trap: a long term outcome and process study of a residential treatment for treatment refractory...
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TRAP:A long term outcome and process study of a residential treatment for treatment refractory
adolescents with personality disorders
Dineke Feenstra & Joost Hutsebaut
September 2009, Ghent
PTC De Viersprong
PTC De Viersprong is a third line mental health setting. It offers specialized assessment and treatment programs (outpatient, day hospital and inpatient) for adolescents and adults with personality disorders
De Viersprong has its own research department, the VISPD: Viersprong Institute for Studies on Personality Disorders
Research group
Joost Hutsebaut Dineke Feenstra Annelies Laurenssen Jan van Busschbach Roel Verheul Els Havermans
Background:Outcome research in adolescents
Progress in child- and adolescent psychotherapy outcome research:– Psychotherapy is an effective treatment for children and
adolescents (mood-, anxiety-, eating-, and conduct disorders) (Kazdin & Weisz, 2004).
– Improvement in methodological qualities of research (more controlled studies, treatment protocols etc.) (Kazdin, 2002).
Background:Outcome research in adolescents
Limitations in child- and adolescent psychotherapy outcome research:– Uncovered area: personality disorders (PD) in adolescents
– Lack of developmental sensitivity: treatment models as well as outcome instruments are little developmentally sensitive
• Review of 25 empirically supported psychotherapies in adolescents (Weisz & Hawley, 2002)
– 14 effective treatments
– 7 adult models, 6 child models, 1 adolescent model (MST)
Background: Treatment of PD in adolescents
Adolescents are left out of multidisciplinary guidelines for the treatment of PD’s
No evidence based models for the treatment of adolescent PD
Few handbooks: Kernberg, 2000 (psychodynamic approach); Bleiberg, 2001 (relational approach rooted in attachment theory); Miller et al., 2007 (DBT); Freeman & Reinecke, 2007
Background:Outcome studies adolescents with PD
Chanen et al., 2008: – RCT Cognitive Analytic Therapy (CAT) versus manualised
good clinical care
Rathus & Miller, 2002: – Quasi experimental investigation of an adaptation of
Dialectical Behavior Therapy (DBT)
TRAP-study: Rationale
Rationale: – First: little is known about severe personality disorders in
adolescents
– Second: little is known about intensive inpatient treatment (for personality disturbed adolescents)
– Third: we know little about developmental sensitive outcomes of psychotherapy for adolescents
TRAP-study:Objectives
Objective 1: treatment outcome
Objective 2: prediction of treatment outcome
Objective 3: relation between relational changes and relapse
TRAP-study:Design
Naturalistic study Include 130 adolescents with personality pathology
who are admitted to the inpatient unit of the youth department of De Viersprong (duration of treatment is 1 year)
Measurements at start of treatment, 6, 12 and 24 months after the start of treatment
TRAP-study:Instruments
Instrument
Intake/ Start
of treatment
6 months after start
of treatment
12 months after start of treatment
24 months after start of treatment
General questionnaire
Anxiety Disorders Interview Schedule for DSM-IV (Adis-C)
Structured Clinical Interview for DSM IV axis II Personality Diusorders (SCID-II)
Brief Symptom Inventory (BSI)
Severity Indices of Personality Problems (SIPP-118)
Autnomy and attachtment quest. (AHV)
Depressive experiences quest. For Adolescents (DEQ-A)
Competence quest. for adolesc. (CBSA)
Life events
Quality of relationships Inventory (QRI)
Family Assessment Device (FAD-N)
Outcome quest.
IQ (KAIT)
Stigma
Therapeutic alliance
Group cohesion
TRAP-study:Sample charachteristics
Sample characteristics (baseline):– N = 133
– Gender = 113 female (85%); 20 male (15%)
– Mean age = 16.55 (range 14-19)
– Mean IQ = 104 (range 78-137)
TRAP-study:Sample characteristics
Sample characteristics (baseline):– Axis I: 100 adolescents (75.19%) had at least 1 Axis I
disorder
* Other axis I disorders were diagnosed in less than 10% of the adolescents.
Axis I disorder N %
Dysthymic disorder 36 27.07
Social phobia 34 25.56
Major depressive disorder 16 12.03
PTSD 14 10.53
Any Axis I disorder 100 75.19
TRAP-study:Sample characteristics
Sample characteristics (baseline):– Axis II: 63 adolescents (47.37%) had at least 1 Axis II
personality disorder
Axis II disorder N %
Borderline PD 33 24.81
Avoidant PD 22 16.54
Depressive PD 5 15.15
Obsessive-compulsive PD 4 3.01
PD not otherwise specified 7 5.26
Any PD 63 47.37
TRAP-study:Drop out
Dropping out of the treatment:
N %
Drop out 44 33
No drop out 89 67
Total 133 100
TRAP-study:Results symptom level (BSI)
Brief symptom inventory (BSI)
General symptomatology
00,20,40,60,8
11,21,41,61,8
2
Start of treatment 12 months after start oftreatment
BSI-score (PD)
BSI-score (no PD)
BSI-score (meanpatiënt)
BSI-score (meannormal)
TRAP-study:Results personality functioning (SIPP)
SIPP domain self-control
3
4
5
6
7
Start of treatment 12 months after start of treatment
No PD
PD
SIPP domain social concordance
3
4
5
6
7
Start of treatment 12 months after start of treatment
No PD
PD
SIPP domain identity integration
3
4
5
6
7
Start of treatment 12 months after start of treatment
No PD
PD
SIPP domain relational capacities
3
4
5
6
7
Start of treatment 12 months after start of treatment
No PD
PD
SIPP domain responsibility
3
4
5
6
7
Start of treatment 12 months after start of treatment
No PD
PD
TRAP-study:Results other outcome measures (self report)
Drug use
0
10
20
30
40
50
60
70
80
No drugs Monthly Weekly Daily
%
Start of treatment
12 months after start oftreatment
School
0
10
20
30
40
50
Not goingto school
Less thanhalf of the
time
Missingschool only
now andthen
Always
%
Start of treatment
12 months after start oftreatment
Self-harm
0
10
20
30
40
50
60
No self-harm
Monthly Weekly Daily
%
Start of treatment
12 months after start oftreatment
Contacts with police
0
20
40
60
80
100
No contact 1 >1
%
Start of treatment
12 months after start oftreatment
TRAP-study:Strengths & limitations
Strengths:– Use of developmentally sensitive (and positive) outcome
instruments– Several measuring points– Including severely personality disturbed adolescents– Use of semi structured interviews to assess both Axis I and Axis
II disorders
Limitations: – No control group– High level of drop-out– Underrepresentation of boys– No treatment manual
TRAP-study
Conclusion:– A group of severely disturbed adolescents underwent an
intensive inpatient treatment program. A large group of these adolescents dropped out of treatment. The adolescents that stayed in treatment showed improvement in symptom level, personality functioning and developmental tasks (f.e. school).
– This is a first step (pilot study) in investigating the uncovered area of adolescents with severe personality disorders. Further research is needed, investigating manualized treatment programs with methodologically stronger research designs.
