Competencies for working with people with personality disorder. Prof Tony Roth

Transcription

1 Competencies for working with people with personality disorder Prof Tony Roth

2 Thinking about competence no one is going to disagree about the merits of competence

3 Where s the evidence for competence? Webb, DeRubeis and Barber (2010) meta-analysis of studies which link adherence and/or competence to outcome included wide range of studies: range of therapeutic approaches range of conditions/presentations

4 Where s the evidence for competence? Webb, DeRubeis and Barber (2010) adherence-outcome (32 studies) range of effect sizes to 0.47 mean weighted effect size 0.02 competence outcome (17 studies) range of effect sizes to 0.73 mean weighted effect size 0.07 BUT significant heterogeneity across studies

5 Where s the evidence for competence? need to acknowledge that evidence is mixed some studies link competence to outcome, some don t we don t understand why evidence is so mixed methodological issues may be relevant worth looking at individual studies that indicate links between adherence/competence and outcome:

6 Alliance rupture and repair in CAT for Borderline PD Bennett, Parry & Ryle (2006) examined how therapists managed threats to the therapeutic alliance selected from therapies with known long-term outcomes 4 good and 2 poor outcome cases task analysis used to build a model of rupture resolution initial model based on expert opinion (best guess) see if this fits with the way therapists actually behave update the model and see if this is a closer fit (etc)

7 Acknowledgement Exploration cycling between stages is expected Linking & explanation Negotiation Consensus Understanding and assimilating warded-off feelings Further exploration Changes to patterns/ aims Closure

8 Alliance rupture resolution and outcome good outcome cases poor outcome cases did therapist recognise rupture? 84% 34% resolved in manner consonant with model? rupture unresolved? 87% 23% 13% 77%

9 Rupture resolution CAT for adolescents with BPD (Daly et al. 2010) large clinical trial of CAT for adolescents selected sessions containing alliance ruptures subsample of 5 clients with known outcomes used Bennett et al. model to examine: how ruptures were managed whether this links to outcome

10 Rupture resolution in adolescents with BPD (Daly et al. 2010) followed the model? > 3 stages (10 ruptures) < 3 stages (8 ruptures) Significant improvement No significant improvement repaired the rupture? Rupture resolved (10 ruptures) Rupture unresolved (8 ruptures) Significant improvement No significant improvement

11 Therapist competence and practice assignment in CBT Ryum et al. (2010) 25 clients with Cluster C PD (avoidant/anxious) session recordings rated for therapist competence in assigning practice assignments controlling for initial symptom improvement: greater therapist competence associated with better outcome

12 CBT-PD Quality (and quantity) of therapy Norrie et al (2013) contrast of CBT to treatment as usual 38 patients with BPD allocated to CBTpd statistical modelling used to estimate impact of competence on number of suicidal acts suicidal acts less likely with higher levels of competence greatest impact with a combination of greater competence and more therapy

13 Impact of competence on effectiveness of parenting programmes Scott, Carby & Rendu (2008) 94 children, aged 3-8 years referred with antisocial behaviour 13 therapists mix of professions group intervention each run by 2 therapists

14 Skill and outcome post-treatment antisocial behaviour predicted by the therapists skill in implementing specific parenting interventions effect is independent of: pre-treatment antisocial behaviour/ severity quality of alliance with parents

15 child aggression improvement Quality, quality, quality Child (Scott, outcome Carby and and professional Rendu 2007) skill Scott, Carby and Rendu (2008) lowest lower third middle third upper third Skill of professional in delivering programme

16 Supervision and training importance of training and supervision as a way of boosting competence is widely acknowledged but the sentiment is not always acted on

17 Extent of supervision/ training in evidence-based therapies Roth, Turner and Pilling (2010) our hypothesis: training and supervision is central to trial designs but because this is poorly reported in papers it is easily overlooked reviewed 27 reports of high-impact trials of CBT what training and supervision was offered in each trial? often needed to contact the researchers and/ or consult additional papers to find out!

18 What we found training and supervision: is central to trial designs is often poorly reported therapists in clinical trials are: carefully selected carefully trained carefully supervised carefully monitored

19 Implications for transporting therapies evidence-based interventions are more than a manual more accurately, an evidence-based intervention comprises: manual training in the approach (outcomes oriented) supervision of practice

20 Framework development: Some principles

21 Developing the frameworks : Principles: Retaining the role of clinical judgment competence frameworks are intended to be indicative, not prescriptive they spell-out how something is done they indicate what would be helpful but they don t prescribe it is for therapists to choose how they implement competences: whether when how

22 Methodology: An evidence-based approach we want to identify the competences most likely to produce effective delivery of an intervention these competences: are those used by therapists in research trials which demonstrate efficacy are described in the manuals used in these research trials yields information about best practice

23 Methodology a) find the right trials identify trials of interventions, based on: reviews of the literature (e.g. NICE and SIGN) oversight from an Expert Reference Group b) find the manuals associated with these trials locate the manuals used in these trials (both published and unpublished) c) extract the competences translate ideas into actions

24 Organising competence lists undifferentiated competence lists are rarely helpful an architecture is needed to help users navigate through the lists reflected in competence maps maps reflect the way that therapist s think about their practice

25 Usual structure of competence maps underpinning knowledge and professional skills common to all approaches assessment and formulation skills applicable across approaches packages of interventions for which there is evidence of efficacy metacompetences

26 Supervision competence framework complements modality frameworks developed as part of IAPT offers guidance on standards for supervision (as far as possible) evidence-based sets out: a generic model of supervision of all psychological therapies also specifies modality-supervision skills: CBT psychodynamic IPT systemic humanistic

27 Competence framework for individuals with personality disorder

28 Expert Reference Group co-chaired with Prof Steve Pilling Carole Allen Prof Anthony Bateman Wyn Bolton Marco Chiesa Prof Susan Clarke Prof Kate Davidson Christine Dunkley Ian Kerr Prof Tom Lynch Mary McMurran Susan Mizen Tom Mullen Prof Glenys Parry Steve Pearce Alex Stirzaker Michaela Swales Heather Wood

29 Management of co-existing issues (depression, anxiety, substance misuse, trauma, eating disorders, learning disabilities, psychosis, other personality disorders) Therapeutic stance, values and assumptions Core competences for work with individuals with Personality Disorder (PD) Generic Therapeutic Competences Assessment & formulation General clinical care Specific psychological therapies Meta competences Knowledge of the range of presenting and diagnostic issues in individuals with PD Ethical and legal issues Knowledge of legal frameworks relating to working with individuals with PD Knowledge of, and ability to operate within, professional and ethical guidelines Knowledge of, and ability to work with, issues of confidentiality and consent Knowledge of, and ability to assess, capacity Knowledge of models of intervention, and their employment in practice Ability to collaboratively engage clients with the treatment model & options Ability to foster and maintain a good therapeutic alliance and grasp the client s perspective and world view Ability to understand and respond to emotional content of sessions Assessment Ability to undertake a comprehensive assessment Ability to assess the person s functioning within multiple systems Ability to undertake risk assessment and management Formulation and planning Generic structured clinical care Psychoeducation and Problem Solving programmes: STEPPS programme PEPS programme Consulting to individuals and teams regarding clients with personality disorder CBT for Personality Disorder Schema-focused CBT Dialectical Behaviour Therapy Mentalisation-Based Therapy Transference Focused Psychotherapy Interpersonal Group Psychotherapy Metacompetences for work with people with PD Professional skills and values Ability to work with difference Ability to manage endings and service transitions Ability to develop a formulation Cognitive Analytic Therapy Ability to operate within and across organisations Ability to make use of measures (including monitoring of outcomes) Ability to feedback the results of assessment and agree an intervention plan with all relevant parties Ability to engage and work with families and significant others Ability to respond to and manage crises Ability to co-ordinate casework or intervention across different agencies and/or individuals Knowledge of psychopharmacology in individuals with Personality Disorder Ability to deliver group-based interventions Knowledge of common physical health problems in individuals with PD, and their management Ability to make use of supervision and training

30 Core competences knowledge of range of presenting issues in PD knowledge of ethical & legal issues working with difference working within and across organisations engaging families and significant others basic knowledge of pharmacology for PD o legal frameworks (e.g. Mental Health Act) o professional & ethical guidelines o working with issues of confidentiality and consent o capacity basic knowledge of physical health problems in people with PD

31 Core competences knowledge of presenting issues Therapist stance and values ethical & legal issues professional issues (work with difference working with and within organisations) working with families/ carers knowledge of pharmacology knowledge of physical health problems

32 Therapeutic stance, therapist values and therapist style Therapist stance - e.g.: committed to collaboration ensuring the client has a sense of direction and control committed to understanding the client s experience from a developmental and psychological perspective

33 Therapeutic stance, therapist values and therapist style Therapist values - e.g.: able to work with the person in their family/ social and cultural context able to recognise and focus on strengths and resources able to reflect on own emotional and behavioural responses to the client

34 Therapeutic stance, therapist values and therapist style Therapist style - e.g.: affording the client the experience of being understood (and so demonstrating that their perspective is being taken seriously) focused on maintaining mutual respect between client and therapist recognising and addressing the risk of clients feeling disempowered

35 Core competences ethical & legal issues professional issues (work with difference working with and within organisations) working with families/ carers knowledge of pharmacology knowledge of physical health problems Therapist stance and values Generic therapy skills knowledge of models of intervention ability to engage clients ability to build and maintain an alliance ability to understand and respond to emotional content ability to manage endings ability to use measures ability to make use of supervision

36 Core competences ethical & legal issues professional issues (work with difference working with and within organisations) Therapist stance and values generic therapy skills basic therapy skills and knowledge engagement Assessment & formulation comprehensive assessment assess functioning within multiple systems risk assessment & management working with families/ carers knowledge of pharmacology knowledge of physical health problems assessment alliance building managing emotional content develop formulation feedback outcomes from assessment and agree an intervention plan with all relevant parties co-ordinate within and across teams

37 How frameworks guide a specific (stand-alone) intervention sets out competences in a structured and logical order set out theory / basic principles/ therapeutic stance show how to put principles into action across each phase of the intervention: engagement and assessment formulation and planning carrying out the intervention completing the intervention

38 Core competences ethical & legal issues professional issues (work with difference working with and within organisations) working with families/ carers knowledge of pharmacology knowledge of physical health problems Therapist stance and values generic therapy skills basic therapy skills and knowledge engagement assessment alliance building managing emotional content Assessment & formulation c prehensive assessment assessment functioning in multiple systems risk assessment develop formulation & intervention plan f/back assessment co-ordinate casework General clinical care Generic structured clinical care Psychoeducation and problem solving (PEPS and STEPPS) Consulting to individuals and teams regarding individuals with PD

39 Core competences ethical & legal issues professional issues (work with difference working with and within organisations) working with families/ carers knowledge of pharmacology knowledge of physical health problems Therapist stance and values generic therapy skills basic therapy skills and knowledg e engagem ent assessm ent alliance building managing emotional content Assessment & formulation c prehensive assessment assessment functioning in multiple systems risk assessment develop formulation & intervention plan f/back assessment co-ordinate casework Generic Clinical Care Specific psychological therapies CBT for PD Schema-focused CBT for PD Dialectical Behaviour Therapy (DBT) Mentalisation-Based Therapy (MBT) Transference Focused Psychotherapy Interpersonal Group Psychotherapy Cognitive Analytic Therapy (CAT)

40 Core competences ethical & legal issues professional issues (work with difference working with and within organisations) working with families/ carers knowledge of pharmacology knowledge of physical health problems Therapist stance and values generic therapy skills basic therapy skills and knowledg e engagem ent assessm ent alliance building managing emotional content Assessment & formulation c prehensive assessment assessment functioning in multiple systems risk assessment develop formulation & intervention plan f/back assessment co-ordinate casework Generic Clinical Care Specific Psychological therapies CBT for PD Schemafocused CBT for PD Mentalisation- Based Therapy Transference Focused Psychotherapy Interpersonal Group Psychotherapy Cognitive Analytic Therapy working with coexisting issues: depression, anxiety, substance misuse, personality disorder, trauma, learning disability, psychosis, other personality disorders

41 co-existing issues Core competences ethical & legal issues professional issues (work with difference working with and within organisations) Therapist stance and values generic therapy skills basic therapy skills and knowledg e engagem ent Assessment & formulation c prehensive assessment assessment functioning in multiple systems risk assessment Generic Clinical Care Specific Psychological therapies CBT for PD Schemafocused CBT for PD Mentalisation- Based Therapy Metacompetences working with families/ carers knowledge of pharmacology knowledge of physical health problems assessm ent alliance building managing emotional content develop formulation & intervention plan f/back assessment co-ordinate casework Transference Focused Psychotherapy Interpersonal Group Psychotherapy Cognitive Analytic Therapy

42 Common features across interventions structure, consistency and validation able to work with and across teams (professional and organisational competences) good relational capacities and capacity for alliance building and for building collaboration capacity to implement and maintain care that is structured/ boundaried and consistent capacity to assess, monitor and manage risk

43 Using the framework map of competences represents: a curriculum for developing training programmes a benchmark for current trainings a procedure for identifying competent practice an agenda for supervision

44 Using the framework a way of linking the evidence-base to practice identifying interventions with current evidence for efficacy setting standards for competence setting standards for training a resource for planning psychological intervention services

45 all materials can be downloaded from