Jo Anderson – Clinical Psychologist Max Pickard – Consultant Psychiatrist

1. Training Course for Staff Caring for People with a Personality Disorder and Intellectual Disability Jo Anderson – Clinical Psychologist Max Pickard – Consultant Psychiatrist Emma Rye – Consultant Clinical Psychologist

2. Rationale: referrals Many clients being seen in MDT clinic with similar presentations Complex attachment/trauma histories Mainly in supported living/ residential services Problems with relationships – staff, carers, other service users Emotion regulation problems Risk: self-harm difficult for staff to manage Described by staff as “manipulative” and “attention seeking” May or may not have formal diagnosis of PD

3. Rationale: impact Impact of psychiatric interventions is limited for these clients Clients may not be able to engage in psychological therapy Limits of behavioural approaches However pressure from staff to us to do something Staff/carer burn-out is a major factor Frequent placement breakdowns: compounding loss & trauma Clients often go through periods of crisis related to loss of staff/carers, other perceived rejection

4. Plan Provide psychodynamically informed training for staff teams: managers and carers Increase understanding of the complex processes being played out within relationships Decrease distress for both carers and clients

5. Overview Three weekly 2-hour sessions 3 staff from each service (manager +2) to attend all 3 sessions Total number of participants: 9-12 Key topics covered in teaching format Discussion: drawing on personal experiences and examples encountered Handouts each week Homework given to the group between sessions

6. Session 1 Introductions, expectations, confidentiality: importance of being honest about “negative” feelings Outcome measures. What is a Personality Disorder? – ICD-10 criteria, limitations/advantages of this diagnosis/label. Relationship to attachment, trauma - may include some discussion of the trauma histories of people being cared for, these may be unknown; difficulties thinking/ talking about clients’ histories of trauma; impact on current relationships with staff/ others. Splitting - staff pulled into rescuer/ abuser position Impact on individuals/ teams, examples from the group: flipchart HOMEWORK: Notice any examples of splitting.

7. Session 2 Recap session 1, reiterate confidentiality, importance of being able to speak freely and safely. Flipchart from last week on the wall. Sharing of reflections, ideas, thoughts about splitting. Strategies to avoid this: promote autonomy, avoid neglect. Countertransference – unconscious communication - rather than “manipulative” behaviour. Staff emotions mirror how the client feels: a form of communication from the client to staff. Discuss staff experiences: flipchart. Dissociation

8. Session 2: flipchart “I wanted to kill her” Hopeless “You haven’t got a clue” Despair “I might as well not be here” Numb Empty Guilty “What’s the point?” Physically sick Failure Exhausted Fear Anxious Anger HOMEWORK: Notice any examples of unconscious communication. Try to use this knowledge to change responses.

9. Session 3 Recap session 2, share experiences of unconscious communication. Flipchart from previous weeks on the wall. Practical problems and strategies - validation, use of empathy: flipchart. How to deal with “boundaries” and staff feelings Risk management. Burnout and emotional exhaustion. Repeat outcome measures.

10. Evaluation Controllability Beliefs Scale (Dagnan, Grant & McDonnell, 2004) & bespoke measure completed before & after. Significant change in mean total scores on the CBS. At the end of the course staff perception regarding the amount of control clients had over their behaviour reduced. Attribution of control affects emotional response to behaviour: the more control staff feel clients have, the more frustrated and angry they may feel with their clients. Hopefully reduced risk of placement breakdown/ admission. No significant change on bespoke measure (5 questions eg “How well do you think you understand your clients and their emotional needs?”) possibly because staff rate selves highly to start with. Excellent verbal feedback: providers want more! It is never enough (mirrors client group)

11. Reflections (1) Psychodynamic concepts are complicated! Helps to use staff’s own language. Carers want to know and understand these ideas – several asked about recommended reading. Normalising negative feelings towards clients is essential. Staff sometimes disclose issues in their own families. Practical strategies were seen as the important; but understanding comes first. Difficulties for managers: need space to share while supporting staff & containing their anxieties. Placement breakdown (-) vs knowing limits & serving notice (+) rather than trying to continue to “rescue”. Some staff may decide to resign.

12. Reflections Discussion and hearing examples from other services were core components of the training. Starting to build up critical mass in Kent: staff coming with basic knowledge of the concepts. Courses booked up as soon as advertised (£90 pp for 3x 2 hours) Separate courses for CLDT staff (social workers, care managers, nurses, OT, SaLT, physio etc) Possibility of separate courses for managers in future. Training manual to be published. Train the Trainer courses in future.