Good Practice, Evidence Base and Implementation Issues: Personality Disorder. Prof Anthony W Bateman SMI Stake Holder Event

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1 Good Practice, Evidence Base and Implementation Issues: Personality Disorder Prof Anthony W Bateman SMI Stake Holder Event

2 Treatment for Borderline Personality Disorder A range of structured treatment programmes for BPD shown to be effective in RCTs (DBT, TFP, SFT, CAT, CBT, MBT) but these are superior mostly against TAU or inadequate comparison AND /OR high maintenance (cost) specialist interventions (extensive training and continued supervision) Meaningful trial needs to meet the following minimal criteria: comparison group receiving a structured treatment organised in a coherent treatment programme with equivalent supervision delivery of both treatments by professionals trained to the same level adequate statistical power to detect relatively small differences representative sample of clinically referred men and women with confirmed diagnosis of BPD and at high risk of suicide.

3 Psychotherapeutic Techniques de Groot, E., Verheul, R,. Trijsburg, R. (2008) An integrative perspective of psychotherapeutic treatment for borderline personality disorder. Journal of Personality Disorders Techniques MBT DBT TFP SFT CBT Psychoeducation Motivational Behavioural Cognitive Affective Interpersonal Psychodynamic Mindfulness Experiential Nonverbal

4 168 patients screened for eligibility MBT v SCM Consort Diagram IOP Study: Patient Recruitment Flow-Chart 34 patients excluded: 10 did not attend interview 12 declined participation 5 did not meet inclusion criteria 4 met exclusion criteria 3 were uncontactable 134 randomized 71 patients allocated to MBT-OP 63 patients allocated to SCM-OP 6 attended < 6 months 13 attended 6-12 months 10 attended < 6 months 6 attended 6-12 months 52 completed treatment 47 completed treatment 71 included in analyses 63 included in analyses

5 DBT versus General Psychiatric Management McMain, S., Links, P. et al Amer J Psychiatry patients diagnosed with borderline personality disorder were randomly assigned to receive 1 year of dialectical behavior therapy or general psychiatric management. Primary outcome measures were frequency and severity of suicidal and non-suicidal self-harm episodes. Results: Both groups showed improvement on the majority of clinical outcome measures after 1 year of treatment Both groups had a reduction in general health care utilization borderline personality disorder symptoms symptom distress, depression, anger interpersonal functioning. No significant differences across any outcomes were found between groups.

6 Generalist Treatments

7 Good Clinical Care Developed by Chanen et al (2008, 2009) CBT informed using a problem-solving paradigm as the core treatment intervention plus high value placed on effective organizational structures CBT trained clinical psychologists provided both the therapy and case management, all clients had a psychiatrist on team; all clients discussed weekly in team meeting Frequency of contact: Therapy sessions flexible up to a maximum of 24 sessions over six months (Mean-11, 50 minute sessions). In addition flexible case management sessions highlighting that intervention involves more than just formal psychotherapy (Chanen et al, 2008).

8 Supportive Psychotherapy Developed by Ann Appelbaum and Monica Carsky, drawn partially from previous work by Larry Rockland (1992) Strong emphasis on establishing and maintaining a comfortable relaxed therapy relationship with minimal use of interpretation Provides emotional support-advice on the daily problems facing the patient The fundamental vehicle of change is seen as the client identifying with the clinician s consistent attitudes towards them of benevolence, interest, kindness and nonjudgmental acceptance (Appelbaum, 2006). Frequency of sessions: Weekly supplemented with additional sessions as required

9 General Psychiatric Management Developed by Paul Links, Yvonne Bergmans, Jon Novick, Jeannette LeGris Based on and compliant with the 2001 American Psychiatric Association (APA) guidelines Treatment: Psychodynamically informed psychotherapy, case management and symptom targeted medication as adjunct using APA algorithm. Psychodynamic approach drawn from Gunderson (2001) emphasizing early attachment and disturbed attachment as a primary deficit. Therapy provided by clinicians with expertise, aptitude and interest (McMain et al, 2009) in the treatment of BPD (66% were psychiatrists) Frequency of sessions: one hour weekly

10 Structured Clinical Management Developed by Anthony Bateman, Peter Fonagy, Rory Bolton, Eric Karas at Halliwick Unit, St Ann s Hospital, London Treatment based on a counselling model closest to a supportive approach with case management, advocacy support, problem solving and included crisis plans, medication review and assertive follow-up if sessions missed Medication as an adjunct as per 2001 American Psychiatric Association (APA) guidelines and National Institute for Health and Excellence (NICE) UK government guidelines Treatment provided by non-specialist practitioners Frequency of sessions: Regular weekly individual and group sessions

11 Expert consensus

12 Experts Bateman and Fonagy (2000) Well structured treatment Treatment theory that is coherent Clear focus of treatment goals Active clinician Encouragement of a powerful attached therapy relationship Monitoring of treatment and clinician competencies Integration with other services.

13 Experts Gunderson and Links (2008) Structure; Contracting Monitoring clinician competencies and practice Client encouraged to link emotions and actions BPD specific clinician training and experience Active and involved clinician clinician qualities of good affect tolerance, empathy and self-sufficiency Attending to clinician counter-transference clinician supervision and/or consultation.

14 Experts Paris (2008) Therapy alliance Empathy Problem solving Structure Validation Encouraging client self-observation.

15 Experts Zanarini (2008) Lessening client pain Judicious use of validation Clarifications of bilateral inaccurate communications Future orientation that values life outside of therapy as a major forum for repair and recovery.

16 Conclusions

17 Summary Commonalities of effective treatment Accurate diagnosis Starting therapeutic stance Clinicians who choose to work with people with BPD Clinicians who are enthusiastic, hopeful and welcoming in working with people with PD Organization willingness Therapy relationship Therapeutic alliance Alliance as Treatment goal consensus Collaborative agreement on how to achieve these goals Empathy and validation

18 Summary Treatment model features Treatment that is well structured Active clinicians as structure Regularity of scheduled sessions as structure for the adult treatments Clinician monitoring and quality assurance Treatment model that One believes in Has clear focus Is theoretically principled and coherent

19 Summary Treatment Model Features Supervision/team Self-observation clinician Patient Skills in managing suicidality including balanced response to suicidality Identifying emotions Analysis of events leading up to and following events, especially sentinel events

20 Summary Most people with PD are and will always be treated within generalist rather than specialist settings Generalist treatments are based on skills and knowledge that mostly already exist in the repertoire of quality skilled generalist mental health clinicians, thereby requiring relatively modest adaptations rather than learning new techniques, and thereby requiring only modest training and supervision to be effective All four of the generalist treatments shown to be effective are strong on feasibility and utility; having taken place in real world clinical contexts, and designed to deliver standardized high-quality treatments achievable in economically developed countries

21 Summary There will always be important places for both generalist and specialist treatments A hopeful future research will guide decision-making at the outset of treatment to best match client severity, stage of change, resources and other client, clinician, organization and model characteristics

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