The development and testing of joint crisis plans for people with borderline personality disorder: a feasibility study
Background: This dissertation focuses on effective crisis management for people with borderline personality disorder. The dissertation reports a single-blind randomised controlled trial investigating the effectiveness of joint crisis plans (JCPs; a type of advance statement regarding future treatment preferences for people with mental health problems) compared with treatment as usual for community-dwelling adults meeting research diagnostic criteria for borderline personality disorder. Methods: During the developmental phase, three focus groups were held with mental health service users, clinicians and academics in order to adapt an existing joint crisis plan template, the utility of which was then tested in a small (N=13) pilot study. Participants in the resulting larger trial were recruited from community mental health teams in south London and randomised to receive either treatment as usual (TAU) or a joint crisis plan plus treatment as usual. Participants were assessed on a number of variables prior to randomisation and again at six-month follow-up and these included self-harm, engagement with services, therapeutic alliance and health-related quality of life. Results: Eighty-eight adults out of the 133 referred were eligible and consented before being randomised to receive a joint crisis plan in addition to treatment as usual (n = 46) or TAU alone (n = 42). This represented approximately 75% of the target sample size. Follow-up data were collected on 73 (83.0%) participants. A modified intention-to-treat analysis revealed no significant differences in the 6 proportion of participants who reported self-harming (odds ratio (OR) = 1.9, 95% CI: 0.53–6.5, P=0.33) or the frequency of self-harming behaviour (rate ratio (RR) = 0.74, 95% CI: 0.34–1.63, P=0.46) between the two groups at follow-up. No significant differences were observed between the two groups on any of the secondary outcome measures. JCPs were viewed favourably by participants, who reported referring to their JCPs both during and between crises. Approximately half of participants (47%) reported a greater sense of control over their mental health problems and an improved relationship with their mental health team when using a JCP. Conclusions: This dissertation expands the knowledge about effective crisis management for people with borderline personality disorder, a group who have traditionally been alienated from mainstream mental health services and are still perceived to be difficult to help. The study showed that it is possible to recruit and retain adult service users with borderline personality disorder to a trial of joint crisis plans. Although the intervention was not clinically effective, the findings suggest that the brief intervention was perceived as helpful to participants with borderline personality disorder. Future research - including a definitive trial with a more comprehensive process analysis - may provide further information about the potential benefits of JCPs to people with borderline personality disorder.
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