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?