An Integrative Relational Step-Down Model of Care: The Project Air Strategy for Personality Disorders

Personality disorders, particularly borderline disorders, represent a significant treatment challenge for mental health services, in part because of the severity of the disorder, but also because of the high prevalence. Approximately one quarter of emergency mental health presentations and inpatient admissions are people with personality disorders. Evidence-based treatment for Borderline Personality Disorder is psychological therapy based on clinical guidelines, yet the prevalence of the disorder presents a challenge to specialist intervention programs that typically are unable to meet the high clinical demand. Similarly, the particular nature of the disorder can challenge the capacity of teams to maintain compassion towards clients, given the particular features of the disorder that can induce negative countertransference responses. An integrative step-down whole of service approach, based on a relational model, is described; this focuses on both the intrapsychic difficulties of the individual and broader interpersonal conflicts that can challenge treatment teams, families and carers, and the broader community. The model includes the whole system supporting the client in the strategy. The Project Air Strategy for Personality Disorders outlines approaches to clinical leadership and service redesign, targeted training, the provision of brief and longer term treatments, rapid access to psychological assistance, support for families and carers, and better access to information and clinical resources to provide a more hopeful and integrated treatment. 34 Globally, the treatment of personality disorders, particularly Borderline Personality Disorder (BPD), in mental health services is under significant pressure due to their high prevalence and the cost and burden of treatment. People with personality disorders present in significant numbers to Emergency Departments as well as to Mental Health and Drug and Alcohol services. An analysis of data from one large mental health service that are reasonably representative of the State of New South Wales (NSW), Australia, demonstrates that 26% of emergency presentations and 25% of inpatient admissions to mental health beds were for patients classified, using ICD-10, as having personality disorders and related conditions, as shown in Figure 1. Figure 1. Percentage of all mental health emergency department presentations (Fig A) and inpatient admissions (Fig B) based on ICD10 classification of diseases coding (affective disorders, psychotic disorders, personality disorders, drug and substance use disorders, and other disorders). Data are for four years from Nov 2008–Nov 2012, Illawarra Shoalhaven Local Health District (total sample N = 6338).