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NHS Grampian development of MBT interventions for people with BPD. Dr Linda Treliving, Consultant psychiatrist in psychotherapy, Head of GSPS, Chair of SPDN. Local context. NHS Grampian Psychological therapies steering group, a multidisciplinary committee

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Nhs grampian development of mbt interventions for people with bpd

NHS Grampian development of MBT interventions for people with BPD

Dr Linda Treliving,

Consultant psychiatrist in psychotherapy,

Head of GSPS, Chair of SPDN


Local context
Local context with BPD

  • 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 context1
Local context with BPD

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 with BPD

A Guide to delivering evidence-based Psychological

Therapies in Scotland

“The Matrix”



General approach and management 1. with BPD

  • establish and maintain the therapeutic alliance while managing risk

  • maintain flexibility

  • establish conditions to make the patient safe


General approach and management 2 with BPD

  • tolerate intense anger, aggression and hate

  • promote reflection

  • set necessary limits


General approach and management 3 with BPD

  • 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.



Effective ingredients of treatment bateman and tyrer
Effective ingredients of treatment (Bateman and Tyrer) world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

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
Grampian Specialist Psychotherapy Service world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

  • 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
Process of referral to Psychotherapy Department, Aberdeen. world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

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
Referral accepted world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

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
Symptom Check List 90, (SCL 90) world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.Derogatis et al

90-item self-report checklist measures psychological distress

Symptom measures of :

Somatization

Obsessive-compulsive

Interpersonal sensitivity

Depression

Anxiety

Hostility

Phobic anxiety

Paranoid ideation

Psychoticism


Scl 90 global indices
SCL 90 world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.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
CSA Men Pre & Post Treatment world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

SOM O-C IPS DEP ANX HOS PHANX PARID PSY GSI PSDI PST


Referral accepted1
Referral accepted world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

Patient sent an

  • SCL 90

  • Department questionnaire ( biographical details)

  • SAE.

  • On return of the questionnaire the patient is sent an assessment appointment.


Assessment
Assessment world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

  • 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 world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

  • PDQ-4 is designed to assess 12 personality disorders.

  • http://www.pdq4.com


Pdq 41
PDQ 4 world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

  • 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 42
PDQ 4 world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.


  • The CTQ screens for 5 types of maltreatment:

  • Emotional Abuse

  • Physical Abuse

  • Sexual Abuse

  • Emotional Neglect

  • Physical Neglect


Assessment1
Assessment world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

  • 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
Standard 14: There is a record of a diagnosis or diagnoses world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

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
The Therapeutic programme world of the individual with BPD can impact on attempts of the professionals and agencies involved to engage effectively.

  • 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
a. Mentalization based therapy for Borderline personality disorder

  • 1 day programme for 6 month therapy.

  • Intensive Outpatient programme.


Hub day
Hub day disorder

  • 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



Morning group
Morning group disorder


Psychoeducation
Psychoeducation disorder

  • 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
Structured Clinical Interview for DSM IV diagnosis II (SCID) disorder

  • 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
Psychodrama psychotherapy disorder

  • 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
Mentalization based therapy disorder

  • group conducted by a Mentalization based therapist and co facilitated by other member of clinical team.


Staffing
Staffing disorder


Mbt intensive outpatient programme
MBT Intensive outpatient programme disorder

  • 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 programme1
MBT Intensive outpatient programme disorder

  • 8 patients

  • Slow open group

  • 18 months attendance time frame

  • expected to attend individual and group sessions



Mentalizing: disorder

A new word for an ancient concept

Implicitly 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
MBT perspective disorder

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


The mediator between the genotype and the phenotype is the attachment process

Bulletin of the Menninger Clinic (2003) , 67,3:pp187-211


Mentalization based therapy1
Mentalization based therapy attachment process

  • 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
Internalised persecutory sense of self attachment process

……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
The result? attachment process

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
Suicide attachment process

  • 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.


Lack of Mentalisation attachment process

Stability 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
Lack of Mentalisation attachment process

…adults who act violently, impulsively,

inconsistently and with emotional

volatility show reduced mentalising

capacities and are protecting an

unstable sense of self.


Treatment strategies
Treatment Strategies attachment process

The 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
Identification of affects attachment process

  • 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 attachment process

This is an ability to continually question the

internal mental states both within the patient

and 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?


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