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A Cognitive Analytic Multicomponent Psychotherapy Program, for the Treatment of Severe Personality Disorders in an Intensive Outpatient Unit.

Mirapeix, C., Landin, S. and Alvarez, V., 2004. A Cognitive Analytic Multicomponent Psychotherapy Program, for the Treatment of Severe Personality Disorders in an Intensive Outpatient Unit.. Reformulation, Spring, pp.10-13.

Carlos Mirapeix.
Psychiatrist, Director of the PDU.

Susana Landin.
Psychologist. PDU Clinical and research coordinator.

Violeta Alvarez.
Psychologist. PDU Training coordinator.

Personality Disorders Unit.
Marquis of Valdecilla Foundation / Institute for Psychotherapeutic Studies
Ministry of Health and Social Services.
Cantabria Government.
SPAIN

INTRODUCTION

The Cantabria Personality Disorders Unit (www.utp-cantabria.org) emerged as a result of the recommendations made by the expert committee evaluating the mental health needs in our Region for the next 5 years. They concluded that: usually interventions with this type of severe disordered patients were either inadequate or insufficient. PD are undertreated and their needs require complex therapeutic programs. The fact that the delivery of treatment needs a highly specialized service was why for our Institute was asked to run and design an intensive outpatient Unit. Our group has been working in the area of PD during the last few years (Mirapeix 1996, 1999, 2000, 2002, 2003). We have built up, in the public sector, a specialized, cognitive analytic multicomponent and integrated treatment program, where the coherence derived from a basic theoretical frame of reference is sustained in the cognitive analytic developments. It is also supported in the bio-psycho-social model as a longitudinal integration between different levels and the schema theory as transversal integration at the psychological level. The longitudinal integration (bio-psycho-social) is well understood under general system theory, and links are made through transversal integration at the psychological level. This is the basic requirement of an integrated psychotherapy, the integration of behaviour, cognition and affect. In my view, schema theory is the most powerful theory linking longitudinal and transversal integration. Schema theory is the vertex at which longitudinal and transversal lines of inbtegration cut across each other. This longitudinal and transversal integration is supported in a complex revision of the procedural sequence model into a multilevel (sequential and parallel) information processing theory that will be published elsewhere.

Severe personality disorders need a coherent and specialized treatment team, with a coherent theory, shared training and supervisión, and must be integrated with other services of the mental health network. Due to the high emotional demands of working with these patients, one of our specific requirements is that all therapists in our Unit are employed part time. We are also developing a research program linked to the Social Psychiatry Research Unit (World Health Organization) directed by Prof. JL Vazquez-Barquero.

Our Unit is designed to treat 60 new patients every year and the length of treatment varies between 6 and 18 months.

SOCIODEMOGRAPHIC AND CLINICAL FEATURES

At 31 August 2003, after 5 months of the official allocation of the new facilities and after a previous pilot phase of 1.5 years, we present some basic sociodemographic and clinical data.

There was a total of 53 patients at that date and their characteristics are summarized in the following table:
See Table 1 below..

Table 1. SOCIODEMOGRAPHIC DATA
AGE Media Range	30 years 18-44 years
SEX Men Women	% 32.5 67.5
CIVIL STATE Single Married Divorced	% 62.5 27.5 10
CLINICAL DATA
PERSONALITY DIAGNOSIS BPD Mixed Others	% 67.5 20.0 12.5
PARASUICIDE BEHAVIOUR DURING THE PAST YEAR Yes No	% 57.5 42.5
TREATED AS INPATIENT DURING LAST YEAR Yes No	% 62.5 37.5
PREVIOUS PHISICAL OR PSYCHOLOGICAL ABUSE Yes No	% 42.5 57.5
HISTORY OF SEXUAL ABUSE Yes No	% 30.0 70.0

The basic profile of a patient in our Unit is a middle aged single woman, with borderline personality disorder, who has been treated as an inpatient during the last year, usually for a suicide attempt, with a personal history of physical, psychological or sexual abuse.

REFERRAL CRITERIA

As an intensive outpatient unit, our unit is a third level resource for specialized treatment. It is not open to the general public and GPs can’t directly refer patients to the Unit. Only specialized teams headed by psychiatrists or psychologists can refer patients to our service.

In order to be referred to the unit the patient must meet the following criteria: Inclusion criteria:

• Patients aged between 17 and 45 years old.
• Patients must present a personality disorder as principal diagnosis, preferably belonging to Cluster B, especially with borderline personality disorder.
• With GAF (DSM-IV Global Assessment of Functioning) as severity index. In this scale it’s necessary that patients reach marks between 41 and 60.

Exclusion criteria:

• Patients who suffer active psychosis.
• Organic and/or toxic psychopathology.
• Low intellectual level.
• Drug users, unless they are simultaneously in treatment in a specialized Center and have 6 months of no drug use.
• Psychopathic Personality features without high motivation for their treatment.
• Auto or hetero aggressive behaviours (aggression directed to the self or others) which require hospital treatment.

THEORETICAL BACKGROUND

Despite the complexity of different formats of therapy used in our program (individual, group, family and couples therapy), all of them shared a common understanding of the basic process under a Cognitive Analytic Therapy background (Ryle and Kerr 2002). We have introduced some innovations to bridge the gap between inner object relations and more directive interventions devoted to training skills in order to keep the patient alive. Severe personality pathology requires a theoretical framework that gives sense to all the complex interventions, and the team must share a common language in order not only to understand the patients, but also to potentiate the sinergy between formats, and avoid collusion and splitting within the team.

Why a multicomponent program?

• An authentic bio-psycho-social integration is needed to treat complex PD properly.
• Medication as a tool to regulate homeostasis for increasing effectiveness of psychotherapy (patients gain accessibility to a better data processing).
• Different formats of psychotherapy (individual, group, family and couples) are required.
• Sociotherapy is also needed as a rehabilitation component for very disturbed patients.

Why Cognitive Analytic Therapy?

• A bio-psycho-social integration is at risk of being a technical eclecticism without a guiding theory.
• CAT gives the theoretical support to understand the pathology as well as acting as a guide in developing the individualized treatment program at a Bio-psycho-social level.
• Helps to understand the sequential strategic treatment program.
• Makes sense of team and institutional dynamics. The use of contextual reformulations.

CAT understanding gives theoretical support to explain the pathology and acts as a guide in developing an “individualized treatment program” at the bio-psycho-social level. A pill could be interpreted by the patient in very different ways, inner proccesses and RRPs clarify the integration of the medication within the patient’s inner world and in the treatment context. Also CAT theory helps us to understand the “sequential strategic treatment program”. The inclusion into the group programs is not standardized, we individualize the sequence, based in a broad understanding of the sequence in the complete program. Finally CAT theory and diagrammatic technology helps to make sense of the team and institutional dynamics with the use of contextual reformulations.

One of the characteristics of our program, shared with Sue Clarke’s, is that we use Linehan’s Dialectical Behavioural Therapy technology. The big difference is that the Sue Clarke model uses a sequential approach of CAT and DBT, while we use both in an integrative package with the theoretical support of the CAT procedural sequence model, re-formulated into a complex system of information processing.

Linehan’s groups have proved the theory’s efficacy in helping patients to control self destructive behaviours. They promote an increase in self care and improve the external behaviour of patients, while CAT is working with the internalized roles that gives sense to the inner world of the patient as well. Both CAT and DBT work on emotions as the central element. CAT introduces an individualized analysis of the sequential information processing. Multilevel data are processed in parallel by hidden units, personal schemas that with the interaction with other events (internal or external) activate specific states of mind that often shift and are splendidly explained by the multiple self states theory of BPD developed by Ryle (1997). The identification of the shifting sequence and the regulation of emotional process are basic components in the treatment of severe personality disorders, which might be characterized by the lack of the individual´s ability to regulate emotional intensity and shifting between self states.

Recent developments of Semerari’s (2003) theory of metacognitive disfunctions in severe personality disorders are very useful in order to describe more accurately this complex area of metacognition. BPD have disrupted metacognitive capacities that interfere in their lives and therapy, and produce severe symptoms like impulsivity or dissociation. Metacognitive function is defined by the capacity of individuals to make heuristic cognitive operations on their own and other people´s psychological behaviour, and the capacity to use this knowledge to solve problems and to cope with specific mental states which are a source of subjective suffering. We believe that the increase of the metacognitive function represents an important therapeutic factor in psychotherapy, closely connected to the stability of the improvements (Semerari 2002). The author uses a very similar description to that used in CAT for defining metacognitive processes. This implies regulation and control which include activities such as: defining a problem, being able to predict one’s own performance, planning a cognitive activity, foreseeing the efficacy, monitoring the processes and adjusting them according to the aims.

To have a metacognitive competence one needs to have a Theory of Mind (ToM) meaning the capacity to represent to oneself mental events, to attribute to oneself and to others mental states and to foresee and explain the manifest behaviour on the basis of these representations (Semerari 2002).

Some very disturbed patients with a high deficit in these metacognitive functions need prior training in improving their ability to process complex data before entering in a formal psychotherapeutic protocol. We are developing a specific module as a subprogram in our multicomponent approach.

THERAPEUTIC STRUCTURE

Treatment goals are:

1. Stabilisation of high risk behaviour;
2. Improvement of interpersonal and self-management skills;
3. Generalisation of new behaviour over time and in different contexts.

Our cognitive analytic multicomponent psychotheapy program is integrated by the following subprograms:

1. Evaluation and Psychological Education

• Welcome to the Unit, evaluation of risk behaviours and information about norms. Allocation of the patient to the evaluation program or simultaneous assignment to brief containment psychotherapy.
• Structured individual evaluation (4 sessions: psychiatric, psychological (2) and social evaluation). Using structured instruments for research purposes.
• Patients’psychological education (5 sessions covering the following topics: understanding Personality Disorder, General Schema Theory, states of mind and self states, understanding and managing high risk behaviors).
• Families’ psychological education (5 sessions, covering similar topics).
This phase is highly motivational and guided to promote introspection.

2. Individual psychotherapy:

• Brief containment psychotherapy: only used with those patients whose risk behaviours need immediate intervention to increase self-management. Supportive, paedagogic and CAT oriented to identify self destructive procedural sequences.
• Long term individual CAT: weekly sessions, high risk behavior prevention and containment, working to establish a case re-formulation, SSSDs, and setting goals that will be re-evaluated every 6 months. Core schemas, reciprocal roles, significant points in early history, multiple self states, sequential diagramatic reformulations are used as tools within and outside therapy.

3. Group programs:

• CAT group: weekly, emphasis on sharing disfunctional patterns of interpersonal relationship, reciprocal role procedures, shifts in states of mind and diagramatic reformulations. All of them may be shared on a flip chart with the entire group, without using group reformulations as usual tool.
• Operational group: weekly, directive group inspired by DBT technology for teaching skills for self care. Adapted and transformed from Linehan’s model, and integrated into our theoretical model, it incorporates reciprocal role understandings of skills training.
• Families’ Group: (biweekly, advanced understanding of Severe Personality Disorders, communication skills training, symptoms and disruptive behaviours management, support, selfhelp).
• Family and couples therapy under a CAT perspective, when it is needed.

4. Other interventions:

• Medication control, a short consultation of at least 20 minutes a month with a psychiatrist from the Unit.
• Sociotherapy, leisure activities, working with the community, pre-work training.
• 16 hour phone accessibility program (8 am to 12 pm). Staff are trained in managing suicidal crisis and skills coaching, in order to decrease suicidal behaviour and increase generalisation of skills training, as well as offering the sense of containment.

These complex programs need intense team group work. We meet weekly, planning general strategies for case management, searching for synergies between the programs and avoiding confusing, contradictory or split sources of information.

FINAL COMMENTS

We are at a very early stage in the development of our program, and we have a large number of questions to be resolved. I want to share some of our concerns.

• Clinical level:
• How to incorporate dispositions of temperament that are genetically determined, such as: risk avoidance, novelty seeking, dependency on reward and persistence (Cloninger)
• How to deal with metacognitive disfunctions (Fonagy, Semerari)
• We need to include a severity index for strategic planning.
• The role of the case manager and the individual therapist.
• CAT groups could be very emotional and overwhelm patients with low processing capacities.
• Trauma group, still unstructured, focussed on actual symptoms associated to past or present abuse, reorganisation of the trauma experience,
• Post-Traumatic Stress Disorder interventions within a CAT framework.
• Operational groups (DBT inspired) incorporating reciprocal role understandings of skills training need a more sophisticated development.
• Research:
• The problem of randomization
• Selection of internationally accepted instruments
• Inter-rater reliability of case formulation in CAT
• Measures of therapist adherence to treatment.
• Should we move to an international research group on CAT for PD.
• Training and team support:
• Are all therapists prepared to treat severe PD?.
• Therapists in our Unit “must” have a personal therapy.
• Audio and video taped sessions in order to guarantee basic homogeneity in applying therapy.
• Therapist must be supported by intensive group work.
• External supervision is needed

BIBLIOGRAPHY

On request to

Carlos Mirapeix

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