Relational Clinical Care as a model of early intervention for Personality Disorder (Dr Louise McCutcheon)
Introduction: There is now compelling evidence supporting early detection and treatment (‘early intervention’) for severe (borderline) personality disorder (BPD) in 12-25 years olds (Chanen et al., 2022), yet the diagnosis remains controversial and early intervention for personality disorder (EIPD) has not yet been accepted into mainstream youth mental health. The longstanding focus on specialised psychotherapies as the treatment of choice has overly complicated the skilling up of clinicians, has failed to address the diverse needs, particularly low functioning, and has limited access to appropriate care for young people with PD features. Individuals with PD are often care-seeking, and the cumulative prevalence of PD is high. Despite evidence that simple, structured and more pragmatic treatments can lead to good outcomes in young people, many clinicians do not feel competent or confident to take on young people with PD features. This can result in difficulties associated with PD remaining undetected, not being treated and potentially become entrenched, and individuals struggling to access any care at all.
The Helping Young People Early (HYPE) program is an evidence-based, publicly funded, EIPD program at Orygen, Melbourne, and provides comprehensive, pragmatic and relationally informed care to young people with subsyndromal and full threshold BPD. Relational Clinical Care (RCC) provides a pragmatic episode of care that can consist of practical case management, relational understanding, medical support and an optional time limited contract of psychotherapy. The relational approach is particularly helpful for those with relational problems as it provides a way of exploring and addressing the relational difficulties the lie at the heart of PD. The principles of RCC are simple enough to be delivered in most settings from primary care to tertiary specialised settings.
Objectives: This symposium will describe the core components of RCC, with particular focus on how the model applies a relational framework to case management, work with families and the medical management. The aim is to assist managers of services and individual clinicians to consider how to incorporate principles of EIPD into their own practice.
Approach: An overview of HYPE will be provided by Dr Louise McCutcheon. Relationally-informed case management with particular focus on vocational and educational support will be presented by Jessica O’Connell. The work with families and supporters of young people will be described by Karen Smith, and the role of the psychiatrist in the team will be described by Dr Edward Mullen.
Conclusions: Simpler, structured treatments are needed for the treatment of BPD in young people unable or unwilling to engage in more intensive treatments. The HYPE program has demonstrated that young people receiving Relational Clinical Care have been able to benefit and have improved outcomes.
Relationally-informed case management (Jessica O’Connell)
HYPE aims are to support young people to improve their functioning, better their relationships with themselves and others, and seek care in helpful and adaptive ways. A shared, relational formulation is used to guide a goal-directed and time-limited intervention.
In this presentation, we aim to highlight the opportunities available to all clinicians when working with young people with personality disorders, regardless of specialist training. Through the use of case examples and feedback from young people with lived experience, we will highlight the use of the model of Relational Clinical Care to (i) provide vocational and educational support and intervention, and (ii) work with the care systems that often support high-risk or complex young people to limit restrictive practices and unintended iatrogenic harm.
RCC with families and friends of a young person with PD (Karen Smith)
Relational care assumes families and friends are a potential source of support and involving them where possible promotes effective treatment.
Many of the families we see come with the legacy of their own life challenges such as mental health issues, trauma and loss. Families have also often had challenging relationships with health and welfare services in the past and so themes of blame, shame and mistrust can challenge the initial process of engagement with families. With the consent of the client, families are invited to engage with the treating team at a number of levels and points in the process of treatment, including in assessment and formulation, safety planning, constructing management and in in working towards new ways of managing together. The family work can involve the weaving of separate sessions with the client, parent, partners and siblings to support engagement and promote change. Discussions encourage reflection on how relational patterns between family members either provide relational soothing and support or inadvertently contribute to the client’s feelings of being misunderstood and levels of distress, and therefore maintain unhelpful coping strategies.
The role of a psychiatrist in RCC (Dr Edward Mullen)
Psychiatrists play an important role in Relational Clinical Care (RCC) in terms of assessment of personality and co-occurring mental health and substance use disorders, contributing to the development of a shared formulation and integrated management plan which may include evidence-based psychopharmacology.
The Psychiatrist in RCC works collaboratively with the young person, family and care team to lead recovery focused goal setting, provide feedback and psychoeducation and supports team-based risk management.
We will present a summary of recent evidence in psychiatric treatment of severe Personality Disorders in young people and compare RCC to different models of psychiatric care for this group. We will also present recommendations for training competencies for psychiatrists to work with this group in their practice.