The Not So NICE Guidelines For Borderline Personality Disorder
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and ErikThe NICE guidelines for Borderline Personality Disorder were first published in 2009. These followedon from No Longer A Diagnosis of Exclusion which came out in 2003. While this highlighted thediscrimination of people labelled with this diagnosis, the NICE guidelines were explicit about whatorganisations needed to do to provide a quality service. Perhaps not explicit enough as it turns out:almost 1 in 10 trusts opt to ignore the guidance about setting up specialist services for those withthis label and barely half offer equal access to the services they have put together. There areexcellent services in some areas; however others have merely paid lip service to the guidelines.While NICE talk a little more about diagnosis than we would like, the aim of their guidance is toimprove the experience of mental health services for those labelled with a BPD diagnosis. This is ouraim too. If you’ve just been given this diagnosis please read something else and take heart thatthere is an evidence base for things that can help you. You may well be in an area where you’re ableto get useful help and support. If you’ve lived with the label for a while this might, sadly, seem a bitmore familiar.These 'Not so NICE guidelines to Borderline Personality Disorder' are the result of a collaborationbetween a clinician and a service user. Both have extensive experience of BPD - the clinician havingworked in a number of specialised teams and the service user having experience of accessing mentalhealth services with a diagnosis of BPD. Research estimates 30% community mental health patientshave a diagnosis of personality disorder (Coid et al 2006) with 10% of psychiatric outpatients and20% of psychiatric inpatients meeting the diagnostic criteria for BPD (NHS 2013). However BPD is acontentious diagnosis which many argue, as a construct, is invalid. The notion of personality disorderis highly stigmatised and challenged. Those with a BPD diagnosis tend to be viewed as difficult towork with - their learned behaviours and means of coping in the face of their life experiences areoften interpreted as attention seeking and manipulative by staff: why else would somebody wilfullychoose to cut their arms or burn themselves with cigarette ends.? Because such ways of being wereoften laid down in childhood in the face of traumatic experiences they are well engrained makingchange difficult - this is often interpreted as non engagement or an inability to recover by staff.Despite 85% of those labelled with BPD reporting a history of childhood trauma (Christmas 2008) thelink between trauma and what are classed as BPD symptoms is rarely reflected in treatmentapproaches. How we experience the world contributes to shaping who we are and how we interact.BPD patients frequently report a lack of knowledge and understanding by mental health staff andcertainly within community mental health services and on the wards derogatory comments andlanguage can be heard when discussing 'pd'. This only perpetuates the negative experiences of theso called 'care' patients receive. Currently community mental health services are made up ofprofessionals whose training did not cover what the medical model terms 'personality disorder' orthe difficulties this umbrella term covers.Services are overwhelmed and tend to be set up to assess and treat with time limited interventions.This way of working is not suitable for people who have difficulties with trust, have little expectationthey can make change and who take time to build rapport. Indeed NICE guidelines advise against anyintervention under 3 months for those with a personality disorder diagnosis.A lack of training, a load of stigma and services set up in a way that does not take into account theneeds of BPD labelled patients leads to a significant lack of effective and suitable support. NICEguidelines do exist to guide commissioners and service developers on how to develop specificservices for this group but we both find this is rarely put into practice. Where personality disorder
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and Erikservices do exist they tend to be a dumping ground for 'complex', 'difficult', 'beyond hope' patientsgeneric services have written off.Most staff who join the NHS do it because they want to help people. To be able to staycompassionate and empathic when faced with extreme emotion and self injury takes a lot of work.With little preparation to meet the needs of the client group, with services at breaking point andwith little space to be able to process the difficulties of the job it is understandable that staff blameservice users for how they ‘make’ them feel, and thus become punitive or defensive in their practiceor try to keep away. It may be understandable but it is in no way acceptable. For the 10% of thosewith a BPD label who will die by suicide, for the 1 in 50 people going to A&E with self harm who willbe dead within the year, a change needs to come.So considering all of the above the following is what Personality Disorder services look like - we offera more accurate reflection of how NICE guidelines are implemented (or not) in our experience. Wehope you can't (but expect you will be able to) relate.References:Christmas D (2008) Synopsis of causation: personality disorder. London: Ministry of Defence.Coid J, Yang m, Tyrer P, Roberts A, Ullrich S (2006) Prevalence and correlates of personality disorder in Great Britain. British Journal ofPsychiatry, 5 (188), 423-31NHS (2013) Clinical enquiry and response service: BPD. Scotland: NHS. Available borderline-personality-disorder.aspx (Accessed 20/05/17)
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and Erik1.1 General principles for workingwith people with borderlinepersonality disorder1.1.1 Access to services1.1.1.1 People with borderline personalitydisorder should not be excluded from anyhealth or social care service because oftheir diagnosis or because they have selfharmed.1.1.3 Ensure that people with borderlinepersonality disorder from black andminority ethnic groups have equal accessto culturally appropriate services based onclinical need.1.1.1.4 When language is a barrier toaccessing or engaging with services forpeople with borderline personalitydisorder, provide them with: information in their preferredlanguage and in an accessible format psychological or other interventionsin their preferred language independent interpreters.1.1 General principles for NOTworking with people with borderlinepersonality disorder1.1.1Lack of access to services1.1.1.1 People with borderline personalitydisorder should be excluded from servicesbecause they do not obviously haveschizophrenia or bipolar. You can also use“They might become dependent”,“Services will only make them worse” or“They’ve been referred before and didn’tengage”.1.1.1.3 Where all attempts to exclude fail,services should be populated almostexclusively by white females.1.1.1.4 Any barrier to someone engagingwith services is entirely located within thatperson. Use the “give an inch and theywill take a mile” principle whenconsidering how needs can beaccommodated.
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and Erik1.1.2 Borderline personality disorder and learningdisabilities1.1.2 Borderline personality disorder and learningdisabilities1.1.2.1 When a person with a mildlearning disability presents with symptomsand behaviour that suggest borderlinepersonality disorder, assessment anddiagnosis should take place in consultationwith a specialist in learning disabilitiesservices.1.1.2.1 When a person with a mildlearning disability presents with symptomsand behaviour that suggest borderlinepersonality disorder immediately declinethe referral and send to the LD team. (Seethe Drug and Alcohol Policy)1.1.2.2 When a person with a mild learningdisability has a diagnosis of borderlinepersonality disorder, they, along with everyoneelse with borderline personality disorder,should be excluded from services.1.1.2.2 When a person with a mild learningdisability has a diagnosis of borderlinepersonality disorder, they should have accessto the same services as other people withborderline personality disorder.1.1.3 Autonomy and choice1.1.3 Authority and choice1.1.3.1 Work in partnership with peoplewith borderline personality disorder todevelop their autonomy and promotechoice by: ensuring they remain actively involvedin finding solutions to their problems,including during crises encouraging them to consider thedifferent treatment options and lifechoices available to them, and theconsequences of the choices they make.1.1.3.1 Work in dictatorship with peoplewith borderline personality disorder todevelop their passivity and promote choiceby: ensuring they are informed that theirchoices are causing all the problems encouraging them to consider the onetreatment option you have or nothing atall. “It’s your choice” should be repeatedfrequently and with relish when peoplereact with intense emotion.
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and Erik1.1.4 Developing an hierarchical and inconsistentrelationship1.1.4 Developing an optimistic and trusting relationship1.1.4.1 When you have failed to follow theabove steps to avoid working with peoplewith borderline personality disorder:1.1.4.1 When working with people withborderline personality disorder: explore treatment options in anatmosphere of hope and optimism,explaining that recovery is possible andattainable build a trusting relationship, work in anopen, engaging and non-judgementalmanner, and be consistent and reliable bear in mind when providing servicesthat many people will have experiencedrejection, abuse and trauma, andencountered stigma often associatedwith self-harm and borderlinepersonality disorder. Explain that there is nothing that can bedone. Treatment, if there was any, canonly be done by specialists and that thepatient’s kids will have died of old agebefore they get to the end of the waitinglist. Start by trying to signpost to a differentservice as soon as possible. Wear yourpessimism and reluctance to do thiswork on your sleeve to avoid buildingany kind of rapport. Sigh audibly andsit with crossed arms and legs in ajudgemental manner when the patientdiscloses their life experiences. Cancelappointments at a moment’s notice (orbetter yet, none at all) and follow upafter a few weeks with a discharge letterciting non engagement. Replicate previous relationships bylocating all problems within theindividual (especially ones that appearin your relationship). Label any genuinedisplay of emotion as attention seeking,manipulative or playing games. Explainany difficulties in making progressbeing due to the client ‘sabotaging’ ornot wanting to get better. (It is essentialnot to examine these explanations in anydetail). At any mention of abuse, sendthem to the local trauma counsellingunit or refer them to a psychologicalcoping skills group to dissect their mostpainful memories. Watch as their levelsof self-injury explode.
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and Erik1.1.5 Involving families or carers1.1.5 Excluding families or carers1.1.5.1 Ask directly whether the personwith borderline personality disorder wantstheir family or carers to be involved intheir care, and, subject to the person'sconsent and rights to confidentiality: encourage family or carers to beinvolved ensure that the involvement of familiesor carers does not lead to withdrawal of,or lack of access to, services inform families or carers about localsupport groups for families or carers, ifthese exist.1.1.5.1 Ask directly whether the personlabelled with borderline personalitydisorder wants their family or carers to beinvolved in their care, and, subject to theperson's consent and rights toconfidentiality: Either refuse to tell the family/careranything, including information thatthey already know OR divulgeeverything under the pretence ofsafeguarding. Ensure that not onesyllable voiced by the client is withheldfrom their family, friends andemployers. Consider using social mediato communicate secrets moreeffectively. If the involvement of families or carerswill lead to withdrawal of, or lack ofaccess to services pursue it with all theresources at your disposal. Build false expectations of support byoffering a carer’s assessment. Informfamilies or carers that you have no ideaabout local support groups for familiesor carers, if these exist.1.1.6 Principles for assessment1.1.6 Principles for assessment1.1.6.1 When stuck with assessing aperson with borderline personalitydisorder:1.1.6.1 When assessing a person withborderline personality disorder: explain clearly the process ofassessment use non-technical language wheneverpossible explain the diagnosis and the use andmeaning of the term borderlinepersonality disorderoffer post-assessment support,particularly if sensitive issues, such aschildhood trauma, have been discussed. Drearily go through the motions ofassessment with a particular emphasison reasons not to offer help. use non-technical language wheneverpossible to hide your ignorance of thisdiagnosis. Make your gut feeling sound informedby using the term personality disorderand whatever myths you’ve picked upover the years. Try to explain that thisisn’t a real illness and is ‘justbehaviour’. Chase the client from the building andlock the doors behind them.
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and Erik 1.1.7 Managing endings and supporting transitions1.1.7 Accelerating endings and instigating abandonment1.1.7.1 Anticipate that withdrawal andending of treatments or services, andtransition from one service to another, mayevoke strong emotions and reactions inpeople with borderline personalitydisorder. Ensure that:1.1.7.1 Anticipate that withdrawal andending of treatments or services, andtransition from one service to another, mayevoke strong emotions and reactions inpeople with borderline personalitydisorder. This is medically known assabotage. Ensure that:such changes are discussed carefullybeforehand with the person (and theirfamily or carers if appropriate) and arestructured and phasedthe care plan supports effectivecollaboration with other care providersduring endings and transitions, andincludes the opportunity to accessservices in times of crisiswhen referring a person for assessmentin other services (including forpsychological treatment), they aresupported during the referral period andarrangements for support are agreedbeforehand with them. Discharge or a change of workerhappens with no notice at all: Use theprinciple of the ‘short, sharp shock’ toelicit strong emotional reactions thusconfirming the patient is sabotagingtheir recovery. the care plan , if it is ever written, is asecret document never to be shown toanyone. If it must be shown, ensure ithas meaningless phrases like “increaseself-esteem” or “monitor mental health”. referring a person for assessments inother services (including forpsychological treatment) is as good as acure. Use the ‘out of sight, out of mindprinciple’ here. If entirely unavoidablesee them as little as possible and be sureto convey that this contact is tokenistic,merely to tick a box rather than provideanything useful. Or anything at all.1.1.8 Managing self-harm and attempted suicide1.1.8 Managing self-harm and attempted suicide1.1.8.1 Follow the recommendations in'Self-harm' (NICE clinical guideline 16) tomanage episodes of self-harm or attemptedsuicide.1.1.8.1 Follow the recommendations in'Self-harm' (NASTY clinical guideline 16)to manage episodes of self-harm orattempted suicide.Label all self-harm as attention seeking.Mock any suicidal behaviour for notworking, unless it works. In which case itshould then be labelled a cry for help gonewrong.
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and Erik1.1.9 Training, supervision and support1.1.9 Training, supervision and support1.1.9.1 Mental health professionalsworking in secondary care services,including community-based services andteams, CAMHS and inpatient services,should be trained to diagnose borderlinepersonality disorder, assess risk and need,and provide treatment and management inaccordance with this guideline. Trainingshould also be provided for primary carehealthcare professionals who havesignificant involvement in the assessmentand early treatment of people withborderline personality disorder. Trainingshould be provided by specialistpersonality disorder teams based in mentalhealth trusts (see recommendation 1.5.1.1).1.1.9.1 Mental health professionalsworking in secondary care services,including community-based services andteams, CAMHS and inpatient services,should be trained to diagnose borderlinepersonality disorder, assess risk and need,and provide treatment and management inaccordance with the folklore, myths andlegends of the ‘old hands’ on the ward.Training should also be provided forprimary care healthcare professionals whohave significant involvement in theassessment and early treatment of peoplewith borderline personality disorder asthey will need to cope with the repeatedrejection of all their referrals to otherservices. Training should be provided byspecialist personality disorder teams basedin mental health trusts often located nearthe unicorn enclosure or the porcineaviation unit. (see recommendation1.5.1.1).1.1.9.2 Mental health professionalsworking with people with borderlinepersonality disorder should have routineaccess to supervision and staff support.1.1.9.2 Mental health professionalsworking with people with borderlinepersonality disorder should have an echochamber to confirm and strengthen anystigma, prejudices or punitive attitudestowards this client group. Fostering themost damning interpretation of a client’sbehaviour is the ideal way to keep stafffeeling competent and effective. Theconcept that staff may play a part in theclient’s difficulties must never be spokenof. If the client suggests this is possibleidentify this as a sign of mental disorder.
The Not So NICE Guidelines for Borderline Personality DisorderA satirical overview by Lara Quinn and Erik1.2 Recognition and management in primary care1.2 Recognition and management in primary care1.2.1 Recognition of borderline personality disorder1.2.1 Recognition of borderline personality disorder1.2.1.1 If a person presents in primary carewho has repeatedly self-harmed or shownpersistent risk-taking behaviour or markedemotional instability, consider referringthem to community mental health servicesfor assessment for borderline personalitydisorder. If the person is younger than 18years, refer them to CAMHS forassessment.1.2.1.1 If a person presents in primary carewho has repeatedly self-harmed or shownpersistent risk-taking behaviour or markedemotional instability, consider referringthem to community mental health servicesif you are feeling particularly malevolent.If in a kinder mood advise them nothing isgoing to happen unless they up their gamein the suicide/self-harm area.1.2.2 Crisis management in primary care1.2.2 Crisis management in primary care1.2.2.1 When a person with an establisheddiagnosis of borderline personalitydisorder presents to primary care in acrisis:1.2.2.1 When a person with an establisheddiagnosis of borderline personalitydisorder presents to primary care in acrisis: assess the current level of risk to self orothe
The Not So NICE Guidelines for Borderline Personality Disorder A satirical overview by Lara Quinn and Erik 1.1.2 Borderline personality disorder and learning disabilities 1.1.2.1 When a person with a mild learning disability presents with symptoms and behaviour that suggest borderline personality disorder, assessment and
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