Update on The Melbourne Project - Prevention and Early Intervention for Borderline Personality Disorder

Chanen, A., 2002. Update on The Melbourne Project - Prevention and Early Intervention for Borderline Personality Disorder. Reformulation, Autumn, pp.6-7.


Update on "The Melbourne Project": Prevention and Early Intervention for Borderline Personality Disorder

Dr Andrew Chanen

Two years have elapsed since I introduced the Melbourne-based prevention and early intervention trial for Borderline Personality Disorder (BPD) in this newsletter and it is time to bring you up to date. Those of you present at the March conference will have heard more recent news. I enjoyed the conference immensely and my clinical team (Louise McCutcheon, Dominic Germano and Helen Nistico) and I were very grateful for the enthusiastic support the project received.

Young people showing features of BPD are at increased risk for developing the full BPD syndrome and its complications. Consequently, this study asks: 1) Can a psychotherapeutic intervention reduce the risk, delay the onset of or reduce the severity of subsequent BPD? 2) Is a complex intervention more effective than a simple one?

'The Melbourne Project' is a randomised, controlled trial (RCT) of 24 sessions of CAT compared to 24 sessions of a simple, standardised treatment (ST) for prevention of and early intervention for BPD. Both treatments are 'manual-based' with careful attention paid to ensuring and measuring therapists' competency and adherence to treatment. A significant feature of our study design is our characterisation ('manualisation') of ST. This ensures that we know exactly what treatment these patients are receiving (and what we are comparing with CAT) and we can ensure the quality of this intervention. Although ST is simple, it is not bad treatment! This makes our study a rigorous test of CAT but makes proving CAT's worth a harder task.

Recruitment to the project is now complete. One hundred and eight of 270 referrals aged 15-18 years were eligible for the study, with 86 subjects giving written informed consent. Subjects had one childhood risk factor for BPD and at study entry displayed a minimum of two DSM-IV BPD criteria. Subjects were randomly allocated to one of two interventions. Eight subjects were excluded, prior to the commencement of therapy, for failure to complete baseline assessment. Of the remaining 78 subjects, 33 are still in active treatment. Thus far, 47 of 49 eligible subjects have completed the six-month follow-up and 32 of 33 eligible subjects have completed the twelve-month follow-up. Only one subject has been lost to follow-up.

Available data has not been analysed to ensure continued 'blinding' of clinicians to subjects' outcomes. Six-month data will be analysed when the final subject has completed the intervention (around April 2003). Twelve-month data will be available in September 2003 and final results one year later.

Supervision

Eva Burns-Lundgren has given an account of the distance supervision project in a previous edition of this newsletter. The other supervisors are Tony Ryle, Dawn Bennett and more recently, Jackie Withers. Supervision occurs weekly, via telephone, fax, email and recordings transmitted over the Internet. Feedback occurs in the form of group or individual telephone discussion, e-mail and scores on the STIC (Ryle-unpublished).

The value of this supervision to our team and to the project cannot be overemphasised. It will ensure that every case receives therapy of the highest possible quality, ensuring the integrity of the CAT intervention throughout the length of the trial.

CAT

CAT seems to be very acceptable to young clients and to (not so young!) clinicians and the model appears to be working well with our client group. In adapting the treatment to this group, we have departed a little from the conventional structure of CAT. Early use of diagrams has proved very helpful to manage difficult clients or those who are less verbal. We also encourage clients to share diagrams with family, carers or other significant supports. This can be quite a challenge to manage, as many clients are still in the primary relationships that gave rise to their RRP's.

Some of you will have seen our modifications to the psychotherapy file, which appear to be circulating around the CAT community. Reformulation letters tend to be used in the conventional manner and are generally well received by young people.

Therapy with chaotic young people

Our clinic, called HYPE (Helping Young People Early), has a strong focus upon accessibility and outreach, regardless of which treatment people receive. We believe that the very nature of BPD prevents access to and use of treatment. In other words, you cannot have your cake and eat it! Therefore, we will accommodate a good deal of chaos in the young person's life. In CAT terms, we operate on the principle that it is unreasonable to expect people who lack basic self-management procedures to suddenly acquire them because they are referred to services or seek help. In order to be in their zone of proximal development, we will seek out non-attenders in their homes, schools, youth refuges and other locations. This is especially so in the early stages of treatment. We will then negotiate with the young person with the eventual expectation that they will attend our centre. However, in some cases, we will carry out most or all of their treatment in the community. Is this collusion or boundary violation? There is certainly a danger of this. However we believe that it is a legitimate option if it is a strategic, time-limited and negotiated intervention. If it becomes evident that it is part of problematic role procedure then it will become a focus of treatment.

Future Developments

We are excited about the prospect of completing the intervention phase of the trial by April 2003. We are already planning the next phase of our clinical work and research. One project in development is the use of our CAT intervention in the management of co-occurring BPD and First Episode Psychosis.

In February 2003 we hope to welcome Ian Kerr, Eva Burns-Lundgren and Jackie Withers to our service. We are busy planning training activities around their visit, which we hope will lead to the establishment of some basic CAT training opportunities in Melbourne. Furthermore, all of our clinical team hope to proceed to supervisor training, which will be quite a challenge from 10 000 miles away!

Finally, we would like to extend an invitation to anyone who might be coming to Melbourne to visit us.

Dr Andrew Chanen. Department of Psychiatry, University of Melbourne. ORYGEN Youth Health, Melbourne, Australia.

Full Reference

Chanen, A., 2002. Update on The Melbourne Project - Prevention and Early Intervention for Borderline Personality Disorder. Reformulation, Autumn, pp.6-7.

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