Evidence-based psychological interventions for borderline personality disorder in the United Kingdom. Who falls through the gaps?

Over the past fifteenyears, access to evidence-based psychological interventions (EBPIs) for borderline personality disorder has dramatically increasedin the United Kingdom. However, some patients continue to fall through the gaps. This paper presents a novel analysis of evidence on patients who are currently unable to benefit from EBPIs and explores possible solutions, with particular reference to dialectical behaviour therapy and mentalization based therapy.At one end of the spectrum, patients with less severe difficulties often do not meet the threshold for receiving EBPIs in dedicated personality disorder services. The nascent evidence base for a possible solution —implementation of streamlined versions of EBPIs in generic mental health or even primary care services —is reviewed. At the other end, asizeable minority of patients receiving long-term EBPIs discontinue treatment prematurely and/or experience poor outcomes. This is a highly distressing experience with potential for iatrogenesis—yet the evidence base for what to do next is non-existent and follow-on treatment pathways in services are unclear. Difficulties in the therapeutic alliance, a failure to overcome epistemic hypervigilance, and therapist non-adherence to the model are reviewed as possible contributing factors. The importance of understanding the patient perspective on what happened, considering the role of both patient and therapist in contributing to difficulties, and offering patients a choice in specifying their onward treatment, is discussed. Finally, increasing access to trauma-focussed EBPIs for post-traumatic stress disorderis recommended as an avenue for the future

\u3cem\u3eTo Fabullus (Invitation)\u3c/em\u3e by Catullus

Translated from Latin by Ranald Barnico

Skills use and common treatment processes in dialectical behaviour therapy for borderline personality disorder

Background and Objectives Dialectical behaviour therapy (DBT) trains participants to use behavioural skills for managing their emotions. The study aimed to evaluate whether skills use is associated with positive treatment outcomes independently of treatment processes that are common across different therapeutic models. Method Use of the DBT skills and three common treatment processes (therapeutic alliance, treatment credibility and self-efficacy) were assessed every 2 months for a year in 70 individuals with borderline personality disorder receiving DBT. Mixed-multilevel modelling was used to determine the association of these factors with frequency of self-harm and with treatment dropout. Results Participants who used the skills less often at any timepoint were more likely to drop out of DBT in the subsequent two months, independently of their self-efficacy, therapeutic alliance or perceived treatment credibility. More frequent use of the DBT skills and higher self-efficacy were each independently associated with less frequent concurrent self-harm. Treatment credibility and the alliance were not independently associated with self-harm or treatment dropout. Limitations The skills use measure could not be applied to a control group who did not receive DBT. The sample size was insufficient for structural equation modelling. Conclusion Practising the DBT skills and building an increased sense of self-efficacy may be important and partially independent treatment processes in dialectical behaviour therapy. However, the direction of the association between these variables and self-harm requires further evaluation

Conclusions and questions from a non-randomised comparison of routine clinical services implementing different treatment models for borderline personality disorder

Our study (Barnicot & Crawford 2018) was a non-randomised comparison of outcomes in routine clinical services implementing different treatment models for borderline personality disorder (BPD): mentalization-based therapy (MBT) and dialectical behaviour therapy (DBT). Our study’s contribution lies primarily in its novelty as currently the only head-to-head comparison of these treatment models, and its potential to generate exploratory findings for further testing in a definitive randomised controlled trial. We thank Luyten and colleagues for their useful commentary

Recovery in Borderline Personality Disorder (BPD): A Qualitative Study of Service Users' Perspectives

PMCID: PMC3355153This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

The Role of Skills Use, Common and Extratherapeutic Factors in Dialectical Behaviour Therapy for Borderline Personality Disorder

PhDThis thesis investigates the role of specific, common and extratherapeutic factors in dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) with self-harm, using both quantitative and qualitative methods. The overall aim is to generate evidence on the mechanisms by which patients with BPD can achieve change. The premise of the thesis is that DBT has been shown to be more effective than control treatments in reducing self-harm in patients with BPD (Brazier et al. 2007, Binks et al. 2006, Stöffers et al. 2012), but the mechanisms by which this is achieved have not been empirically established. Identification of these mechanisms could enable them to be enhanced in existing interventions or even in routine treatment for patients with BPD, so that improved outcomes are achieved (Llewellyn & Hardy 2001, Kazdin 2007). Theories on the mechanisms of change in psychotherapy have identified three types of factor that may contribute to treatment outcome: specific factors, common factors and extratherapeutic factors. Specific factors are those outlined in the theory of a particular therapy as a central mechanism for patient change (Oei & Shuttlewood 1996). In DBT, patients are taught a set of skills to better regulate their emotions, and patients’ use of these skills is identified in the DBT manual as a key mechanism for achieving change (Linehan 1993a, b). Linked to this, the thesis focuses on three specific factors in DBT: perceived understanding, frequency of use and perceived helpfulness of the DBT skills. Common factors are aspects of treatment which are common to all therapies (Oei & Shuttlewood 1996). The contextual theory outlines several factors common to all successful psychotherapy interventions, and argues that these common 17 factors are the key agents of change (Frank & Frank 1991, Wampold 2001). This thesis focuses on three common factors identified by the contextual theory: treatment credibility, the therapeutic alliance, and self-efficacy. Extratherapeutic factors are factors that influence outcome outside of the treatment context (Lambert 2003, Hubble et al. 2005). This thesis focuses on three extratherapeutic factors linked to social support from friends and family: perceived social support, number of social contacts and number of social confidantes. Previous research has shown that more frequent use of the DBT skills is associated with improved outcomes during DBT (Miller et al. 2000, Neacsiu et al. 2010, Stepp et al. 2008). This could suggest that skill use is a specific change mechanism in DBT. Alternatively, Wampold (2001) suggests that specific factors are associated with therapy outcome only because they enhance common factors. For instance, patients who use the skills more are likely to find their treatment more credible, to have a stronger alliance with their therapist, and to feel a stronger sense of self-efficacy. They may also receive more social support from friends and family. No research to date has examined whether skill use is associated with outcome independently of common and extratherapeutic factors. Such research could yield valuable information on how patients receiving DBT achieve change, and on what factors therapists and researchers should focus when aiming to improve outcomes. The first aim of this thesis is therefore to establish whether skills use is associated with the outcome of DBT for BPD independently of common and extratherapeutic factors. Secondly, patients with BPD are often considered to drop out of treatment more frequently than patients with other mental disorders (Bornovalova & Daughters 2004, 18 Horner & Diamond 1996, Kelly et al. 1992). However, very few studies have examined what processes occurring during treatment are associated with dropout. Previous research has shown that a stronger therapeutic alliance is associated with treatment completion in psychotherapy for BPD (Gunderson et al. 1997, Spinhoven et al. 2007, Yeomans et al. 1994). However, the predictive relevance of specific factors such as DBT skills use, other common factors such as treatment credibility or self-efficacy, and extratherapeutic factors such as social support, has not been evaluated. Furthermore, no study to date has examined whether the DBT skills are associated with treatment completion independently of common and extratherapeutic factors. Such research could enable a better understanding of why patients drop out of DBT treatment, and could inform what factors therapists should focus on to prevent this. The second aim of this thesis is therefore to establish whether skills use predicts treatment completion in DBT for BPD independently of common and extratherapeutic factors. Thirdly, quantitative research on the association between treatment processes and outcomes is arguably limited, because although it can show what factors are associated with outcome, it cannot show how these factors lead to better outcomes. By contrast, qualitative interviews with patients can yield valuable insights on how their experiences in therapy enabled them to achieve change, and can enable identification of barriers to change (Hodgetts & Wright 2007). This in turn can inform future quantitative work by giving an indication of what mediating and moderating factors could be evaluated, and can ensure that researchers’ understanding of change mechanisms during therapy remains rooted in the lived experiences of patients rather than tied to abstract academic theories (Black 1994, Denzin & Lincoln 1994, 19 Greenhalgh & Taylor 1997, Miles & Huberman 1994). Since the main focus of the present thesis is on the DBT skills, the qualitative element focuses on participants’ experiences of learning, using and gaining benefit from the skills. The aims are to explore how patients use the skills and how they come to gain maximum benefit from them, what factors facilitate this and what factors act as barriers to this. Based on the above aims, the thesis addresses the following three research questions: 1) Are the DBT skills associated with outcome independently of common and extratherapeutic factors? Specifically: a) Are the DBT skills associated with self-harm frequency during treatment independently of common and extratherapeutic factors? b) Are the DBT skills associated with BPD symptom severity during treatment independently of common and extratherapeutic factors? 2) Do the DBT skills predict treatment completion independently of common and extratherapeutic factors? 3) How do patients experience learning, using and gaining benefit from the DBT skills? Specifically: a) How do patients use the DBT skills? b) How do patients come to gain maximum benefit from the DBT skills? c) What factors facilitate patients in gaining maximum benefit from the DBT skills? d) What factors act as barriers to gaining maximum benefit from the DBT skills? 20 Questions One and Two are addressed using quantitative methods, whilst Question Three is addressed using qualitative methods. The structure of the thesis is outlined below. Chapters One to Four are Literature Review chapters whilst Chapters Five to Seven present empirical data collected and analysed by the doctoral candidate, and Chapter Eight is a Discussion chapter. Chapter One summarises the nature and treatment of BPD, the DBT model, evidence for its effectiveness and the need for research on its mechanisms. Chapter Two reviews the literature on specific, common and extratherapeutic factors in psychotherapy, describes the contextual model and reviews the evidence for and against it, and reviews evidence on the role of specific, common and extratherapeutic factors in DBT. Chapter Three systematically reviews the literature on predictors of symptom change in psychotherapy for BPD, in order to evaluate the weight of evidence in the field and to identify what potential predictors of outcome should be included in the predictive models evaluated in Chapter Five. Chapter Four systematically reviews the literature on treatment completion rates and predictors of completion in psychotherapy for BPD, in order to be able to compare the completion rate in the sample evaluated in Chapters Five and Six, and to identify what potential predictors of completion should be included in the predictive models evaluated in Chapter Six. 21 Chapter Five evaluates the association between skills, common, and extratherapeutic factors and outcome in a sample of patients receiving DBT for BPD with self-harm. Chapter Six evaluates the association between skills, common and extratherapeutic factors and months of treatment completed in a sample of patients receiving DBT for BPD with self-harm. Chapter Seven is a qualitative study using thematic analysis to explore patients’ experiences of learning and using the DBT skills. Chapter Eight discusses the findings as a whole and draws implications for clinical practise and for further researchNIHR Doctoral Research Fellowshi

Dialectical behaviour therapy v. mentalisation-based therapy for borderline personality disorder

Background: Dialectical behaviour therapy (DBT) and mentalisation-based therapy (MBT) are both widely used evidence-based treatments for borderline personality disorder (BPD), yet a head-to-head comparison of outcomes has never been conducted. The present study therefore aimed to compare the clinical outcomes of DBT v. MBT in patients with BPD. Methods: A non-randomised comparison of clinical outcomes in N = 90 patients with BPD receiving either DBT or MBT over a 12-month period. Results: After adjusting for potentially confounding differences between participants, participants receiving DBT reported a significantly steeper decline over time in incidents of self-harm (adjusted IRR = 0.93, 95% CI 0.87–0.99, p = 0.02) and in emotional dysregulation (adjusted β = −1.94, 95% CI −3.37 to −0.51, p < 0.01) than participants receiving MBT. Differences in treatment dropout and use of crisis services were no longer significant after adjusting for confounding, and there were no significant differences in BPD symptoms or interpersonal problems. Conclusions: Within this sample of people using specialist personality disorder treatment services, reductions in self-harm and improvements in emotional regulation at 12 months were greater amongst those receiving DBT than amongst those receiving MBT. Experimental studies assessing outcomes beyond 12 months are needed to examine whether these findings represent differences in the clinical effectiveness of these therapies

Psychological interventions for acute psychiatric inpatients with schizophrenia-spectrum disorders: A systematic review and meta-analysis

BACKGROUND: Acute inpatient psychiatric wards are important yet challenging environments in which to implement psychological interventions for people with schizophrenia-spectrum disorders. No meta-analysis to date has evaluated whether psychological interventions are effective in this context. METHODS: We systematically searched Embase, Medline and PsycInfo databases for randomised controlled trials (RCTs) of psychological interventions implemented in acute inpatient psychiatric settings with individuals with schizophrenia-spectrum disorders. We conducted random effects meta-analyses of between-groups outcomes at post-intervention and relapse/re-hospitalisation rates by follow-up. RESULTS: Twenty-nine trials were suitable for meta-analysis. Psychological interventions improved post-intervention positive symptoms, social functioning and treatment compliance and reduced the risk of relapse/ re-hospitalisation, relative to control conditions. Analyses of specific intervention effects found positive effects of psychoeducation on several key outcomes (power > 80%) and preliminary evidence for positive effects of acceptance and commitment therapy (ACT), cognitive behaviour therapy (CBT) and metacognitive training (MCT) on some outcomes (power < 80%). CONCLUSION: Psychological interventions can be helpful for acute inpatients with schizophrenia-spectrum disorders. However, risk of bias was often high or unclear, and some analyses were underpowered. Further research should use more rigorous RCT designs and publish meta-analysable data on positive symptoms, general psychopathology, relapse/ re-hospitalisation, social functioning and treatment compliance

Loss of relational continuity of care in schizophrenia: associations with patient satisfaction and quality of care

BACKGROUND: Users of mental health service are concerned about changes in clinicians providing their care, but little is known about their impact. AIMS: To examine associations between changes in staff, and patient satisfaction and quality of care. METHOD: A national cross-sectional survey of 3379 people aged 18 or over treated in secondary care for schizophrenia or schizoaffective disorder. RESULTS: Nearly 41.9% reported at least one change in their key worker during the previous 12 months and 10.5% reported multiple changes. Those reporting multiple changes were less satisfied with their treatment and less likely to report having a care plan, knowing how to obtain help when in a crisis or to have had recommended physical health assessments. CONCLUSIONS: Frequent changes in staff providing care for people with psychosis are associated with poorer quality of care. Greater efforts need to be made to protect relational continuity of care for such patients. DECLARATION OF INTEREST: M.J.C. was co-chair of the expert advisory group on the NICE quality standard on Service User Experience in Adult Mental Health. S.J.C. has previously been a member of the Health and Social Care Board Northern Ireland Formulary Committee. D.S. received a speaker's fee from Janssen Cilag in 2011. He is a topic expert on NICE guideline for psychosis and schizophrenia in children and young people and a board member of National Collaborating Centre for Mental Health. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license