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Stephen Kellett Consultant Clinical Psychologist IAPT Programme Director University of Sheffield Sheffield S & HC NHS Trust.

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Presentation on theme: "Stephen Kellett Consultant Clinical Psychologist IAPT Programme Director University of Sheffield Sheffield S & HC NHS Trust."— Presentation transcript:

1 Stephen Kellett Consultant Clinical Psychologist IAPT Programme Director University of Sheffield Sheffield S & HC NHS Trust

2 Present Study Assessment, case description, treatment and long-term outcome of client presenting with Paranoid Personality Disorder (PPD) Hermeutic single case experimental design (Elliott 2002) (1) traditional outcomes measures (2) personal questionnaire daily (3) perceptions of therapy and therapist (4) post therapy interview (5) well described case (6) expert panel or ‘jury’ to consider the evidence for change

3 PPD : DSM-1V (APA, 1994) DEFINITION suspects (without sufficient basis) that others are exploiting, harming or deceiving them pre-occupied with trustworthiness inability to confide reads demeaning/threatening meanings into events grudges perceives attacks on character jealous

4 Present Study cont Repetition of measures focal to PPD across phases of CAT treatment and phases within phases (ie. addition of mindfulness) (1)reformulation/assessment phase (2)CAT intervention (3)follow-up

5 The Case Carl (pseudonym, aged 37, signed off work) Referred by Consultant Psychiatrist opinion re. thought disorder Screened and placed on waiting list Assessed via SCID-II (Spitzer et al, 1997) FactorDescription CHILDHOODfather morbidly jealous of mother used as a ‘spy’ interrogated sibling reinforcement of schema by step-father OCCUPATIONunskilled jobs 2 years benefit fraud investigator 13 years DWP currently

6 The Case cont RELATIONSHIPSmarried – disconnected & distrustful of partner 1 child – few friends ‘COPING’drugs & alcohol MENTAL HEALTHhistory of depression schizoid anti-depressant/anti psychotic SYMTOMATOLOGYdisconnected untrusting suspicious ‘The Game’ vigilance; ‘the radar’ ‘safety’ behaviours conspiracy theories

7 Hermeneutic SCED; what was done and when (1) Traditional Outcome Measures reported at assessment, termination, and follow-up Beck Depression Inventory-II (BDI; Beck et al, 1994) Brief Symptom Inventory (BSI; Derogatis, 1993) Inventory of Interpersonal Problems (IIP-32; Barkham et al, 1994) Personality Structure and Questionnaire (PSQ; Pollock et al, 2001) (2) Personal Questionnaire Actual WordingPPD criteria/conceptFrequencyScale Item 1“I have felt suspicious of other motives today” DSM-IV Subjects that others are exploiting, harming or deceiving others Daily1 ‘not at all’ to 10 ‘all the time’ Item 2“I have been scanning my environment today” Hypervigilance Daily1 ‘not at all’ to 10 ‘all the time’

8 Hermeneutic SCED cont Actual WordingPPD criteria/conceptFrequencyScale Item 3“I have been questionning the motives of others today” Is preoccupied with unjustified doubts about loyalty or trustworthiness of others Daily 1 ‘not at all’ to 10 ‘all the time’ Item 4“I have been in a world of my own today” Dissociation/ Disconnection Daily1 ‘not at all’ to 10 ‘all the time’ Item 5“I have been looking for connections today” ConspiracyDaily1 ‘not at all’ to 10 ‘all the time’ Item 6“I have felt anxious today” AnxietyDaily1 ‘not at all’ to 10 ‘all the time’

9 Hermeneutic SCED cont (3) Perception of therapy and therapist Session Impact Questionnaire (Stiles et al, 1994) 5 ‘impacts’ measured after each session (understanding, problem solving, relationship, unwanted thoughts, hindering aspects) (4) Post-therapy Interview Therapy change interview (Elliott, Slatick & Urman, 2001)

10 Structure of intervention co-working and sharing; reformulation letter SDR (starting to get cognitive) introduction of mindfulness techniques integrating RR analysis and mindfulness homework in session enactments termination issues

11 Mindfulness-based cognitive therapy (Segal, Williams & Teasdale, 2002) Mindfulness of breath Staying present Allowing/letting be Thinking and thought Dealing with barriers

12 Diagram 1: Sequential Diagrammatic Reformulation for PPD Case TOTALLY UNFEELING CUT OFF & EMPTY CORE PAIN anxious fearful insecure hectored CAPTAIN PARANOIA (though I feel complete) INTERROGATING I INTERROGATED `THE GAME` Players versus non-players OBSERVING WATCHING I MONITORED SOCIAL WITHDRAWAL `the radar` SUSPICIOUS I WARY DISTRUSTFUL find this frightening after a while start to feel vulnerable only way I know to feel safe obsess about it start to believe thoughts `peas in the bag` try to see a pattern need to make sense anxiety triggered see threat everywhere when with people, always keep my distance find it hard to `connect` never develop `true` trust start to see threats withdraw into myself mood plummets Hard to tolerate this feel totally exhausted can’t ever relax never ever stop thinking try to make sense of confusion need something to tie it all together start to play this game is real `ha ha; I’ve seen you` win / outwit/ triumph

13 Key question 1 At what stage does active therapy start to work and are there any sudden gains?


15 Table 1; means, (SDs) and F-values for the experimental variables Baseline mean (SD) Treatment mean (SD) Follow-up mean (SD) F-value Suspicious34.33 (2.08)11.82 (7.12)7.00 (0.00) ** Hypervigilent23.67 (9.81)9.61 (11.04)7.00 (0.00)0.06 Questioning21.67 (16.67)9.67 (2.76)7.00 (0.00)1.98 Dissociation20.33 (14.01)11.15 (7.15)7.00 (0.00)1.26 Conspiracy19.67 (17.78)10.48 (6.11)7.00 (0.00)2.49 Anxious27.33 (11.52)16.48 (10.30)17.16 (9.06) 4.24 * * p < 0.05 ** p < 0.01

16 What do significant F-values mean in this context? An overall change in both the intercept (i.e. start of treatment post formulation) and the slope (regression line)

17 Key question 2 Is there any clinically significant change in the traditional outcome measures?


19 Key question 3; are some sessions more impactful/helpful than others? Significant increase in ratings of problem solving in treatment sessions (t = -2.27, P < 0.05) No difference in understanding, relationship, unwanted thoughts or hindering aspects

20 Key question 4 can the client describe what changes were due to therapy and what made the difference the change interview conducted at final follow-up session

21 Change interview results “feel so much better, not be thinking all the time” “not playing the game such a relief … I can manage my thoughts now” 5 = surprised; 1 = expected In therapy actions … ‘developing trust’ Key changes (1) use of SDR (2) integrating mindfulness and RRs “ I see people differently now” Managing the paranoia with somebody, very difficult at first

22 Conclusions for the case Integration the key issue Good evidence of change and change being attributable to the therapy conducted HSCED effective research methodology in PD populations

23 CAT and BPD multi-site HSCED study Project team = Stephen Kellett, Dawn Bennett and Tony Ryle Progress = 8 therapists over 8 sites have completed a 24 plus 4 follow-up session CAT interventions with BPD clients Sessions sampled from each of the therapies and CCAT conducted to attain competency rating (111 CCATs completed)

24 Methodology AT EACH SESSIONAt every 4 th SessionAt 3 month post-therapy CORE-OMDissociative Experiences Scale Elliot Change Interview Personal QuestionnairePersonality Structure Scale Helpful Aspects of TherapyMeasure of alliance Audio tape of session

25 Need for an expert panel/jury We are attempting to recruit a panel of professionals to consider the evidence for change in a number of cases Professionals not aligned to CAT and sceptical about change One day meeting

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