Citation: Forsyth, Angus (2011) Community mental health team's constructions of service users with a diagnosis of borderline personality: an ethnographic study. Doctoral thesis, Northumbria University. This version was downloaded from Northumbria Research Link: http://nrl.northumbria.ac.uk/1623/ Northumbria University has developed Northumbria Research Link (NRL) to enable users to access the University’s research output. Copyright © and moral rights for items on NRL are retained by the individual author(s) and/or other copyright owners. Single copies of full items can be reproduced, displayed or performed, and given to third parties in any format or medium for personal research or study, educational, or not-for-profit purposes without prior permission or charge, provided the authors, title and full bibliographic details are given, as well as a hyperlink and/or URL to the original metadata page. The content must not be changed in any way. Full items must not be sold commercially in any format or medium without formal permission of the copyright holder. The full policy is available online: http://nrl.northumbria.ac.uk/policies.html Community Mental Health Team’s Constructions of Service Users with a Diagnosis of Borderline Personality Disorder: An Ethnographic Study ANGUS STIRLING FORSYTH A thesis submitted in partial fulfilment of the requirements of the University of Northumbria at Newcastle for the degree of Professional Doctorate. Research undertaken in School of Health Community and Education Studies. September 2010 1 1. Abstract The psychiatric diagnosis of Borderline Personality Disorder (BPD) leads to service users experiencing stigmatising and disempowering attitudes from professional mental health staff. To date, a nursing theory has not been developed to understand mental health nurses’ personal and professional constructions towards service users with this diagnosis. The development of such theory may enable improved service user engagement, collaboration and recovery for this group of individuals. This study answered the questions of determining the nature of mental health nurses’ beliefs towards service users with a diagnosis of BPD and how these beliefs affect their therapeutic relationships with this service user group. An ethnographic approach was used in this study. Data was collected using a combination of observation of the patient assessment and allocation meeting within a community mental health team; and ethnographic interviews with named nurses for service users with a diagnosis of Borderline Personality Disorder. A reflective journal was also kept by the lead researcher. N-Vivo Version 7 was used to aid data analysis and this involved examining the scripts for repetitive patterns or sequences including descriptions, figures of speech, metaphors etc. in order to illuminate differences between different practices and contexts. Findings from the study elicited a model of how CPNs construct BPD categorisations and a potential pathway to alienation is described together with recommendations for the development of CMHTs and CPNs when working with BPD. Development of reflexive practice can be a vehicle for developing alternative constructions of BPD and recovery informed practice can reduce stigmatising practices experienced by service users with BPD. 2 Acknowledgements I would like to thanks my principal supervisor Dr Michael Hill for his support throughout the production of this thesis. I am indebted to Michael for his calming influence, his gentle steering of me into areas of critical reflection which has enabled me to become more reflexive in response to a range of challenges throughout the development of my thesis. I would also like to sincerely thank the CMHT that answered my invitation to take part in the study and in particular the participants who shaped this thesis with their own personal accounts and reflections of working with service users and their colleagues within the CMHT. Without them this thesis would have very little to contribute. Throughout my professional doctorate I have been fortunate to have been supported by my former secretary Elaine who retired prior to the completion of this thesis, and who arranged and transcribed interviews and generally helped with course organisation. Also thank you to Lorna who has always been a supportive and encouraging voice which was much appreciated. I am also indebted to my family who have provided much support by enabling me to be absent for large periods of time, to Josh and Callum for putting up with me for not always joining in family activities and for Elizabeth who always gave me motivation to persevere to complete my thesis. Finally a big thank you to my mum who has always provided me with self belief that I can achieve my goals in life. 3 Contents 1. ABSTRACT.............................................................................................................................2 ACKNOWLEDGEMENTS............................................................................................................3 CONTENTS................................................................................................................................4 ABBREVIATONS……………………………………………………………………………7 2. INTRODUCTION.....................................................................................................................8 3. CONCEPTUAL FRAMEWORK AND THEORETICAL UNDERPINNINGS................................16 4. LITERATURE REVIEW........................................................................................................22 CATEGORISING MENTAL DISORDER....................................................................................22 DIAGNOSTIC FRAMEWORKS..................................................................................................28 BPD AS CONTESTED KNOWLEDGE.......................................................................................30 STIGMA...................................................................................................................................33 IN SUMMARY..........................................................................................................................40 5. RESEARCH AIMS AND QUESTIONS....................................................................................42 5.1 RESEARCH AIMS...............................................................................................................42 5.2 RESEARCH QUESTIONS....................................................................................................42 6. METHODS............................................................................................................................44 6.1 DESIGN..............................................................................................................................44 6.2 PARTICIPANTS..................................................................................................................46 6.2.1 PHASE ONE - OBSERVATIONAL COMPONENT:-...........................................................46 6.2.2 PHASE TWO - ETHNOGRAPHIC INTERVIEWS...............................................................47 6.3 DATA COLLECTION..........................................................................................................47 6.4 DATA ANALYSIS................................................................................................................50 6.5 ETHICAL ISSUES................................................................................................................53 7. FINDINGS FROM OBSERVATION PHASE............................................................................55 7.1 CONTEXT OF MEETING.............................................................................................56 7.2 PROCESS OF MEETING.............................................................................................57 4 7.3 DECISION MAKING FACTORS................................................................................74 7.4 DECISION OUTCOMES...............................................................................................86 7.5 REFLECTIONS ON OBSERVATION PHASE........................................................................88 8. FIRST ROUND OF INTERVIEWS..........................................................................................93 8.1 INTRODUCTION.................................................................................................................93 8.2 PRE-ENGAGEMENT.....................................................................................................93 8.3 SERVICE USER PRESENTATION.....................................................................................102 8.4 CPN UNDERSTANDING OF SERVICE USER PRESENTATION.........................................110 8.5 ENGAGING BPD..............................................................................................................124 8.6 EMOTIONAL REACTIONS TO SERVICE USER................................................................137 8.7 RECOVERY FOCUS..........................................................................................................145 8.8 ORGANISATIONAL FACTORS.........................................................................................148 9 SECOND ROUND OF INTERVIEWS.....................................................................................155 9.1 INTRODUCTION...............................................................................................................155 9.2 ADJUSTING TO DIAGNOSIS OF BPD..............................................................................155 9.3 SERVICE USER PRESENTATION.....................................................................................157 9.4 CPN UNDERSTANDING OF PRESENTATION......................................................159 9.5 CPN’S EMOTIONAL REACTIONS TO ENGAGING WITH BPD........................166 10. CONCLUSIONS............................................................................................................176 10.1 IMPLICATIONS FOR PRACTITIONERS WORKING WITH BPD......................................176 10.2 IMPLICATIONS FOR THE CMHT..................................................................................196 10.3 IMPLICATIONS FOR DELIVERING RECOVERY FOCUSSED INTERVENTIONS.............206 11.POSTSCRIPT.....................................................................................................................217 12. REFERENCES...................................................................................................................225 13. APPENDIX 1: PARTICIPANT INFORMATION LEAFLET AND CONSENT FORM..............253 5 List of Figures FIGURE 1 POSSIBLE PATHWAYS TO THE CONSTRUCTION OF ALIENATION .....................178 FIGURE 2 ALTERNATIVE APPROACH OF CPNS’ COPING WITH FRUSTRATION.................193 6 Abbreviations ADHD Attention Deficit Hyperactivity Disorder APA American Psychological Society BPD Borderline Personality Disorder CAMHS Child & Adolescent Mental Health Services CATT Crisis Assessment & Treatment Team CMHT Community Mental Health Team CPN Community Psychiatric Nurse CPA Care Programme Approach CFS Chronic Fatigue Syndrome DSM Diagnostic and Statistical Manual for Mental Disorders DH Department of Health FACE Functional Assessment of Clinical Environments FACS Fair Access to Services GP General Practitioner ICD International Classification of Diseases NHS National Health Service NICE National Institute for Health & Clinical Excellence NVivo 7 Computerised Data Analysis Software PD Personality Disorder PTSD Post Traumatic Stress Disorder 7 2. Introduction Personality disorder according to the American Psychiatric Association (APA) (1994:p275) is “an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment”. Borderline Personality Disorder (BPD) is further defined as a pattern of instability in interpersonal relationships, self-image, affect and marked impulsivity (APA 1994:p280). These definitions of personality disorder would suggest that the long standing nature of the disorder, together with its impact on relationships may have a negative impact on effective interventions (Woods and Richards 2003). Service user experience of mental health services are characterised by negative staff attitudes; coercion; and being passed from one service to another (Fallon 2003). An example of these negative attitudes is where staff are encouraged to direct their efforts away from those with a diagnosis of personality disorder in favour of helping those service users with a diagnosis of schizophrenia (Tredget 2001). Attempts to overcome this deficit in health care provision are highlighted within the policy implementation guidance for people with a personality disorder (National Institute for Mental Health in England (NIMHE) 2003), which indicated that most mental health trusts fail to provide a service for service users with a diagnosis of personality disorder1. The policy context providing the underpinning principles to support the process of therapeutic engagement can be found within the for Mental Health (1999a) which identifies the following themes in delivering care:- 1 The NIMHE Policy Implementation Guide relates to all clients with a diagnosis of personality disorder. This is a general term which is applied to the broad category of personality disorder and the implementation guide also provides specific guidance for specific categories of personality disorder such as Borderline Personality Disorder (BPD). The general term of personality disorder has been used when reference to specific policy guidance but BPD is the focus of this study. 8 • Accessibility; • Choice; • Involvement of service users; and carers in planning care; • Empowerment and support from staff. Whilst engagement with service users is ostensibly at the heart of modernisation agendas, there are concerns that this is more rhetoric than reality (Taylor 2001) with growing examples of government policy being akin to sound bites to capture the public’s attention to gain popularity rather than tackling the complex problems and issues of the National Health Service. Greener (2004) using discourse analysis of health policy since New Labour came to power argues that health policy has undergone three major shifts. Firstly policy was related to continuity and the role of medical and nursing staff as experts who knew the system best. This was followed by a rationalist performance management approach characterised by targets and standards and lastly by consumerism dominated around the concept of patient choice. The author concludes that government health policy can be likened to a garbage can model with a range of problems and solutions are placed but have no real impact on improving services. To counter these criticisms, the National Institute for Clinical Excellence (NICE) was developed to undertake technology assessments of available treatments and to determine which of those treatments are clinically effective and to be made available to the public. However criticisms of this approach state that rather than end the postcode lottery and improve access for patients the approach has been to restrict access to certain treatments for example in the case of specific cancer treatments (Summerhayes and Catchpole 2006) and the treatment Alzheimer’s disease on the grounds of cost effectiveness rather than clinical effectiveness (Kenny 2004; Cerejeira and Mukaetova-Ladinska 2007). 9