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The Gwylfa Therapy Service (GTS). An evaluation. 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.

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What is the gts
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.


Who are the gts
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)


What does the gts do
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


Personality disorder service what works
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


  • Gwylfa therapy services skills base
    GWYLFA THERAPY SERVICES SKILLS BASE.

    • Dialectical Behaviour Therapy.

    • Psychoanalytic Psychotherapy.

    • CBT.

    • CAT.

    • Individual and group work.

    • Staff supervision and consultation.


    Personality disorder service what works1
    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.


    Why evaluate
    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.


    Aim of research
    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.


    Evaluation of the gts
    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).


    Part 1 patient centred evaluation
    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.


    Part 2 service evaluation
    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.


    Part 3 theory based research
    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.


    Part 1a clinical analyses
    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?


    Dbt with the gts
    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.


    Clinical analyses data collection
    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.


    Rationale for choice of psychometric measures
    Rationale for choice of Psychometric measures

    • Linehan (1993) reorganised the DSM criteria of BPD into 5 areas of dysregulation:-

      • Emotional.

      • Cognitive.

      • Behavioural.

      • Self.

      • Interpersonal.


    Psychometric measures
    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.


    Psychometric measures1
    Psychometric measures

    • Novaco Anger Scale and Provocation Inventory (NAS-PI; Novaco, 2003):-

      • Disrespectful treatment.

      • Unfairness.

      • Frustration.

      • Annoying traits of others .

      • Irritations.


    Psychometric measures2
    Psychometric measures

    • Brief Symptom Inventory (BSI; Derogatis, 1993):-

      • Somatisation.

      • Obsessive compulsion.

      • Interpersonal sensitivity.

      • Depression.

      • Anxiety.

      • Hostility.

      • Phobic anxiety.

      • Paranoid ideation.

      • Psychoticism.


    Psychometric measures3
    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


    Psychometric measures4
    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.


    Diary card data
    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).


    Service user data
    Service User data.

    • Number of contacts with services.

    • Number of incidents.

    • Number of hospital admissions.

    • Number of days spent in hospital.


    Study designs and analyses
    Study designs and analyses

    • Psychometric measures:-

      • Repeated measures design looking at pre and post treatment differences.

      • Analysed using Clinical Significance Calculations (Jacobson & Truax, 1991).


    Study designs and analyses1
    Study designs and analyses

    • Diary card data:-

    • Multiple baseline design.

    • Plan to analyse using the Conservative Dual Criteria Approach (Fisher, Kelley, & Lomas, 2003).


    Study designs and analyses2
    Study designs and analyses

    • Service User data:-

    • Repeated measures design

    • Plan to analyse using ANOVA


    Analyses of psychometric measures clinical significance
    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.


    How to determine clinical significance
    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.


    Clinical significance equation
    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.


    Clinical significance equation1
    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



    Example of how to report clinical significance
    Example of how to report clinical Significance that is easy to interpret is difficult.

    • * 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


    Example of how to report clinical significance1
    Example of how to report clinical Significance that is easy to interpret is difficult.


    Examples of how to report clinical significance
    Examples of how to report clinical Significance that is easy to interpret is difficult.


    Examples of how to report clinical significance1
    Examples of how to report clinical Significance that is easy to interpret is difficult.


    Diary card analyses progress report
    Diary card analyses – Progress Report. that is easy to interpret is difficult.

    • 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.


    Cdc continued
    CDC continued that is easy to interpret is difficult.

    • 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


    Applying cdc to diary card data
    Applying CDC to diary card data that is easy to interpret is difficult.

    • 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.


    Simplification
    Simplification that is easy to interpret is difficult.

    • Creating many variables prevent meaningful interpretation, therefore scores were grouped into 4 domains:-

      • Urges.

      • Actions.

      • Emotions.

      • Skills – (if used and were helpful).


    Simplification1
    Simplification that is easy to interpret is difficult.

    • 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.


    44 weeks in dbt patient 1
    44 weeks in DBT (patient 1) that is easy to interpret is difficult.


    22 weeks of dbt patient 2
    22 weeks of DBT (patient 2) that is easy to interpret is difficult.


    57 weeks of dbt patient 3
    57 weeks of DBT (patient 3) that is easy to interpret is difficult.


    48 weeks of dbt patient 4
    48 weeks of DBT (patient 4) that is easy to interpret is difficult.


    70 weeks of dbt patient 5
    70 weeks of DBT (patient 5) that is easy to interpret is difficult.


    92 weeks of dbt patient 6
    92 weeks of DBT (patient 6) that is easy to interpret is difficult.


    56 weeks of dbt patient 7
    56 weeks of DBT (patient 7) that is easy to interpret is difficult.


    122 weeks of dbt patient 8
    122 weeks of DBT (patient 8) that is easy to interpret is difficult.


    The next step
    The next step that is easy to interpret is difficult.

    • 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?


    Service user data1
    Service user data that is easy to interpret is difficult.

    • Most interested in number of hospital admissions.

    • Length of stays in hospital.

    • Hypothesis is that length of DBT will reduce both of the above.

    • All patients service user data was examined for approximately 1 year prior to entering therapy and for duration of therapy.


    Service user results
    Service user results that is easy to interpret is difficult.

    • Patient 1 entered therapy march 2006 and had no admissions in 12 months prior to over duration of therapy


    Patient 2 entered therapy july 2007
    Patient 2. Entered therapy July 2007 that is easy to interpret is difficult.


    Patient 3 entered therapy june 2007
    Patient 3. Entered therapy June 2007 that is easy to interpret is difficult.


    Patient 4
    Patient 4. that is easy to interpret is difficult.

    • Entered therapy March 07

    • 1 admission April 06 for 3 days


    Patient 5
    Patient 5. that is easy to interpret is difficult.

    • Entered therapy November 06

    • No admissions except 2 admissions for 2 days in February 2008


    Patient 6 entered therapy october 2005
    Patient 6.Entered therapy October 2005 that is easy to interpret is difficult.




    Next step
    Next step therapy January 2005

    • To compare particular time phases to establish significant or non-significant reductions in hospital admissions and lengths of stay.


    In summary
    In summary therapy January 2005

    • Clinical Significance calculations show that there is significant movement of scores for some of our DBT patients.

    • Visual inspection of diary cards suggests that urges to self harm emotional dysregulation & acts of self harm reduce whilst skills for managing emotional dysregulation improve, for some patient in particular modules. But we need to apply CDC to test for significance.

    • Visual inspection of service user data indicates a reduction in hospital stays but again this needs to be tested for significance.


    Part 1b

    Part 1b therapy January 2005

    Part 1b - Comparison of those who discontinue therapy with those who continue.


    AIM therapy January 2005

    • To identify reasons why patients discontinue therapy.

    • Why?

    • To channel otherwise limited resources towards those with whom therapy might prove more effective.


    Measures
    Measures therapy January 2005

    • Diagnostic measure - International Personality Disorder Examination- DSM-IV interview (IPDE; Loranger, 1999).

    • Motivational Measure - Treatment Motivation Questionnaire (TMQ; Ryan, Plant, & O’Malley, 1995). examines internal and external levels of motivation to enter therapy.

    • Cognitive measure – Social Problem solving inventory (SPSI).


    Participants
    Participants therapy January 2005

    • 14 female patients who entered therapy between (mean age - 36.90).

    • 7 of whom continued therapy for up to 9 months at the time the study commenced (mean age - 40.43).

    • 7 of whom discontinued after no longer than 4 months (mean age – 33.29).


    Personality diagnosis
    Personality Diagnosis therapy January 2005

    • Tyrer and Johnson (1996) proposed an empirically-based system for classifying the severity of PD based upon the number of conditions diagnosed and whether or not these are from the same cluster. A simple PD is PD in one cluster only, whereas a complex PD is PD’s from more than one cluster.


    Personality diagnosis1
    Personality Diagnosis therapy January 2005


    Spsi results
    SPSI results therapy January 2005

    * All non significant


    Motivation tmq
    Motivation (TMQ) therapy January 2005

    • Continuers of therapy reported significantly more internal reasons to be in therapy compared to discontinuers. For example – personal desires to change

    • Discontinuers of therapy reported significantly more external reasons to be in therapy compared to continuers. For example, pressures from outside agencies such as friends families CPN’s etc.


    Service use over the 9 months

    Continuers therapy January 2005

    4 patients admitted

    16 total admissions

    151 bed days

    Total cost = £39,197

    Discontinuers

    6 patients admitted

    17 total admissions

    379 bed days

    Total cost = £122,444

    Service use over the 9 months


    Tentative interpretation
    Tentative Interpretation therapy January 2005

    • Those with simple PD are more likely to remain in therapy compared to those with complex PD.

    • Those with high levels of internalised motivation more likely to remain in therapy compared to those with high levels of externalised motivation.


    Part 2

    Part 2 therapy January 2005

    Service evaluation


    Part 2 service evaluation1
    Part 2 – Service Evaluation therapy January 2005

    • Part 2a - Examination of what community mental health teams want from the GTS consultation service and what the GTS feels it can provide (Consultation service evaluation).

    • Part 2b - Examination of nursing staff attitudes towards patients with personality disorder using Attitude Towards Personality Disorder Questionnaire (APDQ; Bowers 2004).

    • Part 2c – Delphi survey of patients views of services they have had contact with.


    Part 2a

    Part 2a therapy January 2005

    Consultation service evaluation.


    Consultation service evaluation
    Consultation service evaluation therapy January 2005

    • Aims:-

      • To identify main problems CMHT experiences with referred patients.

      • The type of support the CMHT needs.

      • Increase effective dialogue with CMHT to increase more effective time management.

      • Identify pathways into increasing staff awareness of PD.


    Consultation service evaluation1
    Consultation service evaluation therapy January 2005

    • Constructed a pilot questionnaire to establish what information would be helpful to GTS upon a patient’s referral to service.

    • Gathered information via telephone.


    Method
    Method therapy January 2005

    • 2 Psychiatrists, 2 Clinical Psychologists, 6 Nurses and 4 CPN’s were recruited.

    • All had direct contact with GTS.

    • 3-12 months of consultation.

    • Data broken down into themes and sub-themes via qualitative analysis.


    Results
    Results therapy January 2005

    • Staff descriptions of patients:-

      • Unpredictable.

      • Difficult.

      • Challenging.

      • Needy.

      • Friendly.

      • Pleasant.


    Results1
    Results therapy January 2005

    • Feelings elicited working with BPD:-

      • Frustrated.

      • Helpless.

      • Anxious.

      • Angry.

      • Curious.

      • Interested.


    Results2
    Results therapy January 2005

    • Reasons for contacting GTS:-

      • Can’t progress with patient

      • Lack strategy

      • Need fresh ideas

      • Unstructured approach


    Results3
    Results therapy January 2005

    • Main problems experienced with patient:-

      • Suicidal Ideation.

      • Self-Harm.

      • Substance misuse.

      • Non-compliance.


    Results4
    Results. therapy January 2005

    • Staff reported mainly behaviour centred problems in patients with PD such as self harm, substance abuse and non-compliance.

    • Staff report feeling frustrated and helpless when working with patients with features of BPD.

    • Staff also reported feeling unable to progress with patients with BPD and experiencing a lack of coordination at CMHT level.


    Results5
    Results therapy January 2005

    • What CMHTs ask from GTS:-

      • Help to reduce negative behaviours.

      • Increase both staff and patient insight.

      • Increase patient engagement with CMHT.

      • Skill up staff through training (DBT, CBT etc).

      • Support, guidance and supervision.


    Consultation service evaluation some comments
    Consultation Service evaluation - Some comments therapy January 2005

    • First class service - staff helpful.

    • “Good so far”.

    • Patient adjustment improved during/ after.

    • Service come to late for some - but inevitable.

    • Consultation process too unstructured.

    • Referral process could be managed better.

    • Want Gwylfa to take on complete care - don’t want joint working/ consultation.

    • Referral process too slow, lengthy & service not responsive enough.


    Conclusions
    Conclusions therapy January 2005

    • GTS needs to implement training to allow more autonomy. Such training could include motivational interventions, crisis management, coping with difficult behaviours, DBT and CBT training.

    • Teams need coherent treatment strategies and practice guidelines for handling difficult behaviours, such as self harm or suicidal ideation.


    Part 2b

    Part 2b therapy January 2005

    Nursing staff attitudes towards personality disorder.


    Nursing staff attitudes towards personality disorder
    Nursing staff attitudes towards personality disorder therapy January 2005

    • Aims:

      • Assess CMHT staff attitudes towards and willingness to work with patients with PD.

      • Examine how an interest in PD improves attitudes.

      • Compare Trust staff to other groups working with PD and offer reasons why different levels of attitude exist.


    Method1
    Method therapy January 2005

    Sample:-

    88 nurses who had not volunteered for PD awareness training.

    29 nurses who had volunteered.

    Compared with:-

    645 nurses in high security setting.

    76 nurses who volunteered to work on DSPD unit.

    166 non volunteer nurses on DSPD unit.

    55 prison officers working on a DSPD unit.

    (Carr-Walker, Bowers, Callaghan Nijman & Paton, 2004)


    Method2
    Method therapy January 2005

    • Measure:-

      Attitude Towards Personality Disorder Questionnaire (APDQ; Bowers et al. 2000).

      37 item measure with 5 scales: enjoyment, security, acceptance, purpose, enthusiasm.


    Method3
    Method therapy January 2005

    • Procedure:-

      • Non volunteer group: Researcher visited 12 CMHTs within the Trust with request to completed APDQ in MDT.

      • Volunteer group: Facilitator informed volunteers that completion of APDQ formed part of their inclusion in workshop.


    Method4
    Method therapy January 2005

    • Analyses:-

      • Non parametric comparisons looking at how:-

      • Those who volunteered to PD awareness workshop differ in attitude to those who did not

      • T-tests:-

      • Collapsing above groups into one and comparing with samples taken from Carr-Walker et al. (2004)


    Results6
    Results therapy January 2005

    • Compared to non-volunteer group, nurses who volunteer for PD awareness workshop reported significantly higher levels of:-

      Enjoyment.

      Security.

      Acceptance.

      Purpose.

      But not enthusiasm.


    Results7
    Results therapy January 2005

    • Trust nurses were compared with Prison officers, the latter of whom reported significantly higher levels of:-

      • Security.

      • Acceptance.

      • Purpose.

      • Enthusiasm.


    Results8
    Results therapy January 2005

    • All Trust nurses were then compared with nurses in high security setting.

    • Nurses in high security setting report significantly higher levels of:-

      • Enjoyment.

      • Security.

      • Acceptance.

      • Purpose.


    Results9
    Results therapy January 2005

    • Trust nurses were compared with nurses who volunteer to work in DSPD unit the latter of whom report significantly higher levels of:-

      • Security.

      • Acceptance.

      • Purpose.


    Results10
    Results therapy January 2005

    • Trust nurses were compared with nurses who did not volunteer to work on DSPD unit but did so anyway.

    • DSPD nurses report significantly higher levels of:-

      • Enjoyment

      • Security

      • Purpose


    Conclusion
    Conclusion therapy January 2005

    • Nursing staff require help to feel safe, more accepting and more purposeful with patients PD.

    • Next step is to design suitable training and evaluate its effectiveness.

    • Aim to develop training that changes knowledge, attitudes and skills and eventually how this benefits the patients.


    Part 2c

    Part 2c therapy January 2005

    Delphi survey of patients views of services they have had contact with.


    The delphi survey
    The Delphi survey therapy January 2005

    • Aim:-

    • To gather the views of service users.

    • Establish which areas of mental health and related services need support and guidance that may provide better support for patients in crises.

    • Provide a more seamless transition from first contact to inpatient support.


    Broad findings
    Broad Findings therapy January 2005

    • Police – perceived as kind and helpful but not responsive to needs.

    • General practitioners – generally understanding but pressed for time and can misunderstand level of crises.

    • General hospital staff – disrespectful, disdainful and dismissive.

    • Psychiatric hospital staff tend to be more helpful but there is room for improvement.

    • Psychiatrists and Psychologists were rarely mentioned but were satisfactory.


    Broad findings1
    Broad Findings therapy January 2005

    • GTS generally perceived as:-

    • Respectful.

    • Supportive.

    • Professional.

    • More details can be found in paper below.


    References
    References therapy January 2005

    • Webb, D., & McMurran, M. (2007). Nursing staff attitudes towards patients with personality disorder. Personality and Mental Health, 1, 154-160.

    • Webb, D. & McMurran, M. (2008). A Delphi survey of Patients’ views of services for borderline personality disorder: A preliminary report. Personality and Mental health, 2, 17-24.

    • Webb, D., & McMurran, M. (2008). A comparison of women who continue and discontinue Dialectical Behaviour Therapy-based treatment for borderline personality disorder. Personality and Mental Health. (paper submitted for review).

    • Webb, D., & McMurran, M. (2008). Alexithymia, Emotional Intelligence, and borderline traits in young adults. Personality and Mental Health (Paper in press).


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