Joint Crisis Plans for people with personality disorders

Lead Research Organisation: King's College London
Department Name: Health Service and Population Research

Abstract

People with personality disorders have long-standing problems in the way that they relate to others and experience the world. By virtue of these problems, such people are at greater risk of harming themselves. Little research has been carried out into the treatment of people with personality disorder. In this study, we will develop a new intervention to be used in the management of people with personality disorder and go on to test its effectiveness in a clinical trial. The main aim of the study is to determine whether a negotiated written plan (between a service user and member of staff) is an effective way of helping people with personality disorder to reduce self-harming behaviour. We will begin by working closely with service users and staff in order to adapt the crisis plan from an existing template developed for people with severe mental illness. We will ask service users and staff to give us their views about the most effective research strategies to be adopted in the subsequent trial. In the trial, we will examine whether crisis plans are an effective way of delaying self-harming behaviour in people with personality disorder. Suitable participants will be allocated to receive either the crisis plan or standard care from a community mental health team. Those allocated to the crisis plan will take part in a meeting with their mental health professional, the purpose of which will be to agree the contents of the crisis plan. All trial participants will be followed-up for at least six months, at which point we will measure changes in their self-harming behaviour, the quality of their relationship with staff, their satisfaction with care and the economic cost of the crisis plans. The study will have important consequences for service users, health professionals and researchers. Not only will it improve understanding about the treatment of a common and costly mental disorder, but we anticipate that the use of crisis plans will promote a culture change in the relationship between clinicians and personality-disordered service users.

Technical Summary

The evidence for effective treatments of personality disorder (PD) is extremely limited. People with some types of PD present to services in crisis, threatening self-harm or having committed an act of self-harm. Joint Crisis Plans (JCPs) are aimed at improving the management of crises by increasing the amount of information available during a crisis and empowering patients by ensuring that they have a crucial say in the construction of the crisis plan. JCPs have been shown to reduce the need for involuntary treatment in mental health services. The main aim of this study is to undertake an exploratory randomized controlled trial (RCT) of Joint Crisis Plans for people with PD (J-Pods), in order to test their effectiveness in managing self-harm in this group of patients. The phases of the project are as follows:

Phase 1. The development of J-Pods.
Focus groups will be conducted with service users and staff in order to adapt a previously developed model of Joint Crisis Plans. Further refinement will occur through an established method of acquiring advice from a range of experts (?Delphi? consultation).

Phase 2: A pilot study of J-Pods.
A pilot study will be conducted with a sample of approximately 30 patients, in order to test procedures to be used in the exploratory RCT.

Phase 3: An exploratory randomised controlled trial of J-Pods.
This will be a single-blind RCT of J-Pods compared to a treatment as usual (TAU) control condition involving 120 people with PD who self-harm. The RCT will test the following primary hypothesis: use of a J-Pod will significantly increase the length of time to an act of self-harm compared with TAU. Separate economic and qualitative evaluations will take place to explore the cost-effectiveness of J-Pods and the processes through which they work.


The process of writing a Joint Crisis Plan is one of empowerment of, and negotiation with the service user, and its use would promote a culture change in the relationship between clinicians and PD service users. We will disseminate the findings to service user groups with the assistance of the Service User Research Enterprise at the Institute of Psychiatry. The results will be disseminated to the scientific community in international peer reviewed journals and presented at scientific meetings.

Publications

10 25 50
publication icon
Borschmann R (2013) Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial. in The British journal of psychiatry : the journal of mental science

publication icon
Borschmann R (2012) Crisis interventions for people with borderline personality disorder. in The Cochrane database of systematic reviews

publication icon
Borschmann R (2012) Measuring self-harm in adults: a systematic review. in European psychiatry : the journal of the Association of European Psychiatrists

publication icon
Borschmann R (2010) Crisis Management in Borderline Personality Disorder in International Journal of Social Psychiatry

 
Description Part-funding for a PhD student (whose thesis will be a description of the trial) has been obtained from the hosting academic department
Amount £6,233 (GBP)
Organisation King's College London 
Sector Academic/University
Country United Kingdom
Start 09/2010 
End 09/2016
 
Title Joint Crisis Plans for people with Borderline Personality Disorder who self-harm 
Description With the input of service users and clinicians, we have adapted Joint Crisis Plans (JCPs) for people with Borderline Personality Disorder (BPD). Such plans were originally developed for people with psychotic illness and we have modified them to suit the different needs of people with BPD. We have successfully completed a pilot randomised controlled trial and demonstrated that it is feasible to test the efficay of JCPs for people with BPD who self-harm. 
Type Therapeutic Intervention - Medical Devices
Current Stage Of Development Early clinical assessment
Year Development Stage Completed 2009
Development Status Under active development/distribution
Clinical Trial? Yes
Impact There has been widespread interest among clinicians and researchers and the results have been 1. presented at 2 international conferences, including most recently at the World Psychiatric Association meeting in Prague in October 2012 2. written up as a paper for publication in a high impact journal - the paper is currently under revision with the British Journal of Psychiatry 
URL http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=5252
 
Description Paper presented at World Psychiatric Association 2012 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Paper Presentation
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact The meeting is taking place on 19th and 20th October in Prague.

To be updated
Year(s) Of Engagement Activity 2012
 
Description Presentation of MRC-funded RCT on crisis plans - to School of Community & Social Medicine, University of Bristol 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Talk stimulated questions and discussion + lots of positive feedback.

After my talk the R&D director indicated his potential interest in adopting joint crisis plans for personality disordered service users in the local Trust.
Year(s) Of Engagement Activity 2013
 
Description Presentation to local clinicians 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Participants in your research and patient groups
Results and Impact We have presented the study to 14 community mental teams (totalling approximately 70 clinical staff) over the past year.

The study has generated considerable interest as clinical teams struggle with the management of people with personality disorder.
Year(s) Of Engagement Activity 2010