nhs grampian development of mbt interventions for people with bpd dr linda treliving, consultant...
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NHS Grampian development of MBT interventions for people with
BPDDr 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 PsychologicalTherapies in Scotland
“The Matrix”
Level of Severity
Level of service Intensity of intervention
What intervention? Recommendation
Severe Secondary/ Specialist
Outpatient
High
CBT for personality disordersIndividual therapy (30 sessions over 1
year)
Schema Focused CBTTwice 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)
A2
A3
A6
A4
A1
Severe Secondary/ Specialist
Partial Day Hospital
HighMulti-modal
Mentalization based Day Hospital (Several times per week over 3 years)
A5
Borderline personality disorder
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)• Referrals are discussed at the weekly referral meeting• Decisions are made to either progress the referral, discuss with referrer or make further enquiries.
Eligibility criteria• Aged 18 years upwards• Males and females
Referral accepted
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-compulsiveInterpersonal sensitivityDepressionAnxietyHostilityPhobic anxiety Paranoid ideationPsychoticism
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
40
45
50
55
60
65
pre-treatmentpost-treatment
SOM O-C IPS DEP ANX HOS PHANX PARID PSY GSI PSDI PST
Referral accepted
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:
• 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 staff meeting
10.15 Community meeting Community meeting
10.45 Morning group Morning group
12.15 lunch lunch
1 staff meeting
1.30 Mentalization group Mentalization group
3 pm home supervision
4
Morning group
Psycho education
SCID Psychodrama
psychotherapy1 2 3 4 5 6 7 8 9 10 11 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.
StaffingGrade Sessions
in dept
MBT level
LT Cons 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 therapyfor BPD
Mentalizing:
A new word for an ancient conceptImplicitly 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
Bulletin of the Menninger Clinic (2003) , 67,3:pp187-211
The mediator between the genotype and the phenotype is the attachment process
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 attempts are often aimed at avoiding the possibility of abandonment: they seem to be a last-ditch attempt at reestablishing a relationship.
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.
Suicide
Lack of MentalisationStability 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 StrategiesThe 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 theinternal mental states both within the patientand the therapist
• 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?