local leader of the NHS BIGSPD Annual Conference Manchester 2012 Effectiveness of CAT for borderline PD delivered in routine practice in the NHS

local leader of the NHS Research team 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

local leader of the NHS CAT evidence base Margison (2000) raised initial concerns There remains a popularity versus credibility dilemma (Marriott & Kellett, 2009) Most evidence clusters around BPD treatment (Simmonds, 2011)

local leader of the NHS But! There is no methodologically sound evidence to suggest the superiority of a single psychotherapy modality over another for BPD (Bateman & Fonagy, 2000).

local leader of the NHS Aims for the study (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

local leader of the NHS CAT therapists 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.

local leader of the NHS Patients A total of 19 patients were recruited to the study - 17 completed treatment and follow-up (89.47 % completion rate)

local leader of the NHS Patients details DetailsPercentages Sexuality70.40% heterosexual Qualifications35.70% no educational qualifications Employment57.10% unemployed Service engagement history50.00% seen in CAMS Self-harm92.90% significant history of self-harm Substance misuse57.10% significant history of alcohol/drug abuse 3 malesMean age = 38.00, SD= femalesMean age = 28.27, SD = 8.73

local leader of the NHS Inclusion criteria 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).

local leader of the NHS Measures; therapists competency 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.

local leader of the NHS Qualitative evaluation; the ‘Change Interview’ (Elliott, Slatick & Urman, 2001) A researcher carried out interview after the 3 rd 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).

local leader of the NHS Therapists competency (n=7) TherapistPatientsSessionsMean CCAT (SD) Sessions <20 CCAT score 114,5,11,16, (2.30)0 233,11,15,17,23 4,10,17,19,21 4,8,16,19, (2.48) (1.30) (2.94) 0 311,3,4,8, (0.54)0 415,8,13,14, (6.68)4/5 511,3,13,18, (7.78)1/5 613,7,13,16, (5.89)0 764,10,14,16,23 1,11,16,17,20 3,13,16,19,21 4,8,12,20,21 3,8,11,20,22 6,8,11,13, (1.81) (1.81) (1.00) (2.28) (1.41) (1.30) 0

local leader of the NHS Therapists competency; conclusions 6 of the 7 ( %) therapists routinely delivered competent CAT. The overall session CCAT mean was (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 (SD = 2.79).

local leader of the NHS Table 2; pre-post CORE-OM scores and effect sizes of CAT for BPD

local leader of the NHS CORE-OM pre-post outcome categories CORE-OM outcome categoryN and percent of the sample Recovered3 (17.64 %) Improved4 (23.52 %) Unchanged9 (52.94 %) Deteriorated1 (5.88 %) Therefore, % of the total BPD sample benefitted symptomatically from receiving CAT.

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So what do the trends means? 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 < reduced dissociation F(1,12) = 30.11, p < and increased personality integration F(1,12) = 9.67, p < 0.01).

local leader of the NHS Do CAT patients keep on progressing in the follow-up sessions? 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)

local leader of the NHS Degree and attribution of change to CAT by BPD patients Definite overall improvement Improved 1.54 (sd = 0.77) Somewhat improved Little worseConsiderably worse Change would not have occurred without therapy CAT influencing change 1.62 (sd = 1.13) Therapy influencing change somewhat Therapy influencing change a little No effect of therapy

local leader of the NHS Benchmarking across PBE and EBP evidence for CAT with BPD

local leader of the NHS Conclusions … 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?

local leader of the NHS Thank you! For any further info please