The purpose of the EMERALD Study
The EMERALD Study was aimed at evaluating the introduction of innovative practice at the high support ward for women diagnosed as having Borderline Personality Disorder or Personality Disorder.
Study Summary
Women diagnosed as having Borderline Personality Disorder (BPD) and Personality Disorder (PD) are often hospitalised following a compulsory order, due to their high level of self-harm. The article focuses on the evaluation of innovative intervention methods which include dialectical behaviour therapy (DBT) and shared decision making (SDM) introduced to a high support Cygnet hospital inpatient ward for women with BPD / PD (Such wards were formerly known as closed wards). The EMERALD model built on learning from Springbank, a high support inpatient ward for the same population in Cambridge, where in 2016 the regime changed successfully by introducing Dialectical Behavioural Therapy and Shared Decision-Making as a basis for patient care.
The evaluation reported in the article includes individualised photovoice undertaken by the inpatients, followed by interviewing them concerning changes taking place in their lives on the ward. In parallel we received providers’ reports about every three months.
The ward enabled a large number of activities, including visits in small groups to facilities in the nearby town, and encouraged maintaining family visits to the hospital and to one’s home. It also promoted mutuality through positive peer relationships on the ward, as a key to building a sense of self identity and a life outside hospital.
Promoting a sense of self-responsibility may be difficult for people who experience BPD/PD. DBT and shared-decision-making enhance its development by promoting an enabling hospital environment which focuses on meaningful activities and forward-focused transition planning back to the community.
The cumulative evidence base suggests that indeed the Emerald model has considerable implications for future practice and has the potential to provide an effective frame for hospital-based care delivery for women with PD/BPD. The small sample means that while the evidence base is promising, it is limited, and hence further research would need to be conducted to consider its overall effectiveness.
The Springbank model and the Haven Project
The innovative practices followed the examples of the Spingbank Ward which is based a Fullburn Hospital in Cambridge, and the Haven Project which was based in Colchester.
Springbank, a ward for women diagnosed as having BPD or PD, introduced co-production between service users and service providers. It revoked their compulsory admission upon arrival in order to encourage self- responsibility, it enabled them to leave the ward and come back for specified reasons and time, and it introduced the DBT (Dialectical Behaviour Therapy). The DBT was created by Marsha Linehan in the US, who experienced herself BPD and hospitalisation. The DBT, which combines increased self- responsibility with mindfulness and compassion, has proven its effectiveness in a number of studies.
Springbank has been successful in preventing the need for either isolation or major tranquilisation while reducing self-harm attempts by the women patients since 2019.
The Haven project was a community-based project for women experiencing BPD or PD, which had a small unit in which they could stay for three weeks with professional support, and a number of activities in the lovely house they had in Colchester. The activities included meetings, gardening, research, being trained to become trainers in other trusts. The women diagnosed as having BPD or PD were part of the management of the project. The project reduced significantly the need for further hospitalisation. It was funded by the local NHS mental health trust between 2004 to 2013. It has led to a number of articles and books.