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. GCHT serves a population of approx. 600,000 in South East Wales.
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? • 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 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. • Dialectical Behaviour Therapy. • Psychoanalytic Psychotherapy. • CBT. • CAT. • Individual and group work. • Staff supervision and consultation.
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? • 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 • 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. • 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 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 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 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 • 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 • 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 • 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 • Linehan (1993) reorganised the DSM criteria of BPD into 5 areas of dysregulation:- • Emotional. • Cognitive. • Behavioural. • Self. • Interpersonal.
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 measures • Novaco Anger Scale and Provocation Inventory (NAS-PI; Novaco, 2003):- • Disrespectful treatment. • Unfairness. • Frustration. • Annoying traits of others . • Irritations.
Psychometric measures • Brief Symptom Inventory (BSI; Derogatis, 1993):- • Somatisation. • Obsessive compulsion. • Interpersonal sensitivity. • Depression. • Anxiety. • Hostility. • Phobic anxiety. • Paranoid ideation. • Psychoticism.
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 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 • 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. • Number of contacts with services. • Number of incidents. • Number of hospital admissions. • Number of days spent in hospital.
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 analyses • Diary card data:- • Multiple baseline design. • Plan to analyse using the Conservative Dual Criteria Approach (Fisher, Kelley, & Lomas, 2003).
Study designs and analyses • Service User data:- • Repeated measures design • Plan to analyse using ANOVA
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 • 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 • 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 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
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.
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
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.
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
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.
Simplification • Creating many variables prevent meaningful interpretation, therefore scores were grouped into 4 domains:- • Urges. • Actions. • Emotions. • Skills – (if used and were helpful).
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.
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?