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
Rex
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,
Kathy
