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 SERVICE
WHAT 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 SERVICE
WHAT 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 significantis 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
Table 1
Pre and post DBT scores for NASPI total scale
•
•
•
•
Client
Pre-DBT
Post-DBT
1
124
85*
2
99
80*
3
83†
99>
4
85†
84
5
95
113>
6
101
85*
7
65†
62
8
111
119>
* 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
Significance
Table 2.
Pre and post DBT scores for the IIP total scale
Client
Pre – DBT
Post - DBT
1
126
40**
2
145
146
3
89
58
4
120†
121
5
159
91**
6
168
163
7
57†
79
8
123
153
Examples of how to report clinical
Significance
Table 3
Pre and post DBT scores for the BSI total scale
Client
Pre -DBT
Post DBT
1
3.41
3.18
2
3.46
3.52
3
1.67 †
2.16
4
1.94
2.03
5
2.07
0.39**
6
3.20
2.80
7
1.57†
0.96
8
2.28
2.86
Examples of how to report clinical
Significance
Table 4
Pre and post DBT scores for the SPSI total scale
Client
Pre -DBT
Post DBT
1
3.41
3.18
2
3.46
3.52
3
1.67 †
2.16
4
1.94
2.03
5
2.07
0.39**
6
3.20
2.80
7
1.57†
0.96
8
2.28
2.86
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.
44 weeks in DBT (patient 1)
22 weeks of DBT (patient 2)
57 weeks of DBT (patient 3)
48 weeks of DBT (patient 4)
70 weeks of DBT (patient 5)
92 weeks of DBT (patient 6)
56 weeks of DBT (patient 7)
122 weeks of DBT (patient 8)
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?
Service user data
• 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
• Patient 1 entered therapy march 2006 and
had no admissions in 12 months prior to
over duration of therapy
20
Value
Patient 2. Entered therapy July 2007
Number of admissions
Number of days in hospital
30
10
0
7
b0
Fe 8
n0
Ja 7
0
ec
D 7
0
ov
N
07
ct
O 7
0
ep
S 7
0
ug
A
7
l0
Ju 7
n0
Ju 7
0
ay
M
07
pr
A 7
0
ar
M 7
b0
Fe 7
n0
Ja 6
0
ec
D 6
0
ov
N 6
0
ct
O 6
0
ep
S 6
0
ug
A 6
0
ly
Ju 06
ne
Ju
Month
20
Value
Patient 3. Entered therapy June 2007
Number of admissions
Number of days in hospital
30
10
0
7
b0
Fe 8
n0
Ja 07
ec
D 7
0
ov
N 7
0
ct
O 7
p0
Se 7
g0
Au 7
l0
Ju 7
n0
Ju 07
ay
M 7
r0
Ap 07
ar
M 7
b0
Fe 7
n0
Ja 06
ec
D 6
0
ov
N 06
ct
O 6
p0
Se 6
g0
Au 06
ly
Ju 06
ne
Ju 06
ay
M 6
r0
Ap 06
ar
M 6
b0
Fe
Month
Patient 4.
• Entered therapy March 07
• 1 admission April 06 for 3 days
Patient 5.
• Entered therapy November 06
• No admissions except 2 admissions for 2
days in February 2008
15
Value
Patient 6.Entered therapy October
2005
Number of admissions
30
Number of days in hospital
25
20
10
5
0
feb08
jan08
dec07
nov07
oct07
sep07
aug07
jul07
jun07
may07
apr07
mar07
feb07
jan07
dec06
nov06
oct06
sep06
aug06
jul06
jun06
may06
apr06
mar06
feb06
jan06
dec05
nov05
oct05
sep05
aug05
jul05
jun05
may05
apr05
mar05
feb05
jan05
Month
20
Value
Patient 7. Entered therapy February 2005. No
further admissions since Jun 2006
Number of admissions
Number of days in hospital
30
10
0
6
p0
se 6
g0
au
6
l0
ju 6
n0
ju 06
ay
m 6
r0
ap 6
0
ar
m 6
b0
fe
6
n0
ja 5
c0
de 5
v0
no
5
t0
oc 5
p0
se 5
g0
au
5
l0
ju 5
n0
ju 05
ay
m 5
r0
ap 5
0
ar
m 5
b0
fe
5
n0
ja 4
c0
de 4
v0
no
4
t0
oc 4
p0
se 4
g0
au
4
l0
ju
Month
15
Value
Example of graphed service use data for
patient 8. Entered therapy January 2005
Number of admissions
Number of days in hospital
30
25
20
10
5
0
feb08
jan08
dec07
nov07
oct07
sep07
august07
july07
june07
may07
apr07
mar07
feb07
jan07
dec06
nov06
oct06
sep06
aug06
jul06
jun06
may06
apr06
mar06
feb06
jan06
dec05
nov05
oct05
sep05
aug05
jul05
jun05
may05
apr05
mar05
feb05
jan05
dec04
nov04
oct04
sep04
aug04
jul04
jun04
may04
apr04
mar04
feb04
jan04
Month
Next step
• To compare particular time phases to
establish significant or non-significant
reductions in hospital admissions and
lengths of stay.
In summary
• 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 - Comparison of those
who discontinue therapy with
those who continue.
AIM
• To identify reasons why patients
discontinue therapy.
• Why?
• To channel otherwise limited resources
towards those with whom therapy might
prove more effective.
Measures
• 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
• 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
• 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 Diagnosis
Continuers
Discontinuers
P1 - BPD
P8 - BPD, obsessive/compulsive PD
P2 - BPD
P9 - BPD, Paranoid, Histrionic,
Dependant, Avoidant
P3 - BPD
P10 - BPD, Avoidant
P4 - BPD
P11 - BPD, Dependant, Avoidant,
Schizoid
P5 - BPD
P12 – BPD, Paranoid, Schizoid,
Histrionic, Narcissistic, Avoidant,
Dependent
P6 - BPD, Impulsive PD
P13 – BPD, Impulsive, Avoidant,
Dependant
P7 - BPD, Avoidant PD
P14 – BPD, Histrionic, Avoidant,
Obsessive/compulsive
SPSI results
Continued
Discontinued
MannWhitney U *
Positive Problem
Orientation
7.16 (3.31)
5.57 (4.35)
-0.57
Negative Problem
Orientation
26.33 (5.68)
31.71 (5.18)
-1.08
Rational Problem Solving
42.50 (18.49)
32.57 (21.46)
-1.00
Impulsive/careless Style
16.01 (7.64)
20.14 (10.82)
-0.94
Avoidant Style
13.33 (7.42)
16.14 (4.59)
-0.43
* All non significant
Motivation (TMQ)
• 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
• 4 patients admitted
• Discontinuers
• 6 patients admitted
• 16 total admissions
• 17 total admissions
• 151 bed days
• 379 bed days
• Total cost = £39,197
• Total cost = £122,444
Tentative Interpretation
• 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
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 (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
Consultation service
evaluation.
Consultation service evaluation
• 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 evaluation
• 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
• 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 subthemes via qualitative analysis.
Results
• Staff descriptions of patients:• Unpredictable.
• Difficult.
• Challenging.
• Needy.
• Friendly.
• Pleasant.
Results
• Feelings elicited working with BPD:• Frustrated.
• Helpless.
• Anxious.
• Angry.
• Curious.
• Interested.
Results
• Reasons for contacting GTS:• Can’t progress with patient
• Lack strategy
• Need fresh ideas
• Unstructured approach
Results
• Main problems experienced with patient:• Suicidal Ideation.
• Self-Harm.
• Substance misuse.
• Non-compliance.
Results.
• 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.
Results
• 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
– 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
• 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
Nursing staff attitudes
towards personality
disorder.
Nursing staff attitudes towards personality
disorder
• 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.
Method
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)
Method
• Measure:Attitude Towards Personality Disorder
Questionnaire (APDQ; Bowers et al.
2000).
37 item measure with 5 scales: enjoyment,
security, acceptance, purpose,
enthusiasm.
Method
• 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.
Method
• 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 CarrWalker et al. (2004)
Results
• Compared to non-volunteer group, nurses who
volunteer for PD awareness workshop reported
significantly higher levels of:Enjoyment.
Security.
Acceptance.
Purpose.
But not enthusiasm.
Results
• Trust nurses were compared with Prison
officers, the latter of whom reported
significantly higher levels of:– Security.
– Acceptance.
– Purpose.
– Enthusiasm.
Results
• 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.
Results
• 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.
Results
• 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
• 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
Delphi survey of patients
views of services they have
had contact with.
The Delphi survey
• 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
• 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 Findings
• GTS generally perceived as:• Respectful.
• Supportive.
• Professional.
• More details can be found in paper below.
References
•
Webb, D., & McMurran, M. (2007). Nursing staff attitudes towards patients
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