DBT pilot Forth Valley: Trials and errors

The beginning: something must be done –Existing patients with BPD: time consuming, distressing –No coherent approach –BPD patients drift towards certain therapist –Some therapists ‘don’t mind BPD’

Numbers: in-patients 17 th May 2005 Acute locked Acute open 1 Acute open 2 Chronic locked Male 0411 female 3261 % of beds 25%20%30%8%

Numbers: outpatients

Numbers: out-patients Forth Valley population %: 2000 no way!! Outpatient clinic: 10% 10 GA consultants: 20 BPD each, 10 ‘on the go’ About 100 patients ‘on the go’ Cornton Vale Prison (female)

The plan Use the staff who see BPD patients anyway Increase staffs’ skill Funding: Choose Life Initiative Collect data: lots Don’t tell management Don’t think beyond the pilot

Would you like to receive training in DBT? 85 nurses shout: yes !! Selection by persistence

1. Are you/ currently dealing with BPD patients? 2. How much time do you spent on such patients? 3. Can you/ your team afford to spend more time on such patients? Would you like to? 4. Do you have time for the training? 5. Will you have time for once weekly supervision? 6. Do you have a room to run group sessions in? 7.Have you discussed your application with the local consultant psychiatrists/ service managers? 8.How did they respond? Selecting therapists

Training days 6 therapists Chester 1st training week October 2005 Start treatment beginning Jan 2006 Once weekly group therapy (two groups) Once weekly team meeting Chester 2nd training week June 2006

Data collection Pre- programme: Staff and patient questionnaires Patient demographic information (incl. number of suicide and self harm attempts, medication use, admissions to hospital) Psychometric tests (GAS; HADS; DAST; SADD) During: Weekly patient session evaluations 8 weekly staff questionnaires/ evaluations Weekly therapist time logs Psychometric tests and demographic data to be collected after 6 months. Post programme: Staff and patient questionnaires Demographic data Psychometric tests Follow-up: Demographic data Psychometric tests.

Number games 16 patients (15 f, 1m) 3 patients have dropped out so far

Pre and during programme data N= 166 months pre programme During programme Suicide attempts, accum.103 Selfharm, accum.78 Mean number of in-patient days or IHTTdays/ patient 6 months 234 Mean HADS score2923 Mean SADD score2723

Patient feedback 1.“There are other people the same as me” 2.“they are teaching me to manage my problem” 3.“It’s overwhelming”

Summary of Results low drop – out rate Less often suicide attempts Less alcohol, less time on psychiatric ward Depression and global functioning the same Most patients appreciative of intervention

Therapists’ time per week Admin and prepPeer supervisionGroup work sessions Ind. Patient supervision Mean time per therapist per week (hours and minutes) 200 (3hrs 20mins) 145 (2 hrs 25 mins) 148 (2 hrs 28 mins) 95 (1 hr 35 mins) Total number of therapists 7747

DBT: The problems It ain’t english time consuming: 3.5 hours therapist’s time per week per patient Hidden and open criticism from some colleagues –Rocking the boat –What happens when therapy stops

The delights Patients –Good adherence –They appreciate our efforts –Remarkable improvement in a minority Therapists –Sense of purpose and direction –Cohesion

A sense of purpose and direction? Treatment for PD rather than avoiding patients vehicle for a service development – even if it isn’t DBT!

The active ingredients 1.Validating environment 2.A structure 3.Being removed: ‘the specialists’ 4.Skills based: teaching patients to manage themselves

How to do it better next time 1.Involve management early 2.Think of the time beyond the pilot 3.Try two different models simultaneously 4.Don’t underestimate the time