community.  Most cases involved “a calcified knot of vexed small town relations”.  Witchcraft was helpful in that it placed blame elsewhere and removed responsibility from individuals.  Why has my business failed?  Witches!  And if witches were what you were looking for, they became easy to find. Being able to blame witches meant people could take “a holiday from reason”.

Women were easy targets for the label of witch.  The witch finding manual describes all women as “"a foe to friendship, an inescapable punishment, a necessary evil, a natural temptation, a desirable calamity, a domestic danger, a delectable detriment, an evil of nature, painted with fair colors!” so we can already see an imbalance in society, even before the witch label is applied. 

Its worth looking at the background of the people who are being accused of witchcraft.  Most girls would be sent out to other households to learn the craft of housewifery. “Servant girls fended off groping hands and unwanted embraces from lascivious swineherds, from men of the house, and from visitors to the house, often at appallingly early ages.  Isolated, semi-orphaned, they seldom knew someone to whom they could appeal to wield pitchforks or pray at dawn on their behalf.”   Physical beatings were the discipline method of choice.  The traumatised women lived in a traumatised society.  Their homes were on a frontier where raids, skirmishes, violence and abductions would have been known to most.  

Amidst all that 17th century New England had to offer, a group of young women became afflicted with what was rapidly diagnosed as a diabolical assault.  As they named people who were using their nefarious powers upon them, the accused were interviewed and tried for witchcraft.  One woman had been accused before and was confrontational in her interview.  It’s not clear whether she was confrontational because she had been previously accused or whether she had previously been accused because she was confrontational. Either way, as the young women collapsed when ‘witches’ looked upon them and pointed to ghosts in the courtroom, the court found the evidence it wanted to find. No one accused was cleared and denial of witchcraft was the most likely thing to get you executed.  

Fast forward 400 years and things have changed a bit.  There are more iphones and less puritanism but I wonder if some elements of the Salem era remain.   In the mental health services there is a firm belief in the diagnosis of personality disorder and the magic powers that go along with it.  Much like the villagers of New England, a team of people in authority tasked with addressing the causes of suffering will see a young woman who may not be demure and accepting of the expertise on offer and name her as having BPD.  There will often be a difficulty within this relationship. These difficulties in interactions then become identified as being caused by her BPD and her powers grow.  When the team that was already full of politics, rivalries, hierarchy and resentments begins to split apart, this split is attributed to the traumatised 18 year old who has been repeatedly let down by those who should help her.  Like the witches of Salem, the maleficence isn’t located in one person but can affect others.  Staff who are sympathetic are seen as under the spell of the labelled girl.  They are being manipulated and suckered in.  While taking a ‘holiday from reason’, staff can locate all problems in the patient while protecting their professional persona.  She likes some members of staff more than others – because she has bpd.  She hurts herself worse since we stopped her cutting – because she has bpd.  She complains when  we tell her her difficulties are all her own fault – because she has BPD.  The BPD invalidates any legitimacy to what she is saying and so like the testimony of witches, it can be easily dismissed.  

Much like the witches of yesteryear, those diagnosed with BPD today have a disproportionate experience of trauma compared to the rest of the population, with those experiencing a BPD label more likely to have lived through trauma than those with another mental health diagnosis.  

Like the witchfinders, the staff in our mental health services have had similar training, both formal and informal, about how to identify people with disordered personalities and the special powers that they hold.  This means that rather than seeing someone who has lived a life where those who should have helped have taught them that others can’t be trusted, the modern witchfinder nose sniffs out borderline personality disorder.  Rather than seeing a desperate attempt to manage emotional pain in whatever way works best, staff see an arcane ritual designed to seek attention from staff.  These modern day witches are associated with similar evil intentions to their latter day counterparts.  They desire to manipulate, entrance, sow dissention and wreak havoc because they have BPD. The staff in our mental health services are educated, respected and seen to know better, but they reside in organisations that can mirror the lack of safety and consistency of the frontier.  You might not get mauled by a bear, but people carry a great fear of being scapegoated, suspended and pressured to do more with less.  These are not breeding grounds for reflective and rational thought. 

It didn’t take very long for the people of Salem to become a tad embarrassed about how they’d let misogyny, prejudice and a blind adherence to dogma lead them to murder 20 people.  In an age where many professional bodies and people with lived experience called for the label of personality disorder to be abandoned, the textbooks with personality disorder criteria are still being printed.  People without better ways of understanding reactions to trauma are still labelling personalities as disordered.  Fragile, frightened staff groups are still locating all of the teams problems in distressed individuals.  We don’t execute people anymore, but we do either refuse to let them in to places that should help  or refuse to let them out.  If we see people as witches, it’s hard to treat them with kindness. 

We need to stop training witchfinders.  We can offer different narratives to our students and staff while acknowledging the canon of the textbooks.  We can recognise that we will not get thoughtful reflective practitioners while services have to resort to fire fighting and choosing what fires to tend and what to let burn.  

To conclude, “in the years since its laws has been codified, New England indicted witches over 100 witches, about a quarter of them men.” (Thats 3:1)

Today, BPD is diagnosed in the ratio 3:1 female:male 

If you can bear to read a bit more I’d strongly urge you to apply the witch finding lens to the piece How Not to Get a Diagnosis of Borderline Personality Disorder by Recovery in the Bin.

I very much enjoyed the book The Witches which you can get here. All the quotes in this article are taken from that book.

Apologies to all the worlds genuine witches and Wicca practitioners of the world if the tone of this article isn’t quite right.

“Understanding Persons with Personality Disorders: Intervention in Occupational Therapy” A (very) critical review

It’s not often that you read something and find that you immediately need to go and share your thoughts about it with the world.  The most recent one for me was Hope in the Dark by Rebecca Solent(Highly recommended!) until Friday afternoon when I found myself on a long train journey with some time to kill.  I’d just finished a week of Dialectical Behaviour Therapy training for those diagnosed with Borderline Personality Disorder and while I knew I should have been reading more about that, my mind skipped onto thinking about what was written in the world of Occupational Therapy and “Personality Disorder”.  I know that the answer is ‘very little’ so I decided to throw myself into “Understanding Persons with Personality Disorders: Intervention in Occupational Therapy” by Ann Nott.  You’ll find it in Occupational Therapy in Psychiatry and Mental Health (2014) Edited by Rosemary Crouch and Vivyan Alers.

The chapter got off to a bad start for me by giving one of the Key Learning Points as “Clinical handling of behaviours such as manipulation, lying and deceit”.  Lets take a deep breath and see what else we’ve got…

It opens by sensibly defining personality and what might then describe a personality disorder.  Given that ‘personality disorder’ covers such a spectrum of presentations it then makes some incredible generalisations such as “No feelings of anxiety about his/her behaviour…blame is put upon others…they believe their behaviour is right, ignore or refuse psychiatric help”.  Now I have not conducted a randomised control trial, but I have met many people with this diagnosis who are crippled with anxiety about their actions and choices, they believe they are always, always wrong, they blame themselves to the extent that they have to punish themselves and they cannot get psychiatric help regardless of their levels of distress.  

We are told that long term progress can be poor which is not the case for what gets described as Borderline Personality Disorder.  We are also told that some can have a “good prognosis with excellent work histories, supportive networks and willingness for therapy”.  While I suspect that’s true it reads as “people who have difficulties that don’t particularly affect their lives tend to do ok in life”.  

The chapter goes on to describe the ICD -10 and DSM-5 ways of categorising personality disorder.  Sadly these are presented in a fairly factual way with no critique as to their value.  While personality disorder is one of the most contested psychiatric diagnoses, you would not know this from reading this chapter.  There is equally no comment on the stigma that the diagnosis can bring or the flaws inherent in diagnostic system.  Now this isn’t unique to this chapter and as OTs we need to be more critical about this and challenge our medical colleagues a bit. 

We are invited to consider 4 different theoretical frameworks for the development of personality disorder but the chapter skims over these, leaning most on biological explanations.  There is the interesting statement that for cluster B & C clients (including people diagnosed with borderline personality disorder) “psychoeducation is contraindicated as there is already a distortion of thinking present which would be counter effective in any therapy”.  Ummm, so no therapy then?  Obviously you then have to wonder if this is the one client group in psychiatry with disordered think and whether psycho-education and therapy needs to be withdrawn as an intervention for all.  You can balance this with the widely held view that psychological therapy is the primary intervention for this client group.  

Common Defences

The chapter gets a bit Freudian at this point and while it spouts about ego and unconscious processes, it points out the “defence mechanisms used by the person with personality disorder”.  What it neglects to say is that assuming all the splitting and projection stuff is accurate – these are things that are identified as being used by everyone in the world.  Dividing the world into good and bad is by no means unique to people given the label of personality disorder and if you’re being mean, you might point out that saying this is the case is an example of projection.  Also, it states that “Parasuicide is often seen in persons with borderline personality disorder, and although it is attention seeking behaviour, it should always be seen as a cry for help”.  It doesn’t link these attention seeking cries for help with the fact that one in 10 people with this diagnosis will die by suicide, risking people in distress being dismissed. 

Models of Treatment

We begin with “treatment normally takes place in a psychiatric unit” which I’m not sure is the case at all.  “The person with a personality disorder settles quicker within the contained environment of the hospital” doesn’t fit with my experience whatsoever and while I’m very supportive of admission where it’s helpful, too often I associate it with people who have lived through abuse being restrained for things that would pass unnoticed in the community.  Anyway….

I heartily agree that the team should have a unified approach and shared frame of reference but the absence of a focus on a collaborative approach is striking.  We are told “family involvement….(is) essential for success” but we are not advised to seek permission or consent to do this or consider the extent to which events and behaviours within the family have impacted on the difficulties these individuals experience.    

Some different approaches are outlined.  We hear about behavioural approaches and how OT interventions such as relaxation and assertiveness training fit.  We may have trouble telling the rest of the mental health world these interventions belong to OT. 

DBT is outlined where there “may be positive validation” rather that it being the most important aspect of DBT.  There’s no mention of how OT can fit within this which I think is odd as my version of Occupational Therapy mirrors much of DBT. 

CBT comes next and there’s little for OTs to do other than know that assertiveness skills are useful for those with avoidant personalities.  

The therapeutic community model is described and while I normally love this approach, unusually there isn’t an emphasis on collaboration, consensus and shared power described here.  This could reflect that therapeutic communities are different things in different places but might also reflect a common attitude that people should be ‘done to’ rather than ‘done with’.   

Pharmacological Interventions

We learn that people with personality disorders “take poly-pharmaceutical medicines in a desperate attempt to cope” with no mention that you can only get prescribed these by a doctor (who may well be prescribing them in a desperate attempt to cope).  Despite there being no recommended medication for ‘personality disorder’ the chapter then describes how different medications can be used.  We might be starting to see how these poly-pharmacy issues come about…Occupational Therapy

Into the meat of the chapter!  What can OTs do for this client group? Initially it is quite sensible but in my opinion it starts to meander a bit.  We are given some principles to work on such as…

“Focus on behaviour and not an explanation of behaviour” – I believe if you cannot think about why people do what they do you are likely to be directive, judgemental and often wrong.  Always work out why behaviour makes sense.  If you don’t know what drives it, you will never stop it. 

“Confront and not interpret defence mechanisms” –  I’m going to suggest this language is really unhelpful.  Be curious and wonder rather than confrontative.

“Allow for participation in groups and helping others” – this makes sense but I’m not sure which clients in other areas should be banned from groups or helping others.

But OTs should NOT:

“Listen to repetitious complaints” – Turn your back on people?  Fingers in ears?  See the above about seeking to understand why people do what they do.

“Insist on a contract” – Now I’m not too aware of insisting on a contract being a huge issue but this chapter also contains the advice “the client is…encouraged to take responsibility for behaviour by signing contracts”, “It is imperative in all therapeutic processes that there is contracting”, “The occupational therapist needs to contract in therapy” and “It is useful to get group members…to sign a group contract”.  It isn’t massively consistent.  

“Save face if fooled and resort to blame and punitive acts” – I’m 100% behind avoiding blame and punishment, but I wonder how helpful the idea that people are out to trick you is?

“Lie or present conflicting non verbal messages” – Again, I wonder about the wording of this.  Who is the client group it is useful to lie to?

Different Clusters

For the next part we go through the different clusters of personality disorders and how to be helpful.

For cluster A the author points out that group work isn’t recommended but can be beneficial.  If we need to exclude people it should be because of their specific difficulties rather than their diagnosis. 

For B it’s suggested we manage conflict with confrontation (best way I know to get the ward alarms ringing).  We are warned (and hold your breath here) “students due to inexperience may not cope with the highly demanding, manipulative and undermining characteristics that may emerge in therapeutic intervention”.  This client group is not safe for students?  Wow. “The ‘gentle, do good approach’ is not beneficial and the occupational therapist will need to delineate his/her own boundaries…so the process of therapy…(is) not sabotaged.”  

For working with people diagnosed with borderline personality disorder “take care that there are no physically harmful tools lying around” rather than collaboratively managing risk. 

“The pharmacological approach has been to include both mood stabilisers and antipsychotics” – 3 paragraphs back you were blaming them for their poly-pharmacy!!!

After some discussion on cluster C we then get to look at intervention methods

I’ve got no problem at all with this section.  I have a minor quibble about group therapy being optimal rather than a mix of group and individual, but most of the rest of it makes sense.  The chapter is explicit that OTs could be delivering aspects of DBT which I heartily agree with.  We get given two case studies that have fairly unbelievable changes in functioning and I question the outcome measure of angry drawings becoming happy drawings indicating success.  Aside from that I’m content with this section.

So as a whole I seriously disliked this chapter.  It makes no mention of the stigma clients with this diagnosis face, which is an incredible omission for me given the focus OTs have on the social environment.  The likely explanation for not talking about stigma could be that the attention seeking, sabotaging, manipulative, lying, deceitful, blaming, help refusing, unable to hear information about their diagnosis, think in ways that would counter any therapy, inappropriately medication seeking, demanding, sabotaging and undermining people who are not safe for students deserve everything they get.  I would say that OTs should try and get all the above language out of their practice and out of the environments they work in.  The words we use shape our environment and we should be making it a place where people understand rather than judge.  

Take all of the ways of describing people listed above.  If you walk into work thinking that about people it is going to be impossible for you to develop an empathic relationship.  If the people we work with read this chapter and believe this is not only what practitioners think but that it has enough validity to be published in a textbook – how can they possibly trust us to help them? 

I shudder at the idea that this is the first thing that OT students might read about this diagnosis.  I wouldn’t want it pulled from the shelves but I think as a profession we need to distance ourselves from this total acceptance of the diagnostic system and the judgemental language described.  In the UK the RCOT professional standards state:

11.1 Your language and communication style demonstrate respect to those with whom you are working

Now this is opinion rather than fact, but if you are using the language above I don’t think its possible for you to be working within your professional standards.  

Now having read though all the above I have a mix of feelings.  I know that I’ve taken somebody’s work and eviscerated it.  I’d hate it if it happened to me.  Further, I reckon 15 years ago if I’d been asked to write this chapter I’d have written similar things.  We learn the things we do from our experiences which are shaped by people who know more than us.  I’ve been lucky to be exposed to people who would not let me continue to think like this and not everyone gets that opportunity.  Equally in the UK we have had a few publications that have sought to identify and reduce the stigma around this diagnosis.  They may not be known in other countries however, in a book with international reach (and a publisher based in the UK) I’d expect those publications to  be evident in the narrative.  I know that another OT textbook is currently seeking the views of service users to comment on chapters.  I think this chapter would look a lot different if views had been sought, discussed and understood rather than confronted.  I did ask Facebook and Twitter how influential this book was and unfortunately someone told me it had really influenced them, the personality disorder chapter in particular.  It was then that putting a different view into the world became more important than upsetting someone.  

If you work in education please, please let your students know there are other views on this subject.  I say nothing of the quality of –

Harding K (2016) Working with people with personality disorder. In: J Clewes & R Kirkwood (eds) Diverse Roles for Occupational Therapists. Cumbria: M&K Publishing (p237-250).

– but it is certainly different. 

• I was lucky enough to be able to bounce these ideas off a respected lecturer in Occupational Therapy.  Given that there are many unbalanced aspects to this review and the author they didn’t want to be identified.  Regardless their approval and guidance was much appreciated and needs to be acknowledged.  

• Keir is an Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

• As a result of feedback from this chapter, the E-version of this book has been withdrawn from sale.

Validation - Working with People who Think the Wrong Things

Written a few years ago now but still worth repeating….

After another day of training people around how to work with people who hurt themselves and find it hard to trust others (often diagnosed with Borderline Personality Disorder) I was left thinking about how eager staff are for ways to be helpful. The generic ward and community staff often have a sense that they can offer nothing and that all the skills for working with this client group lie either with psychologists or mystic practitioners of 3 letter therapies. One of the exercises we do on the day looks at how to take the heat out of situations so that people can talk to each other. We normally identify it as ‘validation’ and in all my years of working with people labelled with personality disorder, I think its the most useful thing I’ve picked up.

In the spirit of trying to be helpful to the Keir Harding who struggled to work with traumatised people 15 years ago, I’m going to go through the 6 levels of validation as outlined in DBT. While DBT is a therapy specifically aimed at those with a diagnosis of borderline personality disorder, this way of relating to people is useful for everyone. I even used this to get £300 worth of free mechanical work so this is literally a valuable tool to have in your arsenal.

Level 1 – Being present
I think in the old days we would call this active listening. Eye contact, nodding, smiling in the right places. Budding Elvis impersonators might like to throw in an ‘uh huh’. While this seems like the most obvious thing in the world to do I think back to my early career when I was doing assessments with people. The session tended to move away from a place where we could learn something and instead turned into an exercise in getting a form filled in. I’m pretty sure I’d ask closed questions so as to fill a particular box and then stop listening once said box had been ticked or crossed.
So without being too creepy, look at people with rapt attention, as if in this moment what they are saying (or not saying) is the most important thing.

Level 2 – Accurate reflection
This is where you move on from showing people you are listening to showing them that you have heard them. This can be a simple “So you’ve told me you’re upset” a more hypothetical “It sounds like you’re really sad” or “When you came in you said you wanted x”. All we are doing here is repeating back what people have said in different (but not always) words. Again, when I think of myself doing this badly, I’d get to the end of the form and say “Right then, I’ll write this up and send you a copy. See you next week” which would pretty much give the impression I hadn’t heard anything they said.  It was as if the priority was getting the form filled in, rather than tryin to understand something about the person in front of me.

Level 3 Reading
This is where validation gets more interesting as we get to use our brains a bit more. Here we are taking what someone is telling us and offering something new. “When they walked out and the house was silent, I wonder if you felt utterly alone?” or “When your friend said she didn’t like her present, I wonder if that hurt?”. Again this lets people know that you’re not only listening but thinking about them. Try to avoid telling them what they should have felt.
I think my best (worst?) examples of doing this wrong is similar to the above, where I’ve written down responses verbatim or, where I’ve told people what they should feel.
“So he ran away with my bag”
“You must have been angry”
“I was too frightened”
“You weren’t angry that he took your bag?”
Telling people they should see and feel things your way never tends to work out too well…

Level 4 – Normalising based on past experience
This is one I use a lot and probably the one I’ve done most badly in the past. This is where we show that we are not only listening and thinking about someone, but we know them too. With this we try to show people that what they have felt/thought/done is entirely understandable given their background. It’s something I like to use when people say “I was so BPD”. For example…
“I get so worried about saying the wrong thing I just don’t say anything …it’s just my BPD”
“Well you could think of it as BPD, but you said that when you were younger you used to be severely punished for saying something that your parents disagreed with. I wonder if you learned that saying the wrong thing can be dangerous so it makes sense that you’re frightened.”

Here we are trying to show that their feelings are perfectly understandable, based on what has happened to them in the past. If we don’t know their past we can be curious – “So you say that you feel worried about speaking. Worry makes me think of fear and that makes me think of something threatening or dangerous. I wonder if something has happened that has taught you speaking can be dangerous to you?”. You might get a few “don’t knows” but I’m betting you will build a better relationship with one “I expect there’s a really good reason you feel this way” than you will from a hundred “There’s nothing to be afraid of”s.

Level 5 – Normalising based on it being normal
It’s this one where we help the person who feels freakish and different to see that they’re like everyone else in the world. We take the bizarre, baffling and unfathomable and turn it into pure reason. I often find this is what many staff struggle with and when they can’t understand, they make their own interpretations as to why people do what they do.  To use a real life example …
“I want to go on leave”
“We’ve sent you on leave a few times but you just sabotage it” – might possibly be better framed as:
“when you’re home by yourself you get frightened and desperate, so you cope by doing what you normally do when you’re scared. Everyone does what they can to cope when they are desperate.”
Or
“I get scared that I’ll be on my own forever”
“I think everyone would find the idea of being alone forever fairly scary”

It is in this area that I excelled in invalidating people. I’d learned some CBT on my travels through mental health and I had an obsession with challenging ‘thinking errors’ and ‘negative thoughts’. I would have seized the above statement and tried to convince them that they were wrong to feel what they felt. I’d ask what there was to be afraid of, I’d ask what was so bad about being on their own. I think I would tend to keep going until they felt stupid and ashamed for thinking what they did. I’m not proud…but (sadly) I am certainly not alone in making this mistake. One of the interactions I regularly see in services is someone saying “My life is so shit” and the other person leaps in to tell them they’re wrong.
“I want to die, I’ve got no money, everybody hates me and I’m never going to go out on my own”
“But Rachel, yesterday you were laughing at Simons joke, and this morning you made a cake and said you’d enjoyed it”.
This rarely makes people suddenly believe that their life is worth living and it certainly convinces them you don’t understand.
“I want to die, I’ve got no money everybody hates me and I’m never going to go out on my own”
“I can hear how much you want things to be different. Most people would despair at the idea of being hated and dependent on people”
The other common one I used to do a lot was “I’m never going to get better” at which point I’d leap in with gusto (because remember, my patient not getting better is an explicit criticism of me) ranting “But you’re doing so well!!!” To make me feel better the college lecturer would nod and agree when I told him he’d caught a bus by himself and stayed in the busy shop for a whole hour. In reality I had totally dismissed what he was feeling and instead put some work in to make myself feel better.
It is useful to challenge people but for most, and certainly the group I work with, people hear you louder if you can validate what they’re saying first.

Level 6 – Radical Genuineness
This is the master level of validation that only the true mental health ninjas can achieve, although in essence it’s not that hard. Once we have shown people that we are listening, hearing them, thinking about them, shown it makes sense given their experience, shown it makes sense given the rest of the world would feel like that too, – then we can take the final step, “I would probably feel like that!” or even “I have felt like that”. This can be as simple as:
“When they said I couldn’t get any leave I was fuming and just trashed my room”
“If I’d been planning something all week and someone told me it couldn’t happen I’d be pretty angry too”
Or it can be a bit more personal…
“Its so unfair, I just want to go home and they said they’ll section me if I try to leave”
“My daughter was in hospital once and the consultant said we could take her home. He went off shift and the physio said we couldn’t take her until the Dr said it was OK. Knowing it had been agreed I wanted to discharge her ‘against medical advice’ and the ward staff told me they’d call social services if I tried to take her. I know it’s not the same but I understand some of that feeling of being trapped, threatened and it being unfair.”
It’s possibly my own reading of radical genuineness, but i think there is a value in being, well, genuine with people. I think back to the times when someone has told me of some weekend that Stephen King and HP Lovecraft couldn’t have imagined if they’d had a month together. I’ve nodded along as if tales like this are all in a days work for a consummate professional like me when inside I felt like a cartoon of a shocked man. It might well have been more useful to convey the horror of what they had told me. When it seems helpful I now tend to drop in the odd “If that happened to me I think I’d be terrified”, “I can feel myself filling up as you’re describing that” “I’m trying to listen to you but I’m so worried about what you’ve told me I think I’m going to be useless to you until you get medical attention and my anxiety comes down”.  Non verbally I might wince when someone describes something painful.
The other obvious element of GR is that if you can do something to make the situation better then you do it or at least be really explicit about why you’re not. I’ve known people who were desperate to be admitted to hospital be told that they won’t be admitted because it’s not in their best interest. End of explanation. Either acting, or giving a detailed pros and cons of why you are not acting is a lot more validating than giving the message that they are wrong to want the things they want.

So those are the 6 levels of validation. I find myself using them most when meeting people for the first time and when the situation is becoming heated. Very often I’ve seen someone go up to a member of staff and shout at them. The staff member shouts back. They shout louder and a few minutes later there’s a wrestling match going on for which the staff have a numerical advantage. I’ve seen people shout at staff and the immediate response is that “You can’t talk to me like that”, which is a valid point, although a debate on the niceties of social etiquette is not something anyone whose emotions are dialled up to 11 is ready for.
“Youre a F***ing C*** you are!!!”
“You seem REALLY angry, can you help me understand what’s going on for you”
Or
“You seem really angry at the moment but when you shout at me my anxiety goes through the roof and I can’t think. Can we both take a breath and think together about what’s going on ?”
And you can wrap up with “If that happened to me I think the other person was a bit C***y too”.
In other blogs I’ve talked about wanting to ‘win’ interactions with people. Validation is not about ‘winning’, but giving the people we are talking to the clearest picture possible that we are there for them. When I’m doing training, at some point someone says that we can’t just validate everything. There are limits. Lines have to be drawn. And this is true, there are behaviours that can get people in trouble with the police, hurt people and destroy relationships. We do not validate the behaviour we find unacceptable, but we do validate the motivation. We don’t validate the assault but the anger. We don’t validate the overdose but the hopelessness.
The other question that comes up is whether or not we can challenge people. Of course we can. Most of the people I work with have been repeatedly abandoned so theyre always on the lookout for signs its about to happen again even when the staff are really invested. While being told how much I hate the person I work with, I’ve found a Monty Python style “Oh no I don’t” usually isn’t going to cut it.
“To be honest, I do get a bit frustrated when you interrupt me, but I wonder if I can be slightly irritated sometimes and enjoy working with you as well”
Or
“I can hear you think I hate you. I wonder what I’ve done to make you think that?”
Or
“You seem upset and angry with me. I expect I’ve done something that’s led you to feel that way. Can you help me understand what it might be”
The consistent thing with all those examples is to validate first. Once they know we’re listening we can offer something else. That might be a direct contradiction or it could be a synthesis of ideas:
“I’ve got nowhere”
“I know you feel stuck and that nothings good enough, but I wonder if two things are true, that your standards of success are really high and you haven’t changed as quickly as you wanted”.

So there is validation in a nutshell. It is not rocket science. It is barely paper aeroplane science but it is something that can easily slip when we’re tired and the work is hard. I forget a lot but I tend to be at my most effective when I’m using this a lot. I think this would have been useful to me when i was first starting out in the NHS. I hope it’s useful to you.

If you want us to do some training with you around stuff like this, do get in touch.

The Worst Kind of Deja Vu

Another week passes and another scandal involving the mistreatment of people in Out of Area Placements hits the headlines.  At the Yew Trees hospital in Essex residents were apparently “dragged, slapped and kicked”. “Didn’t I see a Panorama program about that?” I hear you ask.  No, that was a different private unit a year ago.  I wrote a blog following the Panorama program saying that the incidents documented weren’t isolated, they were happening elsewhere right now.  Despite all the call for monstrous staff to be sacked and for health care assistants to be regulated, I want to remind us again that we are in a system that makes these abuses more likely.  Don’t believe me?  Let’s hear from British Medical Association Lead for Mental Health, psychiatrist, Dr Andrew Molodynski…

 “As seen in the cases of Whorlton Hall and Winterbourne, the ‘cut-off’ nature of these institutions can be a breeding ground for the development of harsh and abusive cultures.” (NDTI 2019)

I wrote in the Lancet earlier this month about the push for the NHS to export those it finds troubling into the private sector.  A perk of this process is that risky people become risky elsewhere.  While it’s easy to blame the private sector for the quality of provision, I’m mindful of a training session Hollie Berrigan and I did with a leading mental health provider a few years back.  It would be fair to say that the cohort of people were the least engaged we had worked with.  Some played on their phones in front of their manager, some didn’t answer a question throughout, others came late and left early.  Why were these staff so disengaged from the topic of “personality disorder” when they worked in a specialist personality disorder unit?  It turned out they had only become a specialist unit a week before.  It was a job none of them had sought or applied for, none of them had any enthusiasm about and where none of them had any hope of being able to help people.  In contrast the staff group seemed fully aware that they were not there to provide a specialist service (they were all too aware of their lack of rudimentary knowledge, let alone specialisation), they were there to contain those that were sent out of sight, out of mind.  People were coming from hundreds of miles away with little follow up or interest from their local services.  Now I struggle to believe that anyone is born sadistic or abusive, but if I wanted to turn normally ethically sound and morally upright people into those capable of dehumanising others, this is the system I would use.  

This leads me on to some training I was doing with Hollie recently with a trust keen to reduce its use of Out of Area Placements.  Before we’d arrived one of the members of the trust had raised some reasonable points about why a private company with a vested interest in avoiding placements was coming to lecture them.  Surely a private provider would like the chance to come and evangelise the virtues of inpatient treatment?

The critique took 3 forms –

1 – We are a private company.  

Yes we are.  As an Occupational Therapist within the NHS I found it impossible to influence the use of placements locally.  The roles that could influence placements were reserved for other professions. The thousands of pounds the NHS invested in my MSc education was utterly wasted and clinicians went off to placement avoidance meetings while my research on how a team ceased the use of placements was never asked about.  The only way I’ve found to get the knowledge the NHS paid for into the NHS has been to go private.  It is very frustrating but while it’s frustrating for me, let’s not get started on the NHS use of Lived Experience Practitioners.  Hollie also had the frustration of working in the NHS and seeing people who responded dangerously to restriction being moved into higher levels of security.  In the private sector people see her as an experienced consultant and listen.  In the NHS her skills and experience were squeezed into the box of a peer support worker (banded less than a support worker) who’s voice couldn't be heard and wasn’t allowed to write notes herself.  Being private is not our priority, effectively advocating for the client group we care about is. 

2 – We are anti-placement.

Yes we are.  Emphatically and unapologetically.  We do recognise that sometimes they are needed but nothing like to the extent they are currently used nor the duration they are used for.  We are certainly not alone in having concerns about the use of OOA placements.  By my reckoning, we stand alongside Rethink, the Royal College of Psychiatrists, NHS England, the Five Year Forward Plan, the Nation Development Team for Inclusion and the Care Quality Commission.  It can be useful to judge people by the company they keep, and I see few organisations that could claim to be independent lining up to defend the current or increased use of placements.  Further, our resistance to placements is based primarily on our experience.  It is a heart-breaking thing to see someone who in one part of the country would be supported at home compelled to move 100 miles away.  They often lose their accommodation.  The distances and expense mean it’s easy to lose their family.  It’s harder to accept this when those arranging placements acknowledge it isn’t in the patient's best interests but do it anyway.  We’re in a fantastic position now where we work with some very creative and dedicated commissioners who recognise the repeated lack of value they gain from placements and who are keen to explore other alternatives. 

3 – All the placements currently arranged fit with NICE guidelines.  

This made me raise my eyebrows. There are many ways in which placements are incompatible with what NICE recommends (Is anyone interested in that blog?) but perhaps the most obvious one for me is “ensure that when, in extreme circumstances, compulsory treatment is used, management on a voluntary basis is resumed at the earliest opportunity”.  I think you have to work very hard to convince yourself that this fits with a compulsory placement of a year or more.

 At the end of the training 100% of the people attending said they’d be less likely to argue for placements in future.  That was a reassuring day.  Later in the week I was at a tribunal where the same theme of every tribunal I’ve ever part of came to the fore.  The person is coping in a way that is more likely to lead to death since we started restricting them, so we must continue to restrict them or restrict them more.  Obviously this wasn’t enough to convince a tribunal panel to maintain someone’s detention, but I worry about how few people get to make this case.  I worry about staff who don’t know better evangelising about the benefits of placement (and I’m terrified by the staff who do know better doing it) and I worry that the desire to place those who trouble us far away means that we spend a lot of money giving people contraindicated care. 

So back to Yew Trees.  It’s awful and we can blame the people who worked there but let’s remember that the residents of this hospital arrived there due to the system of care that currently operates. Not one private institution has abducted a patient from the streets.  Every resident had their place sourced by the NHS and theoretically monitored by the NHS.  We will not get decent community services while we fund “care” like this.  We will not stop the abuse of the vulnerable with the system we have.  

This has been a long blog and in many ways it’s the same as the one I wrote last year.  If you were to ask me what it’s about I’m not sure I could tell you, only that it was cathartic to write it.  The sad thing is, I know it won’t be another year before events in the news push me to write another similar one.  At 250k per person per year, the cost for this model of care is too high financially.  For the most vulnerable people in our society who are “dragged, slapped and kicked” in a ‘specialist unit’ by those who are supposed to care for them, the cost is incalculable.

A reading list on Out of Area Placements especially for those diagnosed with "BPD"

We’re doing some training this week for a trust that wants to reduce the amount of Out of Area Placements they use for people with a diagnosis of personality disorder.  As part of the training we want to put together a reading list of papers and reports that talk about the concerns people have about this model of care.  Just for clarity, while an out of area placement can mean a night in a local trust, we are interested in the planned treatment of people outside of their geographical area which claim to be specialist.

A report from the British and Irish Group for the Study of Personality Disorder - Out of Area Placements

A BBC File on Four documentary including examples of poor care and staff at a specialist unit saying they had no specialist training The Forgotten Patients

This is a recent piece by Keir in the Lancet Psychiatry:  The outsourcing of risk: out-of-area placements for individuals diagnosed with personality disorder in the UK

A story that might effect you is this written by Hollie and Keir. Product Placement

A report by Rethink and the RCPsych – In Sight In Mind

A report by the National Development Team for Inclusion Close To Home 

Concerns about rehab placements - Out of Sight, Out of Mind 

An examination of the reality of Locked Rehab Locked rehabilitation’: a need for clarification

 This piece on what happens out of area was a huge influence on me – The Virtual Asylum

As was this piece on over provision for one area An assessment of need for mental health rehabilitation amongst in-patients in a Welsh region

 This is a bit more “personality disorder specific - Psychodynamic programmes for personality disorders: residential versus community treatment

I’m sure there’s other important papers I’ve missed so do let me know.