TRAP: A long term outcome and process study of a residential treatment for treatment refractory adolescents with personality disorders Dineke Feenstra & Joost Hutsebaut September 2009, Ghent

PTC De Viersprong  PTC De Viersprong is a third line mental health setting. It offers specialized assessment and treatment programs (outpatient, day hospital and inpatient) for adolescents and adults with personality disorders  De Viersprong has its own research department, the VISPD: Viersprong Institute for Studies on Personality Disorders

Research group  Joost Hutsebaut  Dineke Feenstra  Annelies Laurenssen  Jan van Busschbach  Roel Verheul  Els Havermans

Background: Outcome research in adolescents  Progress in child- and adolescent psychotherapy outcome research: –Psychotherapy is an effective treatment for children and adolescents (mood-, anxiety-, eating-, and conduct disorders) (Kazdin & Weisz, 2004). –Improvement in methodological qualities of research (more controlled studies, treatment protocols etc.) (Kazdin, 2002).

Background: Outcome research in adolescents  Limitations in child- and adolescent psychotherapy outcome research: –Uncovered area: personality disorders (PD) in adolescents –Lack of developmental sensitivity: treatment models as well as outcome instruments are little developmentally sensitive Review of 25 empirically supported psychotherapies in adolescents (Weisz & Hawley, 2002) –14 effective treatments –7 adult models, 6 child models, 1 adolescent model (MST)

Background: Treatment of PD in adolescents  Adolescents are left out of multidisciplinary guidelines for the treatment of PD’s  No evidence based models for the treatment of adolescent PD  Few handbooks: Kernberg, 2000 (psychodynamic approach); Bleiberg, 2001 (relational approach rooted in attachment theory); Miller et al., 2007 (DBT); Freeman & Reinecke, 2007

Background: Outcome studies adolescents with PD  Chanen et al., 2008: –RCT Cognitive Analytic Therapy (CAT) versus manualised good clinical care  Rathus & Miller, 2002: –Quasi experimental investigation of an adaptation of Dialectical Behavior Therapy (DBT)

TRAP-study: Rationale  Rationale: –First: little is known about severe personality disorders in adolescents –Second: little is known about intensive inpatient treatment (for personality disturbed adolescents) –Third: we know little about developmental sensitive outcomes of psychotherapy for adolescents

TRAP-study: Objectives  Objective 1: treatment outcome  Objective 2: prediction of treatment outcome  Objective 3: relation between relational changes and relapse

TRAP-study: Design  Naturalistic study  Include 130 adolescents with personality pathology who are admitted to the inpatient unit of the youth department of De Viersprong (duration of treatment is 1 year)  Measurements at start of treatment, 6, 12 and 24 months after the start of treatment

TRAP-study: Instruments Instrument Intake/ Start of treatment 6 months after start of treatment 12 months after start of treatment 24 months after start of treatment General questionnaire Anxiety Disorders Interview Schedule for DSM-IV (Adis-C) Structured Clinical Interview for DSM IV axis II Personality Diusorders (SCID-II) Brief Symptom Inventory (BSI) Severity Indices of Personality Problems (SIPP-118) Autnomy and attachtment quest. (AHV) Depressive experiences quest. For Adolescents (DEQ-A) Competence quest. for adolesc. (CBSA) Life events Quality of relationships Inventory (QRI) Family Assessment Device (FAD-N) Outcome quest. IQ (KAIT) Stigma Therapeutic alliance Group cohesion

TRAP-study: Sample charachteristics  Sample characteristics (baseline): –N = 133 –Gender = 113 female (85%); 20 male (15%) –Mean age= (range 14-19) –Mean IQ = 104 (range )

TRAP-study: Sample characteristics  Sample characteristics (baseline): –Axis I: 100 adolescents (75.19%) had at least 1 Axis I disorder * Other axis I disorders were diagnosed in less than 10% of the adolescents. Axis I disorderN% Dysthymic disorder Social phobia Major depressive disorder PTSD Any Axis I disorder

TRAP-study: Sample characteristics  Sample characteristics (baseline): –Axis II: 63 adolescents (47.37%) had at least 1 Axis II personality disorder Axis II disorderN% Borderline PD Avoidant PD Depressive PD Obsessive-compulsive PD43.01 PD not otherwise specified75.26 Any PD

TRAP-study: Drop out  Dropping out of the treatment: N% Drop out4433 No drop out8967 Total133100

TRAP-study: Results symptom level (BSI)  Brief symptom inventory (BSI)

TRAP-study: Results personality functioning (SIPP)

TRAP-study: Results other outcome measures (self report)

TRAP-study: Strengths & limitations  Strengths: –Use of developmentally sensitive (and positive) outcome instruments –Several measuring points –Including severely personality disturbed adolescents –Use of semi structured interviews to assess both Axis I and Axis II disorders  Limitations: –No control group –High level of drop-out –Underrepresentation of boys –No treatment manual

TRAP-study  Conclusion: –A group of severely disturbed adolescents underwent an intensive inpatient treatment program. A large group of these adolescents dropped out of treatment. The adolescents that stayed in treatment showed improvement in symptom level, personality functioning and developmental tasks (f.e. school). –This is a first step (pilot study) in investigating the uncovered area of adolescents with severe personality disorders. Further research is needed, investigating manualized treatment programs with methodologically stronger research designs.

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