Good Psychiatric Management-based post-crisis support for people diagnosed with BPD leaving emergency care

Good Psychiatric Management (GPM) is an evidence-based treatment for borderline personality disorder (BPD) that can be administered by generalist or non-specialist clinicians with minimal training and is designed to be flexible and adaptable to patients’ needs. GPM combines psychoeducation, crisis planning, case management and strategies to enhance engagement with family and community supports. It emphasises collaborative, person-centred care. In this study, people diagnosed with BPD with a history of more than one presentation (including the current presentation) to an Eastern Health emergency department (ED) for a mental health-related crisis will be offered a 10-session, 1-hour-each GPM intervention as step-down post-crisis support over 6 months. A clinician trained in GPM will provide the sessions. The nominated clinician will receive formal training from Spectrum. Spectrum is a public mental health service in Victoria specialising in the treatment of people with personality disorders and complex trauma histories. Since Spectrum has extensive expertise in training non-specialist clinicians in GPM, this is considered appropriate and feasible. Throughout treatment delivery, the clinician will also receive ongoing individual supervision from a senior Spectrum clinician to support intervention fidelity. Training: 1. The nominated clinician will receive 1:1 training in GPM foundations (basic) from a senior GPM-trained clinician at Spectrum via videoconference (Zoom/Microsoft Teams). This will be followed by advanced training in "Working with complex presentations of BPD & coexisting conditions using GPM", a group in-person workshop at Spectrum delivered by two senior clinicians with extensive experience in working with complex presentations of people with BPD. 2. The 1:1 training will be split into four sessions each week (2 hours each, totalling up to 8 hours) in September preceding the group workshop. The group workshop will occur on 22nd October. 3. The Spectrum clinicians have previous experience in providing this training; materials generally used to provide GPM trainings at Spectrum will be utilised. This may include pre-prepared slides, training outlines and pre-recorded videos. Modifications to the content/pace will be made as necessary, based on the nominated clinician's level of experience, study context and skills. 4. The trainings will occur in September (basic) and October (advanced). Intervention is anticipated to start in November. Content covered in the training - Basic: Management strategies using practicality, good sense, and flexibility are emphasised. Listening, validation, judicious self-disclosures, and advisement to build a life rather than focus on being a patient create a positive relationship in which both the concerns and limitations of a mental health professional are explicit. Techniques and interventions that facilitate the patient’s trust and willingness to become a proactive collaborator will be described. Guidelines for managing the common and usually most burdensome issues of managing suicidality and self-harm (e.g., intersession crises, threats as a call-for-help, excessive use of ER’s or hospitals) will be reviewed. Principles for the management of co-occurring disorders and medications from an evidence-based point of view are presented pragmatically. How and when psychiatrists can usefully integrate group, family, or other psychotherapies will be described. Advanced: This workshop will provide instruction in how to adapt GPM to meet the needs of patients with significant co-occurring disorders along with BPD. Depression, anxiety, posttraumatic stress disorder, substance abuse disorder, eating disorders, other personality disorders, and many other disorders frequently co-occur with BPD and can significantly complicate treatment. Many providers believe that co-occurring disorders must be treated before BPD can be addressed, or that BPD must be addressed before meaningful change can occur in co-occurring disorders. This workshop will equip attendees to consider patients with complex cases as whole people and use GPM to most effectively help them. It will review the common co-occurring disorders, the way they interact with BPD, and strategies for combined treatment. The intervention sessions will focus on the following treatment goals: 1. Creating and reviewing a safety narrative: Working with the clinician to understand what helps and what doesn’t help when the patient is experiencing heightened and painful emotions. 2. Developing a clinical formulation: The clinician will work with the patient to make sense of the challenges they experience, history, and patterns of responding so that everyone in the patient's treating team understands what’s going on. 3. Providing trauma-informed care: Recognising how past trauma may affect current emotions and behaviour and responding compassionately. 4. Educating the person about the symptoms they are experiencing: Helping the patient to understand their diagnosis, symptoms, and why they feel and react the way they do. 5. Managing crises: Supporting the patient during emotional crises and helping them develop alternative coping strategies. 6. Strengthening family and community supports: Encouraging the involvement of supportive people and connecting the patient with helpful services. 7. Finding alternatives to self-damaging coping mechanisms: Working together to discover less-harmful ways to manage distressing emotions. Clinicians in Eastern Health ED/crisis assessment and treatment units (CATT)/ psychiatric assessment and planning unit (PAPU) will identify the people most likely to benefit from this intervention and refer them to the GPM clinician within 1 week of their ED presentation. The GPM clinician will deliver the intervention either online or face-to-face on an Eastern Health site over 6 months, in intervals scheduled according to the patient's preferences or needs. Adherence to the intervention will be monitored by collecting data about participants' level of engagement using the Treatment Engagement Rating (TER) scale, administered by the clinician every fortnight while the patient is engaged in treatment. Adherence to the intervention by the clinician will be monitored using the GPM adherence scale (GPM-AS), rated by the clinical supervisor for the GPM clinician every 5 weeks throughout the treatment delivery period. Data on the frequency of emergency department (ED) presentations, including 8-hour-to-bed and 4-hour NEAT metrics*, will also be collected. *In Australian hospitals, time-based performance measures are used to monitor ED patient flow and overcrowding. The National Emergency Access Target (NEAT) is a 4-hour target, referring to the proportion of ED patients who are admitted, discharged or transferred within 4 hours of presentation (4-hour NEAT metric). “Access block” is commonly defined as occurring when a patient who requires hospital admission remains in the ED for more than 8 hours because an inpatient bed is unavailable (8-hour to bed metric).