Transcript Local context - Scottish Personality Disorder Network

NHS Grampian development of
MBT interventions for people with
BPD
Dr Linda Treliving,
Consultant psychiatrist in psychotherapy,
Head of GSPS, Chair of SPDN
Local context
•
NHS Grampian Psychological therapies
steering group,
– a multidisciplinary committee
– which advises to the Clinical Management
Board
– has a strategic overview of the development
of psychological therapies for NHS Grampian.
Local context
GSPS service provision is focussed on Tier 3
and 4 complexity of patients.
– Tier 3 is defined as patients with complex
mental health problems, most likely long
standing and recurrent, significantly impairing
quality of life and daily functioning
– Tier 4 patients have severe mental health
problems with significant impairment of
functioning
Mental Health in Scotland
A Guide to delivering evidence-based Psychological
Therapies in Scotland
“The Matrix”
Borderline personality disorder
Level of
Severit
y
Level of service
Intensity of
intervention
What intervention?
Recommendation
Severe
Secondary/
Specialist
Outpatient
High
CBT for personality disorders
Individual therapy (30 sessions over 1
year)
A2
Schema Focused CBT
Twice weekly over 3 years
STEPPS -Systems Training for Emotional
Predictability and Problem Solving
(CBT approach) 20 group sessions
group + usual treatment
Transference-focused psychotherapy
(twice weekly sessions plus weekly
supportive treatment over one
year)
Dialectical Behaviour Therapy (DBT)
Involves group + individual therapy +
telephone support (Several times
per week over one year)
Severe
Secondary/
Specialist
Partial Day
Hospital
High
Multi-modal
Mentalization based Day Hospital
(Several times per week over 3 years)
A3
A6
A4
A1
A5
General approach and management 1.
• establish and maintain the therapeutic
alliance while managing risk
• maintain flexibility
• establish conditions to make the patient
safe
General approach and management 2
• tolerate intense anger, aggression and
hate
• promote reflection
• set necessary limits
General approach and management 3
• understand the dynamics and monitor
relationships between service user and staff
thereby reducing the potential for splitting
• monitor countertransference feelings to
understand the patients communication
and difficulties
• use a consistent approach.
• The chaos and disorder that characterises
the internal world of the individual with
BPD can impact on attempts of the
professionals and agencies involved to
engage effectively.
Effective ingredients of
treatment (Bateman and Tyrer)
1. to be well structured;
2. to devote considerable effort to enhancing
compliance;
3. to have a clear focus,
4. to be theoretically highly coherent to both
therapist and patient,
5. to be relatively long term;
6. to encourage a powerful attachment relationship
between therapist and patient,
7. to be well integrated with other services
available to the patient.
Grampian Specialist
Psychotherapy Service
• psycho dynamically based out patient service
• offers assessment, consultation and treatment
to patients in Grampian ( pop.540,000).
• 2 centres providing this service are based in
Aberdeen and Elgin.
• offers multidisciplinary training and supervision
at undergraduate and post graduate level
Process of referral to
Psychotherapy Department,
Aberdeen.
Referral
•
Referrals are accepted from all Community mental
health teams.(250 -300 per year)
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Referrals are discussed at the weekly referral meeting
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Decisions are made to either progress the referral,
discuss with referrer or make further enquiries.
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Eligibility criteria
Aged 18 years upwards
Males and females
Referral accepted
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Patient sent an
SCL 90 *
Department questionnaire ( biographical
details)
SAE.
On return of the questionnaire the patient
is sent an assessment appointment.
Symptom Check List 90, (SCL 90)
Derogatis et al
90-item self-report checklist measures psychological
distress
Symptom measures of :
Somatization
Obsessive-compulsive
Interpersonal sensitivity
Depression
Anxiety
Hostility
Phobic anxiety
Paranoid ideation
Psychoticism
SCL 90 Global Indices
Global severity index : (GSI)
Number of symptoms reported combined with the
intensity of perceived distress – best single indicator of
current level of distress
Positive symptom distress index: (PSDI)
Average level for the symptoms that were endorsed –
measure of symptom intensity
Positive symptom total: (PST)
Number of symptoms endorsed (regardless of level
of distress) - a measure of symptom breadth
CSA Men Pre & Post Treatment
65
60
55
pre-treatment
post-treatment
50
45
40
SOM
O-C
IPS DEP ANX HOS PHANX PARID PSY GSI
PSDI PST
Referral accepted
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Patient sent an
SCL 90
Department questionnaire ( biographical
details)
SAE.
On return of the questionnaire the patient
is sent an assessment appointment.
Assessment
• All clinical staff participate in the
assessment process and attend a
supervision group
• Patients attending the department for first
assessment are asked to complete a
PDQ4 ( self report questionnaire for
personality disorder) and a CTQ ( self
report questionnaire on early trauma).
PDQ 4
• PDQ-4 is designed to assess 12
personality disorders.
• http://www.pdq4.com
PDQ 4
• The total PDQ-4 score is an index of
overall personality disturbance.
• Controls generally score 20 or less.
• Patients in therapy generally score
between 20-30.
• A total score of 30 or more indicates a
substantial likelihood that the patient has
significant personality disturbance
PDQ 4
The Childhood Trauma Questionnaire
(CTQ)
The CTQ screens for 5 types of maltreatment:
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Emotional Abuse
Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
Assessment
• The assessor can refer into any component of
the therapeutic programme where the patient is
accepted without further assessment but offered
an introductory appointment with therapist.
• Assessment letters to referrers are structured
under specific headings including
psychodynamic formulation, risk assessment
and management suggestions.
Standard 14: There is a record of
a diagnosis or diagnoses
Criterion 14 a The care record shows:
• the diagnosis or diagnoses
• information on how the diagnosis or
diagnoses was reached following evidence
based guidelines or established diagnostic
criteria where available.
• confirmation that the diagnosis or diagnoses
has been explained to the service user and
informal carer.
• post-diagnosis support is offered.
The Therapeutic programme
a. Mentalization based therapy for
Borderline personality disorder.
b. Group therapy
c. Individual
Brief therapy
Longer term therapy (1-2 years))
a. Mentalization based therapy for
Borderline personality disorder
• 1 day programme for 6 month therapy.
• Intensive Outpatient programme.
Hub day
• 10 patients start each 3 months,
• 2 groups are always running at any one
time.
• retains the broadest principles of the
therapeutic community.
• whole day is considered a therapeutic
intervention, including lunch and social
time
Hub day timetable
Clients
Staff
10 am arrive
10.15 Community meeting
10.45 Morning group
staff meeting
Community meeting
Morning group
12.15
1
1.30
3 pm
lunch
staff meeting
Mentalization group
supervision
4
lunch
Mentalization group
home
Morning group
Psycho
education
1
2
3
4
5
SCID
6
7
8
9
10
11
Psychodrama
psychotherapy
12
13
14
15
16
17
18
19
20
21
22
23
24
Psychoeducation
• conducted by 2 clinical staff
• covering aspects of
mentalization principles
crisis plans,
managing self harm
managing emotions
Structured Clinical Interview for
DSM IV diagnosis II (SCID)
• led by 2 clinical staff
• conducted as a group
• evaluating self and using others
perspectives of self to consider DSM IV
axis 2 criteria.
Psychodrama psychotherapy
• conducted by trained and accredited
psychodrama psychotherapist and co facilitated
by other member of clinical team.
• introduces patients to the important mentalising
task of role reversal.
• may be used as a medium to do some more
focused therapeutic work.
• forum for patients to consider what they might do
once the Hub Day Programme ends.
Mentalization based therapy
• group conducted by a Mentalization
based therapist and co facilitated by other
member of clinical team.
Staffing
Grade
LT
Cons
Sessions MBT level
in dept
8
therapist
PC
Cons
5
therapist
MK
8D
10
therapist
MF
8A
10
Skills trained
MC
7
5
Skills trained
EB
7
7
Skills trained
LC
7
10
Skills trained
MBT Intensive outpatient
programme
• Once weekly individual MBT sessions of
50 minutes
• Once weekly group MBT sessions of 1 ½
hours.
• Therapists for group and individual meet
each week for supervision/discussion.
MBT Intensive outpatient
programme
• 8 patients
• Slow open group
• 18 months attendance time frame
• expected to attend individual and group
sessions
Mentalization based therapy
for BPD
Mentalizing:
A new word for an ancient concept
Implicitly and explicitly interpreting the actions
of oneself and other as meaningful on the
basis of intentional mental states
(e.g., desires, needs, feelings, beliefs, &
reasons)
MBT perspective
BPD is conceived of as a disorder in the self
structure brought about through
environmentally induced distortion of
psychological functioning, which decouples
key mental process necessary for
interpersonal and social function
The mediator between the genotype and the
phenotype is the attachment process
Bulletin of the Menninger Clinic (2003) ,
67,3:pp187-211
Mentalization based therapy
• Evidence based intervention for BPD
• MBT is delivered by generic mental health
professionals
• MBT is a manualised treatment
• Skills training delivered over 3 days
• Continuing supervision by
psychodynamically informed trainer.
Internalised persecutory sense of
self
……when alone feels unsafe and vulnerable
because of the proximity of a torturing and
destructive representation from which he or
she cannot escape because it is
experienced from within the self.
The result?
Patients with BPD react in desperate
manner to changes in relationships with
clinging, apparent aggression, cries of
abandonment, refusal to separate and
acts of self harm.
Suicide
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Suicide attempts are often aimed at
avoiding the possibility of abandonment: they
seem to be a last-ditch attempt at
reestablishing a relationship.
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The child’s experience may have been that
only something extreme would bring about
changes in the adults behavior and that the
caregiver used similar measures to influence
the child’s behavior.
Lack of Mentalisation
Stability is maintained through ;
- mental isolation not knowing,
- acts of aggression justified by perceived
threat,
- inaccurate representations of
interpersonal interactions,
- projective mechanisms that force
mental states onto the other and thus
prevent its genuine perception
Lack of Mentalisation
…adults who act violently, impulsively,
inconsistently and with emotional
volatility show reduced mentalising
capacities and are protecting an
unstable sense of self.
Treatment Strategies
The overall goals of treatment are to stabilise the
self-structure through
 the development of stable internal representations
 formation of a coherent sense of self,
 capacity to form secure relationships.
 identification and appropriate expression of affect.
Identification of affects
• To continually clarify and name feelings
• To understand the immediate precipitant of emotional
states within present circumstances
• To understand feelings in the context of previous and
present relationships
• To express feelings appropriately, adequately and
constructively within the context of a relationship to
the day hospital team, the individual session and
group therapy
• To understand the likely response of the team
member involved in an interaction
A Mentalising Stance
This is an ability to continually question the
internal mental states both within the patient
and the therapist
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Why is this patient saying this now?
Why is the patient behaving like this?
Why am I feeling as I do now?
What has happened recently in the therapy or
in our relationship that may justify the current
state?