The Gwylfa Therapy Service (GTS)

1. The Gwylfa Therapy Service (GTS) An evaluation

2. What is the GTS? Specialist Service for people with a Personality Disorder. Based in St. Cadoc’s Hospital, Caerleon. Service started end of February 2005 Provided by Gwent Health Care Trust. GCHT serves a population of approx. 600,000 in South East Wales.

3. Who are the GTS? • Consultant Clinical Psychologist (1WTE) • Psychiatric Nurse (1WTE) • Principal Clinical Psychologist (1WTE) • Consultant Psychotherapist/Psychiatrist (0.4 WTE) • PhD Research Student (1 WTE) • Administrator (0.5 WTE)

4. What does the GTS do? • Provide consultation/ advice/ support/ supervision service to CMHT’s. • Implement a clinical service for a small number of severely distressed patients who cannot be managed at CMHT level. • Provide Assessment/gatekeeping to patients who are referred to Out of Area PD Services. • Provide training and staff development

5. PERSONALITY DISORDER SERVICEWHAT WORKS? • Dynamic psychotherapy, DBT, Therapeutic Community Tx, Schema Focused Tx. • CT and CAT show some promise. • Pharmacotherapy - target specific problem areas - Soloff’s Medication Algorithm:- • Cognitive/perceptual • Affective • Impulse dyscontrol • No magic bullet • Drugs alone insufficient to treat PD

6. GWYLFA THERAPY SERVICES SKILLS BASE. • Dialectical Behaviour Therapy. • Psychoanalytic Psychotherapy. • CBT. • CAT. • Individual and group work. • Staff supervision and consultation.

7. PERSONALITY DISORDER SERVICEWHAT WORKS? • Main features of effective treatment:- • Well structured. • Apply effort to enhance compliance. • Clear therapeutic focus. • Theoretically highly coherent to P and T. • Relatively long term. • Encourage powerful attachment relationships (which are worked within). • Well integrated with other services.

8. Why Evaluate? • Growing evidence basis - no clear evidence of outcome of any one approach. • New developing field. • Formulation driven clinical service requires measurement on single case basis. • Are GTS outcomes similar to that in controlled group studies – different therapists, patients, service context etc? • High intensity work – demonstrate worth. • All new PD services need built in ongoing evaluation.

9. AIM OF RESEARCH • To develop methodologies, measures, methods of analysis etc. • To share these with other practitioners. • To develop our clinical service. • Ongoing work. • Progress report. • Further analyses to be conducted.

10. Evaluation of the GTS. • 3 areas of research:- • Part 1 - Patient centred evaluation. • Part 2 - Service evaluation. • Part 3 - Theory driven research (not discussed here).

11. Part 1 - Patient Centred Evaluation • Part 1a – Clinical analysis of effectiveness of DBT. • Part 1b - Comparison between those who remain in therapy with those who drop out.

12. Part 2 - Service Evaluation • Part 2a - Examination of what community mental health teams want from the GTS consultation service and what the GTS feels it can provide. • Part 2b - Examination of nursing staff attitudes towards patients with personality disorder. • Part 2c - Examination of patients views of services they have had contact with.

13. Part 3 - Theory based Research • Part 3a - Examination of relationship between emotional dysregulation, cognitive dysregulation and features of BPD. • Part 3b - Examination of relationship between Emotional Intelligence, Alexithymia and features of BPD.

14. Part 1a - Clinical analyses • 2 principle questions:- • Can we develop an effective method of evaluating clinical change over long-term inclusion in DBT? If yes:- • To what extent is DBT helping those who enter therapy?

15. DBT with the GTS • One-to-one weekly therapy session. • Weekly skills group teaching 4 skills modules (takes approx 6 months):- • Mindfulness (repeated between each module). • Distress tolerance. • Interpersonal effectiveness. • Emotion regulation.

16. Clinical analyses-data collection • Data gathered from 3 sources:- • Psychometric measures, completed every six months over course of DBT. • Daily diary cards, completed by patient outside of therapy setting. • Service user data, drawn from patient’s records.

17. Rationale for choice of Psychometric measures • Linehan (1993) reorganised the DSM criteria of BPD into 5 areas of dysregulation:- • Emotional. • Cognitive. • Behavioural. • Self. • Interpersonal.

18. Psychometric measures • We chose measures that:- • Broadly map onto the 5 areas of dysregulation as defined by Linehan (1993). • Specifically they focus on therapy targets as agreed by each patient and their clinician.

19. Psychometric measures • Novaco Anger Scale and Provocation Inventory (NAS-PI; Novaco, 2003):- • Disrespectful treatment. • Unfairness. • Frustration. • Annoying traits of others . • Irritations.

20. Psychometric measures • Brief Symptom Inventory (BSI; Derogatis, 1993):- • Somatisation. • Obsessive compulsion. • Interpersonal sensitivity. • Depression. • Anxiety. • Hostility. • Phobic anxiety. • Paranoid ideation. • Psychoticism.

21. Psychometric measures • Inventory of interpersonal problems (IIP; Horowitz et al., 1988):- • Domineering/Controlling • Vindictive/self centred • Cold/distant • Socially inhibitted • Non-assertive • Overly Accommodating • Self Sacrificing • Intrusive/needy • Total IIP

22. Psychometric measures • Social Problem-Solving Inventory – Revised (SPSI-R; D’Zurilla, Nezu, & Maydeu-Olivares, 2002):- • Positive Problem Orientation. • Negative Problem Orientation. • Rational Problem Solving. • Impulsivity/Carelessness Style. • Avoidance Style. • SPSI Total.

23. Diary Card Data • Normally completed by patient daily outside of therapy setting but can be completed during weekly session • Can be idiosyncratic but normally covers range of areas:- • Urges – self harm*, suicide* • Emotions – pain*, fear*, sadness*, shame* & anger* • Experiences - active passivity*, dissociation*, crisis*, self hate* • Drug use – prescription, OTC, illicit • Skills use – were they used, did they work, to what extent? *(Clients use a 0-5 rating scale of severity/intensity).

24. Service User data. • Number of contacts with services. • Number of incidents. • Number of hospital admissions. • Number of days spent in hospital.

25. Study designs and analyses • Psychometric measures:- • Repeated measures design looking at pre and post treatment differences. • Analysed using Clinical Significance Calculations (Jacobson & Truax, 1991).

26. Study designs and analyses • Diary card data:- • Multiple baseline design. • Plan to analyse using the Conservative Dual Criteria Approach (Fisher, Kelley, & Lomas, 2003).

27. Study designs and analyses • Service User data:- • Repeated measures design • Plan to analyse using ANOVA

28. Analyses of Psychometric measures – Clinical significance • Statistical significance versus clinical significance (meaningful change). • Statistical significance – reveals if significant change has occurred or not. • Not useful if statistical change (or lack of) has no meaning to patients situation. • Clinical significance or meaningful change – although not necessarily statistically significant- is change that has large implications for a patients daily functioning and/or quality of life.

29. How to determine clinical significance • Jacobson & Truax propose 3 ways:- 1. A post treatment score on any given measure must fall within 2 standard deviations of a functional population norm for the measure. 2. A post treatment score on any given measure must fall beyond 2 standard deviations of a non-functional population for the measure. 3. Ideally both of the above. Because overlap of SD’s can occur use equation – on next slide. When SD’s are large – advised to use 1 SD.

30. Clinical Significance equation • Multiply the SD of a functional population mean by the dysfunctional population mean. • Next:- • Multiply the SD of a dysfunctional population mean by the functional population mean • Next:- • Add both sums together, then • Divide this figure by:- • SD of functional population + SD of dysfunctional population.

31. Clinical Significance equation (SD of f’nal pop x M of dysf’nal pop) + (SD of dysf’nal pop x M of f’nal pop) SD of f’nal pop + SD of dysf’nal pop

32. Due to number of scales per measure, gaining meaningful data that is easy to interpret is difficult. • Therefore:- • Only Total scales were used to determine there has been any clinically significant change.

33. Example of how to report clinical Significance • * Clinically significant change to within 2 standard deviations of the functional population mean. • ** Clinically significant change to within one standard deviation of the functional population mean • † Client score fell within functional population range prior to treatment • > Clinically significant change to beyond functional population range

34. Example of how to report clinical Significance

35. Examples of how to report clinical Significance

36. Examples of how to report clinical Significance

37. Diary card analyses – Progress Report. • The Conservative Dual Criteria approach (CDC; Fisher et al. 2003):- • Designed for the analysis of single case data. • Accounts for autocorrelation within data. • A baseline mean and regression line is computed. • The standard deviation of the baseline mean is then computed and multiplied by .25. • This value is added to the baseline mean line and the regression line.

38. CDC continued • The adjusted mean lines and trend lines are plotted in the intervention phase. • Any intervention score that falls above or below both of the lines is considered a success. • Autocorrelation increases the risk of a type I error, but this can be counterbalanced by; • Only counting an outcome as a success if it falls above or below both lines, then raising these lines by .25 standard deviations • The number of successes in the intervention phase is compared to the number expected by chance. A significant change at the <.05 level can also be established

39. Applying CDC to diary card data • Diary cards cover range of areas; • Urges – self harm, suicide. • Emotions – pain, fear, sadness, shame, anger. • Experiences - active passivity, dissociation, crisis, self hate. • Drug use – prescription, OTC, illicit. • Skills use – were they used, did they work, to what extent? • But this creates many variables to be analysed.

40. Simplification • Creating many variables prevent meaningful interpretation, therefore scores were grouped into 4 domains:- • Urges. • Actions. • Emotions. • Skills – (if used and were helpful).

41. Simplification • In order to map diary card domains onto skills modules a mean score was calculated for each module. • Each was then graphed for visual inspection.

42. 44 weeks in DBT (patient 1)

43. 22 weeks of DBT (patient 2)

44. 57 weeks of DBT (patient 3)

45. 48 weeks of DBT (patient 4)

46. 70 weeks of DBT (patient 5)

47. 92 weeks of DBT (patient 6)

48. 56 weeks of DBT (patient 7)

49. 122 weeks of DBT (patient 8)

50. The next step • To apply the CDC to predetermined modules that map onto the diary card data that we expect to change in accordance with the module. • For example is there a reduction in scores on emotional dysregulation when undertaking emotion regulation module?