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The outline of the case including factors in connection with history, presentation and the need for a revised therapeutic approach in many ways mirrors the clinical case evaluation detailed by Sherry (2006) in the application of ‘an Attachment Theory Approach to the Short-Term Treatment of A Woman With Borderline Personality Disorder and Comorbid Diagnoses’. This study highlights the difficult support/treatment pathway of borderline personality disorder (BPD) which stems from the comorbidity with other diagnoses including
severe depression, panic disorder, post-traumatic stress disorder (Zimmerman & Mattia, 1999) and harmful misuse of alcohol and other substances (Trull et al, 2000) which are all clearly present in Ruth’s life. The symptoms typically identified with these disorders are often challenging to mental health practitioners and there appears to be a groundswell of opinion that suggests the disorder is largely untreatable because they are entrenched within the personality and coping mechanisms of the individual. (Raven. 2009)
As is common with many people who experience severe mental distress, Ruth has been unable to respond to the demands of the workplace and therefore financial insecurity is likely to be a significant factor for her and also in shaping the life options and experiences of her daughter, Megan. Gould (2006) identifies some of the most pertinent and enduring difficulties that contribute to child poverty in situations where parents have poor mental health and details the difficulties of securing employment (just 24% of people with long term mental health issues in employment), the typically low level of remuneration for people in this category and inflexible nature of moving from benefit claimant through into employment as limiting factors in increasing the life chances of children and young people in this kind of situation. To support this claim the more general findings of Tunnard (2004) are highlighted which link parental ill health problems and family poverty and indicate that ‘50% of disabled people have incomes below half the national average, this rises to 60% for disabled adults with children (Gould 2006). Speculation in this report suggests that the figures would be worse in families where one or more parents experience significant and enduring mental problems. Therefore it is reasonable to presume in the case of Ruth and Megan that their level of income is and will remain at a low level without some significant lifestyle changes. Specific links between financial hardship and mental health are taken from an unpublished paper by Social Exclusion Unit in 2004 detailing the impact of poverty on mental ill health, the difficulty people experience had in accessing financial advice /services, disproportionate dependence on state benefits, fluctuating incomes determined by health status and the challenge of securing the right level if benefit/personal finance. General findings about the impact on family poverty are also relevant in the case of Ruth and Megan and it is a factor that is very likely to add to the symptomology common to people diagnosed with borderline personality disorder.
Furthermore, as benefits and social care resources are constrained against a backdrop of central government’s drive to put people back into work, Spencer and Baldwin (2007) argue “that many parents in the UK are expected to bring up their families in the context of unreasonably scarce resources’. Therefore, practitioners need to take into account Ruth and Megan’s social and economic factors when assessing their individual needs, risk and in determining a therapeutic pathway for this family. As might be expected, given these negative financial, health and well-being determinants social exclusion is a likely to be a factor that needs to be overcome if an holistic, person-centred approach is to be adopted in supporting this family. Developing strategies to overcome the destructive behaviours that Ruth has developed as her personal coping from mechanisms is a key factor in addressing the wider concern of her and Megan’s social exclusion and isolation.
Megan’s current situation, which is one of compromised opportunity, a limited social life, burdensome responsibilities, isolation, scarce personal resources and a lack of attention to her own needs, represents the situation of many carers in the UK, especially so those who have or have had responsibilities as a young carer. . Research by Aldridge and Becker,
(1999, p.306) suggests that children who provide caring support to parents with mental illness ‘ will be more susceptible to increased levels of anxiety, depression, fear, change in behavioural and social patterns as well as being more at risk of transmission of the particular parental condition’. As caring moves through into adulthood the future tends to remain bleak and research from the Health and Social Care Information Centre (2010) reports increased evidence of poor health, low income and a general sense of hopelessness for carers in the light of on-going cuts to social care budgets. The prospect for any significant improvement is equally depressing.
In considering the details of this case the eclectic and reflective nature of social work is an approach that seems suitable for the complexities supporting people with mental ill health, particularly the ever changing presentations of people who have a diagnosis of borderline personality disorder. Payne (2009, p.100) describes the usefulness of these approaches in case work highlighting how practitioners can adopt and use theories ‘together, perhaps all at once or perhaps successively’ or use ‘different theories in different cases’. Because this method requires significant skill and discernment Payne cites Epstein (1992) who suggests that flexible team approaches to reflection, debate and application offer a useful way forward to the delivery of flexible ‘moment to moment’ practice in response to complex cases. Payne (2009) identifies systems theory as being an important aspect of eclecticism. Pincus and Minahan (1973) applied the approach to social work practice and describe three types of system these being ‘informal or natural’ (friends/family), formal (community groups, etc.) and societal systems (hospital/schools, etc.). People with mental health problems are likely to have some difficulty in using helping systems to improve their health, life experiences and general well-being. Applying systems theory involves identifying the point, and problems individuals experience in the interactions with their environment. The phases of this include assessing; making/negotiating contracts; forming/coordinating actions; re-forming and influencing action systems; terminating change efforts. Payne (2005) extends the application of this approach and makes clear links to ecological systems theory, crisis theory/models and task centred working. The application of these, particularly crisis intervention, could work in connection with Ruth’s current difficulties and potentially offers short term bridge toward longer term therapeutic work. However in adopting this approach it is worth considering the caution raised by Doel (2009) and he notes that if done poorly than crisis/task centred work can become inflexible, routine and possibility lead to some level of social control. Doel suggests using these methods should be accompanied by training that considers factors such as values, attitudes and their application in practice.
Sherry (2007) identifies the increasing consideration and application of attachment theory (Bowlby 1973) in the causation of borderline personality disorder and cites numerous influences as threats to attachment in childhood. Risk factors in this regard include sexual traumas (Laporte & Guttman, 1996), parental neglect (Paris, 1997, 1998), family instability and emotional neglect all of which are considered to contribute to the development of personality styles in adult life. For practitioners, the reasoning of Ivey 1989 who suggested extreme behaviour by clients could be linked to their development history and the way they respond and bring meaning to their experiences in later life. Therefore poor parenting experienced by Ruth could have been instrumental part in the development of behaviours that for her now carry the label of borderline personality disorder (West & Sheldon-Keller (1994). Therefore the gathering of information in assessment processes can be a crucial factor in working out the style and content of social work intervention.
In considering the pathways of someone who experiences significant mental health issues it is clear that from many perspectives that society perceptions, life opportunities and thereby individual well-being are compromised in many areas of life. The fight for a more balanced and supportive approach to mental health has been carried by the service user/survivor movement for many years and the need for reform has led to many campaigns. It is easy to understand the need secure better treatment and push through system reforms given oppression, rejection and widespread ignorance that characterises the history of mental health in the UK. Ferguson (2008) highlights how the now accepted position of the survivor movements pushing for greater recognition of the plight of people with mental health issues came from the enduring effects of stigma, powerlessness, inequality and segregation which have been utilised to push governmental thinking and maintain mental health, well-being and social care as political issues. The fight for improved rights and opportunity among the survivor movement only really gathered pace in the 1970s (Campbell 1996) (Beresford, 1997) and in the early stages tended to focus on small scale self-help and mutual support initiatives. More recently there has been greater, towards collective national campaigns concerning treatment, responding the revisions of the mental health legislation and broader struggles to change attitudes and understandings of madness and distress. This has been key to shifting the stigma of mental health and clearly it is something that needs to continue.
General concerns expressed by Campbell (2005) link well to Ruth’s situation and the pressing structural concerns that tend to bring of poverty, lack of opportunity, isolation, boredom, hopelessness and therefore a continuing commitment to state imposed legal and medical restrictions are clearly relevant to the case study. Evidence of the negative impact of mental ill health can be found in the health inequalities highlighted in research carried out for the Disability Rights Commission in 2006 which showed that people with severe mental illness are at higher risk of ill health across a number of conditions. Their report ‘Equal Treatment: Closing the Gap’ highlighted increased incidence of clinical obesity, coronary heart disease, diabetes, high blood pressure among people with severe mental health issues. It also noted higher risks in connection with people developing high blood pressure, stroke, respiratory problems and bowel and breast cancer. They are also more likely to smoke. Although the reasons for this inequality are complex and have far reaching implications for public health policy makers, the consequence remains that people who experience long-term mental ill health die on average 5 to 10 years younger than other people, often from preventable illnesses. The response to this research and the continued focus on issues of inequality, injustice and stigma by organisations such as ‘Rethink Mental Illness’ is yielded some significant results with increased focus on physical health being pursued within community mental health teams, increased focus on talking therapies and Mental Health (Discrimination) Bill moving through to the House of Lords for further debate. (Rethink, 2012)
However it is increasingly apparent that people with a diagnosis of borderline personality disorder are subject to a specific type of stigma and discrimination that impacts on the relationships that are key to achieving to achieving some level of stability in their lives, these being the ‘therapeutic’ links with practitioners within community mental health services. Ruth’s condition unfortunately fits in with the perception held amongst professionals that it is almost or completely untreatable. Personality disordered patients are often described as the “patient physiatrists dislike” and are often viewed as time wasting, difficult, attention seeking, and manipulative bed blockers. (Hadden & Haigh, 2002). Having previously highlighted the significance of person-centred theory and approaches in developing therapeutic alliances, it is supremely that discrimination within helping professions can be raised so easily as central limiting factor. Markham (2003) highlights multiple differences in the reactions of professional staff towards people who have a diagnosis of BPD. The suggestion is that the label leads to increased social rejection, deceased optimism and adoption of stereo typical attitudes by staff therefore creating risk of less favourable and thereby effective treatment as compared to other groups of people with severe and enduring mental health issues. As might be expected, the research draws heavily on labelling theory:
The negative service user experience detailed by Wright & Jones (2012) in typifies Ruth’s historical therapeutic pathway and include direct quotes that are clearly relevant:
‘Rightly or wrongly, I interpreted the label as a sign that I was fundamentally flawed, that the bad parts of me far outweighed any good attributes that might also be part of my personality’
â€¦and being told
‘that I had a personality disorder and that there was no cure or treatment. The inference was that I was just made this way and that was the end of it.
The article also highlights the findings of Pilgrim (2001) who suggest that poor responses to personality disorder occur because causes are not known and that treatment outcomes are often unpredictable and unreliable. In considering this kind of evidence, it is easy to understand Ruth’s resignation following another A & E admission which in her mind will bring about yet another dissatisfying cycle therapeutic hopelessness with little chance of any success.
(should this paragraph be justified or left centred?)
The situation raised in the case study typifies many of the negative issues associated with
the support that people with a diagnosis of borderline personality disorder receive:
dismissive attitudes, inconsistent approaches and authoritarian approaches seem to be
consistent themes and are obviously not changing the nature and outcomes of therapeutic
interventions. While it might be difficult at this stage, it seems important for Ruth to take
some responsibility possibly self-managing some degree of the presenting risk which is
consistent with the guidance provided by Wright and Jones (2012) and is also in line with
best practice as detailed in the NICE guidance (2009). This should be clearly stated
within the care plan. Mead and Copland (2000) suggest that people are able to grow
through positive risks taking and that empowerment through person centred support can
reframe typical service user response to difficult, crisis situations. Practically this can be
supported through clear and effective care planning and this should be built into an
individual’s treatment and crisis plan. Ruth, along with her care coordinator, should carefully
consider strategies to manage acute and chronic risks developing and incorporating these in
the care plan as appropriate. This will ensure consistency when the care coordinator is
absent, ensuring that Ruth’s care and support follows boundaries and consistency agreed
with her and thereby ensuring she is treated with dignity, respect and compassion.
Although risk to self which Sherry (2007) clearly links to the diagnosis of borderline personality disorder must be responded to in the context of community mental health services, admission to psychiatric inpatient unit should only take place as a last resort and the least restrictive options should be pursued. The stepped care model offers a useful statutory response and if risks remain elevated then Ruth should be considered firstly for the high intensity team then a referral crisis resolution and home treatment team, notwithstanding any negativity that may surround her historical presentations. If possible extra support from care coordinator would be the ideal solution, as this would utilise the therapeutic relationship in place to support and guide Ruth through her crisis. In consistently challenging situations Ruth’s care coordinator could also explore with Ruth and Megan a self-directed support (SDS) package. This package could support with activities of her choice and it is possible for this to be used for Ruth to explore and access some community resources therefore building social networks for Ruth and relieving Megan of some of the pressure of her carer’s role. Hatton and Waters (2011) identify the relative success of SDS/personalisation in connection with people experiencing mental health issues and this is at its most beneficial when individuals pursue direct payments and secure support on their own terms.
Whichever option in terms of on-going support is chosen then it seems that there is need for a more collaborative, shared approach both in connection with risk and also around longer-term support strategies. The work and theories of Rogers (1956, 1957) define the core conditions of counselling including unconditional positive regard (UPR), empathy and congruence for therapeutic relationships to succeed particularly so in the context of personality change. It is important to note that this is a value based approach and faith that the person can shape their own positive future if the condition highlighted above can be provided. It is not a set of tools and techniques that can be turned on and off to suit practitioner needs at a given time or opportunity. It links well to considerations around motivational approaches and Ruth’s and Megan’s desire to move on is a good indicator in this regard. Fundamentally, by adopting humanistic approaches, the aim is to develop a pattern of interaction and support which keeps Ruth centrally involved in the nature and shape of the therapeutic relationship which will naturally involve key decisions about, risk, treatment options, care planning and goal planning. Clearly this type of interaction is difficult to outline to all involved professionals but careful entries and assessment within electronic records can help significantly in modifying the responses all statutory workers who may encounter Ruth in the professional work. If this person-centred approach is adopted then it will represent a significant shift in the care and support Ruth has received in her ‘short psychiatric career’.
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