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 17th May 2005

Acute locked

Acute open 1

Acute open 2

Chronic locked

Male0 4 1 1

female3 2 6 1

% of beds 25% 20% 30% 8%

Numbers: outpatients

Numbers: out-patients

• Forth Valley population 200.000 19-65• 1%: 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= 16 6 months pre programme

During programme

Suicide attempts, accum. 10 3

Selfharm, accum. 7 8

Mean number of in-patient days or IHTTdays/ patient 6 months

23 4

Mean HADS score 29 23

Mean SADD score 27 23

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 prep Peer supervision Group 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

7 7 4 7

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