Monday, 30 June 2008

Alphabetti spaghetti therapies

Sometimes I have interesting email conversations with colleagues, which I edit and put on this blog when they might help to illuminate some corner of the PD /TC /Greencare world.
Here is one that I found on my HDD today, over four years later, but which still seems relevant today. It is part of a wider conversation from the TC Open Forum, between myself, Aldo Lombardo (a TC psychiatrist and director in Rome) and an ex-service user.

20 June 2008
Dear Rex, I was in Milan for a 2 days workshop with Marsha Linehan 2 days ago. She told us about her Dialectic approach to BPD. Although she is a cognitive behaviour therapist she maintains that if you drop the cognitive part  the treatment and work only on behaviour therapy, it is effective anyway. She seems to be very skilled and passionate and caring - and keen on research to provide good EBM results. 
Marsha Linehan, originator of DBT,
'comes out' in the New York Times
She demonstrated that DBT is more effective than any other traditional treatment and prevents drop out with more success. She also insist that DBT works as long as there is a group of interacting patients and a team and explained to us the importance of moving dialectically from  acceptance  to change. I liked a lot what she had to say and how she  passionately said it. She also claims to be mandatory for a single therapist to be the key  or main worker available on the phone 24h a day to discuss any problem and support a patient through any eventual crisis and gave us vignette and suggestions to deal with a call effectively. 

Anthony Bateman, who with
Peter Fonagy, has developed
Mentalisation Based Therapy (MBT)
When I asked her if the role of the person of the therapist could be taken up by a whole group of peers she liked the idea but said that no research data are available on this to her knowledge. I mentioned day TC approach and she immediately asked me to produce the manual of the approach! She only knows of Fonagy and Bateman’s Mentalisation approach which she considers  very good,  as in a way it applies DBT principles. 

As the discussion went on she asked me to produce research evidence of TC approach effectiveness to BPD. And this is the reason why I ask you, and the list, the best striking evidence of the effectiveness of TC approach to BPD to give to her as food for more thoughts. I only remember Dolan, 1996, on cost offset after average 211 days treatment and Janine Lees et al meta analysis of over 8000 papers on TC effectiveness.

I would appreciate if you or some of this list members would help me  quote papers  to her so that she knows there are other effective ways of helping BPD.... who knows. maybe, as she seems to be a very practical person, she could modify and improve a method she acknowledges can be improved,  particularly as she is fully aware  that there is no single standard treatment for this disorder yet.

By the way, at the beginning she wanted to try her approach on every case of attempted suicide admitted to A&E dept in Washington and she  has produced a lot of research work on DBT effectiveness.... a great stimulus for us all. In my mind DBT can be very well integrated in TC approach and what I saw in Acorn ward witnesses this to the full.
Kind regards.
Aldo Lombardo

28 June 2008
Dear Aldo
Yes – of course DBT and MBT are good things, but I do worry about the way they are packaged, branded and marketed.

To me, the ‘essential therapeutic elements’ are much more subtle and nameless than the things that get written in a manual. The UK NICE guideline for borderline PD (which is out for consultation until 4 Aug) actually does rather well at capturing some of it (like long-term treatment, well organised, paying attention to attachment and endings, with a coherent theory background)  but it is paradoxically perhaps BECAUSE of a lack of RCT evidence that it has come out like this. Unless things change, when the next version comes out in approx 2012 it will be able to give much a more directive guide about which ‘brands’ of therapy ‘work’ – and something will be lost when the non-specific therapeutic elements become secondary.

Another perversion of therapeutic intent, in my book, is how manuals and the intellectual property business objectify and reify therapies into buyable and sellable commodities – which feeds the greedy competitiveness and selfish commercialisation of mental health that I still want to argue against (maybe not many of us left now!). These ideas should belong to us all – and all those who seek our services: not those who play the RCT and academic game best (of which Marsha and Anthony are clearly the world champions). And I hope that TC ideas do (belong to us all) – because they don’t belong to any one person, are fundamentally value-based and about being ordinary and human, and by some accounts go back for many centuries.

But that is not to say I have anything against DBT or MBT – I don’t – I would just be really worried that if we encourage a Darwinian approach to therapies, the current harsh climate will reduce the biodiversity (psychodiversity?) in a way that we will regret...

The way TCs would do best is to embrace all these things (as, in a way, they already have on the quiet) – and stop trying to maintain that any one theory is more ‘fundamental’ than any other. And act with integrity about subjecting themselves to RCT evaluation (by getting involved with the discussions rather than behaving with a lofty superiority), and with humility about everything that we don’t know how to do best.

End of soap box rant

30 June 2008
Dear Aldo,
I attended a training day last week on DBT based on Marsha Linehan's approach, mainly through curiosity as I'd heard it was the treatement for BPD.  As a past member of a TC, and a current community psychiatric nurse, I wanted to know what was so unique about this treatment that so many professionals saw it this way. 

I attended with a psychiatrist trained in CBT, and a Systemic Family therapist - so we all had different backgrounds.  As it is closely aligned with CBT, I expected my medical colleague to see the worth in it.  I have to say that my family therapist colleague and I both felt this approach alone was too behavioural and simplistic for long-lasting effects to be had which could not be gained from any other approach. 

Perhaps my views are simplistic, but I feel that the main gain from having therapy within a TC is the effect of the group itself - more than the collective members, it has a power of its own to contain, affirm, nurture, challenge and educate.  It allows for members to re-learn how to be, in a more healthy way. 

I agree with Rex that there are many more elements that don't have names which are so important in helping those diagnosed with BDP to move away from being 'sick' and learning to love themselves enough to want to lbecome healthily attached to the 'others' in their world. 

If there was one definitive way of managing and healing BPD, it would have been discovered and marketed by now, I would think!!

BPD has been with us always, if we look at the Bible and Shakespeare for example, so I reckon we need to use every possible tool we can. Including ourselves, and our groups, to find a way to help those who have been categorised in this way to be seen as human beings not disorders. I wish there was an easy way to record evidence of TC type treatments - then those in power might not keep closing establishments like the Henderson.  We need all the help we can get!

Sorry - I'm ranting now!!
Best wishes to you all,