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Julie – Successful Rehabilitation of an Individual with Emotionally Unstable Personality Disorder

10 Apr 2019 | BY Matthew Harris

Julie (early 20s) was admitted to John Munroe Hospital in the interest of accessing our Personality Disorder services, on Section 3 of the Mental Health Act in May 2016 from an NHS psychiatric ward. Julie has a diagnosis of Emotionally Unstable Personality Disorder along with a history of substance and alcohol misuse. She had previously been in contact with mental health services from her mid-teens (presenting with low mood, impulsivity with deliberate self-harming behaviour and overdoses) with her first admission to psychiatric services at 18.

Prior to transfer from the NHS psychiatric ward to JMH, whilst being treated in a specialist psychiatric hospital, Julie absconded and made a serious suicide attempt, resulting in life changing injuries. Julie was transferred to JMH (High Ash Unit) nearly a year after this serious suicide attempt.

Reports from previous placements indicated that historically Julie had struggled with collaborative working with the clinical team caring for her or engaging in any therapy offered to her.

Upon admission to our mental health rehabilitation service, Julie was immediately introduced to members of the therapy team. Collaborative discussions were held about how the team could best support Julie. She identified various goals that she wanted to achieve and appeared highly motivated, although at times a little unrealistic, in what she wanted to achieve. Julie was supported to break these goals down into achievable smaller goals.

During the time that Julie was an in-patient at JMH, she had periods when she was placed on enhanced 1:1 observation, due to increased risk of deliberate self-harming behaviour. However, Julie worked with the Multi-disciplinary Team, improving her coping strategies and negotiating least restrictive options to enable improvement in her independence and autonomy.

Following a period of multidisciplinary assessment, a team formulation identified: poor distress tolerance and emotion regulation skills, unprocessed past trauma and associated symptoms, unhelpful coping patterns, a disorganised attachment style and schemas concomitant with pervasive low self-worth, shame and mistrust. This formulation subsequently informed the development of an individualised intervention plan, incorporating Occupational Therapy, Clinical Psychology, Psychiatry and nursing/ward care.

Work with her designated occupational therapist included: Anxiety and Relaxation (individual sessions); Coping Strategy Enhancement (individual sessions); Art and Craft (individual and group sessions); Functional Skills work (individual meal preparation sessions); Budgeting and Debt management support (individual). During the time that Julie was an in-patient at JMH she arranged a charity fundraiser (coffee and cupcake afternoon) for a nation-wide charity. Also, during her individual art and craft sessions, Julie chose to make ‘preemie octopi’ which were then given to parents of premature babies.

Julie was offered weekly Clinical Psychology sessions, which adopted a Schema-Focused and Attachment Narrative model of treatment. In addition, EMDR was used to facilitate the processing of traumatic memories, which in turn enabled the development of a stronger sense of self identity. Although she demonstrated motivation and generally good engagement, Julie found many of the themes explored within her therapy overwhelming; therefore, a gradual approach accommodating this tendency towards avoidance was used. Julie was able to reflect upon the origins of individual, maladaptive schema in her childhood experiences and the unmet developmental needs that had continued to affect her functioning and as a result, strengthened her capacity to form warm and trusting relationships. Training/consultation with the wider team was also an integral part of the Clinical Psychology intervention, in order to support and reinforce the use of the Schema mode in Julie’s overall care and treatment.

Also, over time, the need for Julie to be on enhanced observation was reduced. She began to have unescorted ground leave and then unescorted community access. Less than 12 months after her admission to our independent mental health hospital, Julie was discharged from her section. Julie continued to work with the clinical team at JMH, building on her skills and coping strategies, whilst planning for discharge into the community. Julie was ultimately discharged into her own accommodation, with support from the local CMHT.