Readiness for referral

An intervention to anticipate the delay has been suggested in this journal based on a transtheoretical model of change so as to ‘guide how to increase readiness for referral and when to refer’.^{Reference Roughley, Maguire, Wood and Lee5} This is complicated, including psycho-education about EUPD, personal formulation, crisis planning, motivational interviewing and several other things. But many will fail to negotiate this particular steeplechase of fences. At that point it is frankly ridiculous to expect the CHMT to provide further informed care. This inevitably leads to disenchantment on both sides; patients feel dissatisfied and are increasingly looking for interventions outside the standard systems to satisfy their needs^{Reference Ramsden, Prince and Blazdell4} and CMHTs feel disempowered while at the same time being ‘stuck’ with patients who are reluctant to engage.

The alternative view

A good service for those with personality disorder should be able to provide continuity of care and be able to engage with all those who have personality disorder. Currently, mental health professionals have a fixation with emotionally unstable personality disorder (EUPD) or its DSM equivalent, borderline personality disorder (BPD). This is understandable; it accounts for virtually all published guidelines^{Reference Simonsen, Bateman, Bohus, Dalewijk, Doering and Kaera6} and completely neglects the 84% of people with other personality disorders identified in national studies.^{Reference Coid, Yang, Tyrer, Roberts and Ullrich7} There is another reason for paying more attention to the other personality disorders: their long-term outcome is currently less good than that for borderline personality disorder.^{Reference Álvarez-Tomas, Ruiz, Guilera and Bados8,Reference Yang, Tyrer, Johnson and Tyrer9}

Community mental health teams: a service for all with personality disorders

A good CMHT has: (a) a range of skills that can deal with a wide range of psychopathology, including managing many with comorbid mental illnesses; (b) stability, so that the team will provide continuity of care despite the loss of key individuals; (c) capacity to engage and contain individuals who are treatment resistant – given their experience in providing for those with severe mental illness; and (d) a closer link to general practice than specialist services.

Despite these advantages, nobody can be unaware of the pressures on CMHTs and so any additional service provision requires more training and resources if it is to be successful. In this context, services should be aware that significant funding is coming to community mental health services in the next 2 years (Tim Kendall of NHS England has pointed out that this funding includes a ring-fenced sum of £1.3 million for each 50 000 population group for community mental health and crisis-related services (T. Kendall, personal communication with permission, 2 June 2021)). This is genuinely new money and all should be prepared for this bonanza and ready and able to spend it wisely. This extra funding should enable a CMHT to include training in a simple assessment procedure that will allow it to separate those with significant personality disorder from those with lesser personality difficulties. Fortunately, the simple classification by severity in the new ICD-11 classification^{Reference Tyrer, Mulder, Kim and Crawford11} is suitable for this task and straightforward scales are available to help with diagnosis.^{Reference Bach, Brown, Mulder, Newton-Howes, Simonsen and Selbom12,Reference Kim, Tyrer and Hwang13} Patients with personality disorder who are not treatment seeking currently account for a disproportionate proportion of total costs^{Reference Lenzenweger, Lane, Loranger and Kessler14} and to fail to address their extra needs is negligent.

The procedure adopted by each trust could be along the following lines:

1. (a) one or more members of the CMHT are trained in the principles of identification and management of personality disorders

2. (b) on entry to the team each patient has their personality function assessed

3. (c) the trained CMHT members will take over the care-coordinating role for the patients with the more severe disorders

4. (d) when needed, a separate team with expertise in psychological treatments can be called in for advice and guidance, adding elements of the specialist interventions such as DBT but not involving taking over care from the CMHT

5. (e) the specialist team has an oversight role for patients with personality disorder in any part of care; this may often be particularly important when in-patient care is needed

6. (f) relevant information and care plans from the CMHT services will be shared more closely with primary care and crisis resolution teams, and day services when necessary, so that discontinuity in care can be reduced as much as possible

7. (g) greater use is made of primary care services and additional resources such as social prescribing, which has great potential in this group of patients but has been insufficiently embraced in mental health.^{Reference Maughan, Patel, Parveen, Braithwaite, Cook and Lillywhite15}

The advantage of this arrangement is that all personality disorders are recognised, including the Galenic syndromes^{Reference Tyrer and Mulder16} (closely intertwined mental state and personality disorders, named after Galen, who first postulated the link between personality and disease) such as substance misuse, impulsive disorders and anxiety and avoidant disorders (the general neurotic syndrome). Continuity of care and informed feedback are also more likely when patients are transferred to different parts of the services, and there is also much better transition from secondary to primary care.

This is the way forward, not the further accumulation of specialist teams.