TREATING ASPD IN THE COMMUNITY: FURTHERING THE PD OFFENDER STRATEGY. Jessica Yakeley Portman Clinic Tavistock and Portman NHS Foundation Trust

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1 TREATING ASPD IN THE COMMUNITY: FURTHERING THE PD OFFENDER STRATEGY Jessica Yakeley Portman Clinic Tavistock and Portman NHS Foundation Trust

2 Treating the untreatable?

3 Lack of evidence base for ASPD Only small number of studies have been conducted among people with ASPD Challenges of working with ASPD engagement, risk, substance misuse, co-morbidity Confusion over diagnostic criteria and conceptualisations of psychopathy versus ASPD Differences in defining and measuring outcome Focus on behavioural and symptomatic change rather than personality traits.

4 Cochrane review (2010) No study reported change in any antisocial behaviour Insufficient trial evidence to justify any psychological intervention for adults with ASPD Further research is urgently needed for this prevalent and costly condition

5 Why MBT?

6 Why MBT? Psychodynamic treatment developed by Bateman and Fonagy for Borderline Personality Disorder, shown to be effective in trials Mentalization model based on attachment theory Increasing evidence that a sub-group of ASPD is a disorder of attachment, particularly those who are less psychopathic Ability to mentalize protects against violence

7 Why MBT? Trials of MBT for BPD have included patients with ASPD. In a trial comparing MBT with structured clinical management (SCM) which included problem solving and social skills, MBT was found to be more effective than SCM in patients with ASPD for reduction in hospital admissions, self-harm and suicide incidents and use of psychotropic medication. However, effectiveness of both was reduced when compared with BPD patients without ASPD.

8 Research hypothesis and question MBT improves interpersonal functioning and capacity to think rather than act, resulting in improvements in frequency of violence, psychiatric symptoms and psychosocial function Does participation in an MBT-ASPD programme for 12 months result in A) reduction in aggressive acts B) improvement in indices of psychological functioning C) lower use of services

9 MBT-ASPD treatment programme Initial assessment including psycho-education Weekly group therapy (slow open group) plus monthly individual therapy for 12 months Crisis and risk management and psychiatric review Psychotropic medication only for co-morbid conditions, not ASPD per se Manualised treatment, video recording of sessions and supervision to ensure adherence to model

10 Pilot trial over 2 sites 2 out-patient PD services: Portman and St Anne s Men with ASPD referred for violence and aggression 1/3 dropped out after starting group Problems with engagement, attendance, minor boundary violations Those that complete treatment show decrease in selfreported aggression OAS-M and scores on Brief Symptom Inventory

11 Furthering the PD Offender Pathways Strategy Development of new MBT/ASPD community services across 12 sites in England and Wales Sites are current Probation Trust/Health Service Providers delivering the Personality Disorder (PD) community service specification Services delivered jointly in probation premises by probation staff and health service provider clinicians Tavistock and Portman NHS Foundation Trust is lead coordinating site for project management Training and supervision provided by Anna Freud Centre.

12 Participating sites LONDON East London North London Southeast London MIDLANDS Nottinghamshire Lincolnshire Staffordshire SOUTH Bristol Devon and Cornwall Wales NORTH Yorkshire Lancashire Merseyside

13 Participants Inclusion criteria Over 25 SCID-2 diagnosis of ASPD Evidence of aggressive acts in 6 months prior to assessment Under Probation and subject to a community order of at least 6 months Able and willing to provide written informed consent Some motivation for treatment Exclusion criteria Current diagnosis for schizophrenia or bipolar disorder Substance or alcohol dependence Psychopathy score above 25 Learning disability or significant cognitive impairment Inadequate English to participate in informed consent and group therapy

14 Pilot RCT Pilot RCT within 4 of 12 sites 20 participants to be recruited from Probation Service local to each participating centre. Randomised to 12 months MBT-ASPD or TAU stratified for age and gender If results of pilot and research funding successful, extend RCT to more sites

15 1 6 months Recruitment of participants from Probation Intended sample of 20 participants per site (10 in each treatment and control group) across 4 sites Baseline measures administered SCID-I to confirm diagnosis of ASPD Randomization 6 18 months Weekly MBT group treatment Monthly 1:1 session with MBT trained clinician Repeat measures at 3, 6, 9 and 12 months Or Treatment as usual Repeat measures at 3, 6, 9 and 12 months months (follow-up) Repeat measures at 18 and 24 months

16 Outcome measures MacArthur Community Violence Screening Instrument Aggression Questionnaire MOAS Modified Overt Aggression Scale The Social Functioning Questionnaire Euroqol-5 Service Engagement Scale Client Satisfaction Questionnaire Barratt Impulsiveness Scale Drug Abuse Screening Test Alcohol Use Disorders Identification Test Symptom Checklist Locus of Control Suicide and Self Harm Inventory

17 Research challenges Engagement / drop outs Response to randomisation Small effects likely Health intervention in a CJS setting issues of clinical responsibility, crisis management, confidentiality etc

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