KATHY TAYLOR RMN, MSc WOKINGHAM CMHT BERKSHIRE HEALTHCARE NHS FOUNDATION TRUST

“How can attachment theory, in particular the concept of the secure base, help inform Care Coordinators in the process of discharging patients with Borderline Personality Disorder from the Community Mental Health Team?”

Aim Of The Research Care Coordinators in Community Mental Health Teams face problems managing the attachment needs of patients with severe BPD who do not fit into specialized therapy (Koekkoek et al., 2009). In this dissertation, the researcher explored how attachment theory, specifically the concept of the secure base, can help inform the management of the discharge process from the point of view of the Care Coordinators.

Attachment theory describes the search for security as the starting point for survival (Bowlby 1960; Holmes, 2001) and proximity-seeking behaviour as automatic in the face of real or perceived threat. Bowlby (1979) argues that the search for the secure base is normal, natural behaviour in response to ordinary anxiety, and an essential part of the developmental cycle. It is neither pathological nor something we grow out of; across the life span, human beings need a secure base to return to, especially in times of stress.

Aiyegbusi (2004) defines the secure base as a “pattern of increasing independence when feeling secure, and proximity-seeking when feeling insecure” Many BPD patients want someone who can meet their every need (Norton, 1996) and the fear, or actual, loss of their care-giver eg Care Coordinator (through discharge for example) may trigger an ‘angry’ response (Bowlby, 1984). ‘Disordered’ attachment-seeking behaviour.

What was happening in the team? Some patients remained in the service for many years, firmly attached to the team Team members and services’ attempts to help patients ‘move away’ were thwarted Increased demands on services Hospital wards full No room on CCs caseloads; waiting lists Gridlock… no ‘wiggle-room’… what could change?

Purpose of questionnaire The researcher’s intention was to enquire into clinicians’ thoughts and fears regarding discharging BPD patients; whether the CMHT provided a psychologically secure base for staff, and if rates of discharge could be sufficiently improved by the formation of an informal staff support group or through a formal discharge panel.

Action Research Findings Staff Support Group met 4 times. Questionnaire completed by 21/34 (61.8%) of CMHT clinicians. Discharge Panel meets once a month.

Action Research Findings 54% clinicians appeared to demonstrate psychological mindedness when dealing with unplanned contact from difficult patients. 70% clinicians found it “quite difficult” to discharge BPD patients. Risk, relapse and family were main factors that caused concern for clinicians, when considering discharge.

Action Research Findings CMHT was a psychologically secure base for all participants. Staff Support Group – a peer group of mainly Care Coordinators to provide a safe space to discuss discharging difficult patients. 100% success rate. Devolved into… Discharge panel – more hierarchical, formal process. 75% success rate. Advantages and disadvantages.

Criticism of findings Questionnaire was a pilot, not standardised. Some questions were unclear. Small sample. Participant bias? Researcher bias?

Service Implications Advantages of Time-limited treatment: Can be helpful in reducing dependency, especially if good-enough attachment relationship. Focus on endings at the beginning – secure base provided by CC can enable greater exploration/development of new skills. Focus on patients’ strengths.

Service Implications Disadvantages: Time-limited treatment can set up unhelpful, repetitive pattern of disrupted attachments: “Some people need more time than others”. Conflicting policies eg CPA v Time limited: CCs are the filling in the sandwich lunch of insatiable systems! Remote working reduces availability of clinicians’ physical secure base (represents professional internal secure base?)

Service Implications Erosion of ‘thinking time’ due to ‘feeding the machine, results in increased staff anxiety/stress: a reduced capacity by nurses to think and reflect on their own mental states and those of their patients was implied in the recent Francis Report on Mid Staffordshire NHS Trust This impacts on clinician-patient relationship and increases attachment-seeking behaviours (in both). Direct impact on discharge process ie less referrals?

Service Implications As the Trust moves towards increased remote working for clinicians, along with greater demands to meet targets set by the Department of Health and the NHS, the organisation may be unconsciously militating against the idea of the psychologically secure base of the CMHT and, by implication, undermining the healthy discharge of BPD patients. Staff who are stressed and anxious are unlikely to succeed in providing such attachments, unless they themselves have a secure base to ‘hold’ them (Haigh, 2004; Nolan, 2013).

Service Implications “The enemies of compassionate organisations are individuals who are emotionally under-resourced; place too little emphasis on self-understanding… [along with organisations’] over-emphasis on targets… ” (Nolan, 2013, p. 181). Staff thrive in a good working environment which includes attachment, containment, communication, involvement and agency - components of a psychologically secure base. (Haigh, 2004)

Service Implications Understanding the concept of the secure base can help clinicians and organisations recognize and appreciate the stresses that CCs and patients experience when faced with significant life changes, especially the process of discharge. Endings need to be done mindfully. Let’s give CCs more time to think!

Summary Attachment is an essential psychological building block for every human being. Attachment is not a phase we grow out of; nor is it tangible or necessarily a conscious experience. It is part of being human. Integrating attachment theory into current scientific understanding could enhance both clinicians’ understanding of, and the development of improved services for, BPD patients. Healthy attachment naturally progresses to healthy detachment, thus enabling patients to leave services behind.

Recommendations Reflective space: needs to be protected and valued equally to other aspects of the organisation. Teaching basics of attachment theory (and how this relates to BPD patients) to all clinicians in wider organisation. Understanding our own attachment-seeking behaviours as well as those of our patients

And finally…… For a copy of the full dissertation and results, please me: A last note………