Treatment of personality disorder by generalist mental health clinicians - a good enough treatment? Prof Anthony W Bateman Slagelse 2016
Borderline Personality Disorder: An evidence-based guide for generalist mental health professionals Anthony W. Bateman, Consultant Psychiatrist and Psychotherapist, UK and Roy Krawitz, Consultant Psychiatrist and DBT therapist, Waikato District Health Board, New Zealand • Provides an evidence-based intervention for treating people with borderline personality disorder • Written by two highly experienced clinicians, providing the generalist mental health clinician with a thorough understanding of this disorder • Includes advice on helping the family of the patient - often neglected in the treatment • Outlines top 10 interventions that can be given by general mental health clinicians for people with BPD which helps increase their own skills in the area 978-0-19-964420-9 Paperback | May 2013 £24.99
Acknowledgements n Roy
Krawitz, Waikato District Health Board, New Zealand n Rory Bolton and staff of Halliwick PD Service, BEH Mental Health Trust n Mark Sampson and Emma Hickey 5BP Mental Health Trust n John Gunderson and Paul Links, McLean Hospital USA
Are specialist treatments for personality disorder necessary?
Specialist/Generalist treatments: q Outcomes
across DBT/TFP/SPT were “generally equivalent” (USA)
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg O. Evaluating three treatments for borderline personality disorder. American Journal of Psychiatry. 2007;164:922-8
‘v’ DBT shows equal outcomes at end of treatment and at follow-up (Canada)
McMain S, Links P, Gnam W, Guimond T, Cardish R, Korman L, et al. A randomized controlled trial of dialectical behaviour therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry. 2009;166:1365-74 McMain S, Guimond T, Cardish R, Streiner D, Links P. Clinical outcomes and functioning posttreatment: A two-year follow-up of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry. 2012;169:650-61
Specialist/Generalist treatments: n
DBT v. TBE Comparison group lacked key features for NICE recommended treatments (USA)
Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and followup of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006 Jul;63(7):757-66
v SCM The TAU group showed comparable reductions in all measures and a larger decrease in para-suicidal behaviours and risk. (UK)
Feigenbaum JD, Fonagy P, Pilling S, Jones A, Wildgoose A, Bebbington PE. A real-world study of the effectiveness of DBT in the UK National Health Service. British Journal of Clinical Psychology. 2011:1-21
DBT v DBT-S + case management v DBT-I JAMA Psychiatry. 2015;72(5):475-482. doi:10.1001/jamapsychiatry.2014.3039 Published online March 25, 2015.
treatment conditions resulted in similar improvements Ø Frequency of suicide attempts Ø severity of suicide attempts Ø suicide ideation Ø use of crisis services Ø reasons for living
Specialist/Generalist treatments: n
Mentalization based treatment (MBT) ‘v’ structured clinical management (SCM) – both were effective treatments. SCM was superior in the intial months at reducing self-harm (UK)
Bateman A, Fonagy P. Randomized controlled trial of out-patient mentalization based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry. 2009;1666:1355-64. n
MBT ‘v’ Supportive Group Ø GAF showed a significantly higher outcome in the MBT group Ø Trend for a higher rate of recovery from BPD in the MBT group Ø Pre-post effect sizes were high for both groups (0.5–2.1 Jorgensen CR, Freund C, Boye R, Jordet H, Andersen D, Kjolbye M. (2012) Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: a randomized trial. Acta Psychiatrica Scandinavica 1-13.
Specialist/Generalist treatments: n SFT
v TFP but no comparison with structured clinical care (Netherlands)
Gieson-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, et al. Outpatient psychotherapy for borderline personality disorder; randomized trial of schemafocused therapy vs transference focused therapy. Archives of General Psychiatry. 2006;63:649-58
v. Community psychotherapists. Comparison treatment was unstructured and heterogeneous (Germany/Austria)
Doering S, Hörz S, Rentrop M, Fischer-Kern M, Schuster P, Benecke C. Transferencefocused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. British Journal of Psychiatry. 2010;196:389-95.
Specialist/Generalist treatments: n
Cognitive analytic therapy ‘v’ Good Clinical Care (GCC) for adolescents with BPD or BPD traits - equally effective with significant improvements across a range of clinical outcome measures (Australia)
Chanen AM, Jackson HJ, McCutcheon LK, Jovev M, Dudgeon P, Yuen HP, et al. Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: Randomised controlled trial. British Journal of Psychiatry. 2008 Dec;193(6): 477-84.
Structured Clinical Management
SCM: Key components n n n n n n n
Reliable appointments. Detailed crisis plans. Clear short term and long term goals. Collaborative care plans done together. 3 Monthly psychiatric reviews. Assertive follow-up if person does not attend an appointment. Group psycho-education and skills sessions.
Personality Disorder Care Pathway
C O M P L E X I T Y
Borderline Personality Disorder identified SCM
DBT or MBT or other SCM
SCM pathway Assessment (socialisation)
Setting Frame (attachment)
Interpersonal (incl. cognitive distortions)
Emotional Regulation Impulsivity
Planning for life without services Transition work Banked Sessions
Assessment (6 - 8 sessions) n Careful
assessment. n Giving the diagnosis. n Information sharing/psycho-education. n Risk. n Development of hierarchy of therapeutic areas.
Setting the Frame (Up to 3 months) n n n n n n
Agreement of clinician and patient responsibilities. Development of motivation and establishment of therapeutic alliance. Risk assessment and risk management. Stabilisation of drug misuse and alcohol abuse. Development and agreement of comprehensive formulation and goals. Involvement of families, relatives, partners and others.
Setting the Frame: Clinical Stance n Attachment
focused. n Attitude - Be Wise and Mentalize. n Reliable and consistent. n Active participation. n Realistic expectations. n Team work and communication. n Hope and optimism.
Giving the diagnosis n Diminishes
sense of uniqueness/alienation n Establishes realistically hopeful expectations n Decreases parent blaming and increases parent collaboration n Increases patient alliance and compliance with treatment n Prepares the clinician
Attachment Styles Our attachment to others can be described as: 1. Secure
2. Insecure -Ambivalent (sometimes called anxious) 3. Insecure – Distanced (sometimes called avoidant) 4. Disorganised
Recovery and secure attachment n To
enable mental health recovery we need to where possible facilitate a secure attachment with the service user.
Ø Co-ordinated Ø Reliable Ø Sensitive to the clients emotional needs Ø Consistent (particularly in emotional response)
Facilitating security in SCM What do you want? What do I want? What would the agreement be here?
n n n
Establishing the contract/agreement/relationship. Necessary to reduce the number of ruptures. Can lead to immediate reductions in self harming behaviour.
Agreeing what we are going to work on: n Need
to be clear in our focus n Develop common focus – what is the agreed goal? n Emphasis on autonomy. n Treatment is community based. n Hospitalisation limited. Ø NOTE: primary aim of SCM is to reduce unnecessary hospital admissions:
Crisis Planning Crisis Plans, Admissions and Prescribing.
Managing safety: seven principles 1. 2. 3. 4. 5. 6. 7.
Assess risk – differentiate non-lethal and true suicide intent Don’t ignore or derogate – express concern Ask what the patient thinks will help – foster sense of self agency Clarify precipitants – chain analysis and seek interpersonal events Be clear about your limits – under or over valuing your importance Explore the effect on treatment Discuss with colleagues
Crisis Planning n Crisis
Plans one of the most important things you can do. n Key pointers to an effective crisis plan Ø Not adequate to have to attend A & E Ø Need to work with the patient to collaboratively come up with the plan Ø Use previous examples (three) that led to self destructive behaviour/or contact to services. Looking to establish early warning signs.
Prescribing Guidance n When
medication is used it should be considered in the context of the longer-term treatment plan. n Prescribing should be integrated into the overall management of the patient. n Crisis prescribing Ø Inevitable but sometimes better to offer follow– up review next day rather than prescribe.
Prescriber Guidance n n n n n
Try and avoid adding medication to current medication regimes during a crisis. Prescribing using the neutral stance. Keep in therapeutic range -avoid higher doses of medication (no evidence for this). Take interest in how the person responds to medication (2 to 4 weeks adherence). Avoid changing until 2 – 4 week period is completed.
SCM Strategies Problem Solving and Foci
SCM: interventions Non-specific interventions n Interviewing skills n Attitude n Empathy n Validation n Positive regard n Advocacy
Specific interventions n Tolerating emotions n Mood regulation n Impulse control n Self-harm n Sensitivity and Interpersonal problems
Clinician Stance n
Active, responsive, curious
Expect patients to be active in controlling their life (agency, accountability)
Challenge passivity, avoidance, silences, diversions
Support via listening, interest, selective validation
Focus on life situations; relationships and vocations
Work > love
Change is expected
Problem Solving Specific Interventions
SCM: Core treatment strategies n Problem
Solving underpins core treatment strategies: Ø Emotion management Ø Mood regulation Ø Impulse control Ø Interpersonal sensitivity Ø Interpersonal problems Ø Suicidality and self-harm and management of risk
How to Solve a Problem n
There are 4 steps in problem solving:
Defining the problem.
Generating potential solutions
Selecting and planning the solution.
Implementing and monitoring the solution.
Emotions Tolerance of Emotions and Mood Regulation
Key Strategies n Psycho-education n Labelling n Normalising n Contextualising n Relaxation
Impulsivity and impulse control n
Not attending: decreased attention – easily getting bored, inability to concentrate on a task, difficulty keeping to topic when something else comes into the mind Not planning: lack of premeditation; limited consideration about or concern for consequences; excitement about risky activities that precludes considering negative consequences Action: action without reflection – going into action rapidly, acting rashly sometimes related to pleasing as well as displeasing emotions
Do something exciting
Awareness of inability to concentrate
Skilful action with others
Awareness of thoughts of entitlement
Find boyfriend, Get drunk
Noticing action urge
Interpersonal Relationships and Sensitivity
Strategy: Interpersonal Skills n n
Ask questions –‘Why are you folding your arms’? ‘Why do you look at me like that?’ ‘What are you thinking?’ State a tentative conclusion and ask for confirmation – I suppose that you feel that …. Is that what you do feel/think at the moment or are you feeling/thinking something else’? Explain how when someone says something or looks at you in a particular way that this results in certain emotions in oneself -‘When you say that, I feel… Is that what you mean me to feel?’ Explain your point of view – if it is not in line with what the other person means ask them to correct you. Consider the context of the interaction.
9. SCM extras Top 10 Strategies, Group work, Family and Supervision.
Top Ten Strategies for clinicians n n
n n n
Mentalizing and mindfulness Valued action irrespective of emotions Ø including identification of emotion Ø acceptance of emotions Self- acceptance Accepting thoughts and valued action Changing thoughts
n n n
Decreasing hyperarousal Chain analysis Structure Ø Joint crisis plans Ø Problem solving Ø Psychoeducation Skills Ø Distress tolerance skills Ø Interpersonal effectiveness skills Clinical feedback of treatment outcomes
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