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BIGSPD Annual Conference
Manchester 2012
Effectiveness of CAT for borderline
PD delivered in routine practice in
the NHS
Research team
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Stephen Kellett
University of Sheffield & Sheffield Health and Social Care
NHS Foundation Trust, UK
Dawn Bennett
Clinical Psychology Service, Lancashire Foundation NHS
Trust, UK
Tony Ryle
Retired
&
Anna Thake
Schaar, University of Sheffield
CAT evidence base
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• Margison (2000) raised initial concerns
• There remains a popularity versus credibility dilemma
(Marriott & Kellett, 2009)
• Most evidence clusters around BPD treatment
(Simmonds, 2011)
But!
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• There is no methodologically sound evidence to suggest
the superiority of a single psychotherapy modality over
another for BPD (Bateman & Fonagy, 2000).
Aims for the study
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(1) to describe in detail the delivery of CAT by experienced therapists
in routine practice recording uptake, drop-out and follow-up
completion rates
(2) to assess the effectiveness of CAT for BPD under routine care
conditions,
(3) to observe the shape of change in distress, identity and dissociation
in BPD patients undergoing CAT
(4) to assess fidelity to the treatment model in routine care conditions
(5) to bench-mark the outcomes achieved in the current sample by
comparing them with reported outcomes for CAT in BPD.
(6) to assess whether patients attribute change to CAT
CAT therapists
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All treatments were carried out by 10 accredited CAT therapists
All worked in NHS mental health service Trust sites
All therapists had completed the 2-year CAT practitioner training
Five of the ten therapists were qualified to supervisor level and all
therapists were required to be in receipt of regular clinical supervision.
One therapist treated 6 patients, one therapist 3 patients and one
therapist 2 patients (one of whom was lost to follow-up due to
emigration); the remaining therapists all treated a single patient.
Patients
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• A total of 19 patients were recruited to the study - 17
completed treatment and follow-up (89.47 % completion
rate)
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Patients details
Details
Percentages
Sexuality
70.40% heterosexual
Qualifications
35.70% no educational qualifications
Employment
57.10% unemployed
Service engagement history
50.00% seen in CAMS
Self-harm
92.90% significant history of self-harm
Substance misuse
57.10% significant history of
alcohol/drug abuse
3 males
Mean age = 38.00, SD= 1.73
14 females
Mean age = 28.27, SD = 8.73
Inclusion criteria
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As this was a study of routine practice, the establishment of
a BPD diagnosis was made according to normal
diagnostic practice of participating services.
Patients had to meet DSM-IV (APA, 1994) BPD criteria and
to score 28 or more on the Personality Structure
Questionnaire (PSQ; Pollock, Broadbent, Clarke, Dorrian
& Ryle, 2001).
Measures; therapists competency
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• The competency of the CAT sessions delivered was assessed using the
Competency of Cognitive Analytic Therapy measure (CCAT; Bennett & Parry,
2004).
• CCAT is a valid and reliable measure of CAT competency across ten domains
and a global score of above 20 provides a cut-off for therapist competency for
that session (Parry & Bennett, 2006).
• Audiotapes of sessions for CCAT analysis were selected according to two
criteria; (1) where changes in the outcome measure graphs suggested either
sudden improvement or deterioration and (2) on the basis of the patient’s
replies and comments on the Helpful Aspects of Therapy measure (Llewelyn,
1988), which was completed following each session.
• Across the cases, 5 sessions were then randomly sampled from each therapy
(20.88 % per therapy) due to differences between the cases in terms of
available CCATS.
Qualitative evaluation; the ‘Change
Interview’ (Elliott, Slatick & Urman,
2001)
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A researcher carried out interview after the 3rd follow-up session.
The interview essentially involves engaging the patient in a skeptical enquiry of
the degree and origin of change (Elliott, 2002).
Outcome graphs of CORE-OM, DES and PSQ scores were available for the
interviewer to stimulate reflection on change by the patient.
Audiotapes of each interview were then rated by two separate researchers who
had not completed the research interview and who were blind to the outcome.
Ratings were made of (1) the degree of change reported (likert scale ranging
from 1 ‘definite overall improvement’ to 5 ‘considerably worse’) and (2) of the
attribution for change to the therapy (likert scale ranging from 1 ‘change would
not have occurred without therapy’ to 5 ‘no effect of therapy’).
Change interviews were available for 12 of the 17 patients in the study (70.58
%) and the ICC for the degree and attribution of change ratings were 0.91 (p <
0.001). This indicates a very high level of agreement and consistency
between the raters (Landis & Koch, 1977).
Therapists competency (n=7)
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Therapist
Patients
Sessions
Mean CCAT
(SD)
Sessions
<20 CCAT
score
1
1
4,5,11,16,17
37.60 (2.30)
0
2
3
3,11,15,17,23 35.20 (2.48)
4,10,17,19,21 36.80 (1.30)
4,8,16,19,20
34.80 (2.94)
0
3
1
1,3,4,8,10
39.60 (0.54)
0
4
1
5,8,13,14,17
14.20 (6.68)
4/5
5
1
1,3,13,18,23
30.20 (7.78)
1/5
6
1
3,7,13,16,22
31.20 (5.89)
0
7
6
4,10,14,16,23
1,11,16,17,20
3,13,16,19,21
4,8,12,20,21
3,8,11,20,22
6,8,11,13,20
38.40 (1.81)
34.00 (1.81)
38.00 (1.00)
37.20 (2.28)
38.00 (1.41)
35.80 (1.30)
0
Therapists competency; conclusions
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6 of the 7 (85. 71 %) therapists routinely delivered
competent CAT.
The overall session CCAT mean was 34.35 (SD = 6.39)
Of the 70 sessions sampled 65 (92.85 %) met the CCAT
criteria (CCAT > 20) for competently delivered CAT.
The five out of the six CAT therapists’ scoring over 20 on
the CCAT showed highly consistent and competent levels
of CAT delivery with a mean score of 35.90 (SD = 2.79).
Table 2; pre-post CORE-OM scores and effect sizes of CAT
for BPD
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CORE-OM pre-post outcome
categories
CORE-OM outcome category
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N and percent of the sample
Recovered
3 (17.64 %)
Improved
4 (23.52 %)
Unchanged
9 (52.94 %)
Deteriorated
1 (5.88 %)
Therefore, 41.16 % of the total BPD sample benefitted symptomatically from receiving CAT .
50
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CORE-OM, DES and PSQ over the screening, treatment and follow-up
sessions
DES current sample
PSQ BPD
mean
(Pollock
et al, 2001)
35
40
45
DES BPD mean (Pollock et al., 2001)
PSQ current sample
10
15
20
25
30
Scale
CORE-OM PD mean (Barkham et al., 2005)
CORE-OM
current
sample
So what do the trends means?
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There was a statistically significant trend over the
course of the sessions of:reduced psychological distress F(1,26) = 28.56, p
< 0.00
risk F(1,27) = 9.20, p < 0.005
reduced dissociation F(1,12) = 30.11, p < 0.001
and
increased personality integration F(1,12) = 9.67, p
< 0.01).
Do CAT patients keep on
progressing in the follow-up sessions?
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Comparisons between treatment and follow-up phase scores
showed that BPD patients continued to experience: reducing psychological distress (t = 3.32, p < 0.05)
 and reducing dissociation (t= 4.77, p < 0.001)
Degree and attribution
of change to CAT by BPD patients
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Definite
Improved
overall
1.54
improvement (sd = 0.77)
Somewhat
improved
Little worse
Considerably
worse
Change would
not have
occurred
without
therapy
Therapy
influencing
change
somewhat
Therapy
influencing
change a little
No effect of
therapy
CAT
influencing
change
1.62
(sd = 1.13)
Benchmarking across PBE and EBP
evidence for CAT with BPD
Diagnosis
Data source
BPD
Current dataa
BPD
Ryle &
Golynkina
(2000) b
Wildgoose,
Clarke &
Waller
(2001)d
Chanen et al.,
(2008)c
BPD
BPD
a
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Number of
patients
Completers
(n=17)
Completers
(n=27)
Pre
Post
25.83
(8.48)
29.70
(12.14)
19.18
(10.84)
20.19
(15.07)
Completers
(n=5)
88.40
(4.72)
78.40
(14.15)
0.67
Completers
(n=41)
60.27
(8.40)
67.31
(9.81)
0.71
CORE-OM b SOFAS c BDI d MCMI-III
Effect
Size
0.65
0.63
Conclusions …
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• CAT for BPD appears effective in routine care - patients still progressing
after treatment completed in distress and dissociation. Risks reduced.
• The ‘style’ of CAT appears suited to BPD; user friendly and change attributed to CAT.
• BPD patients seem to need to experience some symptomatic
relief before engaging in more challenging integration work - the shape of change differs.
• Methodological concerns; particularly lack of diagnostic certainty
•Therapist competency; you either really are (or you really aren’t!)
what are the training and supervision implications of this?
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Thank you!
For any further info please email:
s.kellett@sheffield.ac.uk