Clinician-judged attachment narrative style & the course and outcome of psychodynamic

therapy in people with intellectual disabilities

Allan Skelly Caitriona Collins Mandip Dosanjh

Psychodynamic Psychotherapy

• Efficacy reviewed by Jonathon Shedler in American Psychologist Feb-March 2010

• Effect sizes of psychodynamic therapy in meta-analytic reviews: median d=.69 to 1.46, depending on methodology [74 studies]

• Effect sizes of CBT median d=0.58 to 1.0 depending on methodology [95 studies]

• Effect sizes of antidepressants approved by the FDA: median d=.17 to .31 [83 studies].

Psychological therapy and people who have intellectual disability

Prout, H.T. and Nowak-Drabik, K.M. [2003] Am Jnl Men Rtdn, 108, 2:82-93.

“A moderate degree of change in outcome measures and moderate effectiveness in terms of benefit to clients”

Prout, H.T. and Browning, B.K. [2011] Adv Mntl Hlth & Int Dis, 5, 5, 53-59.

“psychotherapy, as broadly defined, appears to be at least moderately beneficial”.

What is meant by “psychodynamic therapy”?

1. Focus on affect and the expression of emotion2. Exploration of attempts to avoid distressing thoughts

and feelings3. Identification of recurring thoughts and patterns in the

patient’s ideas4. Discussion of past experience and development5. Focus on interpersonal relations6. Focus on the relationship between therapist and patient. 7. Exploration of fantasy life, e.g. in dreams, ideas and

comments.[From

Shedler, J. 2010]

Attachment measure:Quality of Early Relationships Rating Scale [QuERRS]

• Measuring what?• Narrative style ≠ attachment behaviour• QuERRS: Skelly, A. and Reay, R. [2013] Clin Psy &

P w LD, 11, 1-2.:– 20-item therapist rating scale based on at least 2

assessment sessions where childhood was discussed

– Internally consistent– IRR is good [95+% concordance on sec-insec, 80+

% on category A-D]– Seems to be predictive of HoNOS-LD case severity

Why is the person’s attachment narrative important?

• QuERRS predicts initial severity on HoNOS-LD in terms of identified factors [c.f. Skelly & D’Antonio, 2008]:

• externalising, • internalising, and • social & adaptive aspects of well-being• BUT NOT cognitive status [CCC factor and also IQ

control analysis].

Psychotherapy process measurement can be objective

• Personal Relatedness Profile [Hobson, R.P., Patrick, M.P. and Valentine, J.D.] BJ Psych, 173:172-177.

- A therapist-rated scale of session quality in terms of [a] paranoid-schizoid functioning, and [b] depressive functioning.

- inter-rater reliability established- 2 Factors emergent from Factor analysis that were negatively

correlated- Borderline Personality Disorder diagnosis associated with more

‘paranoid-schizoid’ functioning than in patients receiving a diagnosis of depression

Group process measure

• A short measure intended to test for increasing group ‘membership’

– Empathy– Comments to each other in support– Reality rather than fantasy

• Inter-rater reliability kappa=0.71 to 0.92• Remains to be validated

Patients included in our analysis

• Individual psychotherapy [n=35]• Group psychotherapy [n=6]

– Looked more closely at process on PrP and group measure

• Psychodynamic staff support [n=13]• Overall n=54

• Not randomised allocation to treatment but outcome independently measured; i.e. practice based or ‘service evaluation’ design – a limitation on the findings

Efficiency of psychotherapy: number of sessions ("dose")

5

19

6

3 3 34

01

0 0 0 0 01

0 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74

Number of sessions

Median number of sessions = 8 Mean number of sessions = 13.7

Attachment and Outcome

CHANGE IN HoNOS-LD TOTAL SCORE BY ATTACHMENT CLASSIFICATION

0

5

10

15

20

25

T1 T2

SECURE

INSECURE

TIME F(1,52)=31.85, p<0.01, d=.85

Interaction F(1,52)=5.86, p<0.02

Attachment & Outcome

CHANGE IN HoNOS-LD COG /COMM COMP BY ATTACHMENT CLASSIFICATION

0

0.5

1

1.5

2

2.5

3

T1 T2

SECURE

INSECURE

TIME F(1,52) = 0.49, nsINTERACTION F(1,52) =0.85, ns

Attachment and Outcome

CHANGE IN HoNOS-LD BMR SCORES BY ATTACHMENT CLASSIFICATION

0

1

2

3

4

5

6

7

8

T1 T2

SECURE

INSECURE

TIME F(1,52) = 19.54, p<0.01, d=0.68INTERACTION F(1,52)=10.23, p<0.01

Attachment and Outcome

CHANGE IN HoNOS-LD LAF SCORES BY ATTACHMENT CLASSIFICATION

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

T1 T2

SECURE

INSECURETIME F(1,52)=15.65, p<0.01, d=0.60

INTERACTION F(1,52)=1.12, ns

Attachment and Outcome

CHANGE IN HoNOS-LD INTERNAL DYSREG SCORES BY ATTACHMENT CLASSIFICATION

0

0.5

1

1.5

2

2.5

3

3.5

T1 T2

SECURE

INSECURETIME F(1,52)=24.61, p<0.01 d=0.74INTERACTION F(1,52)=1.40, ns.

Process: improvement in emotional processing

Accumulated mean "paranoid-schizoid" scores from the Personal Relatedness Profile [n=6]

35

45

55

65

Session 1-5 Session 6-10 Session 11-15 Session 16-20

Session progression

Mean improvement 8.97 points

d =0.91 if session 16-20 mean seen as 'outcome'

Mean phased average ratings for the whole group for each rater [mean kappa = 0.88]

6

8

10

12

14

16

18

20

Aug 12 to Oct12 Nov 12 to Jan 13 Feb 13 to Apr 13 Apr 13 to Aug 13

mean r1

mean r2

Group process measure – development of group membership

“Dose effects”

• Those classed as insecurely attached attended more sessions [on average 5 more sessions] but not significantly more [t(43)=1.42, ns]

• There was a positive association between number of sessions and change on the HoNOS-LD Total Score [rho(45) =.44, p<0.01].

Narrative style suggested attachment categories

Our clinical sample

Unresolved31%

Hostile17%

Preoccupied15%

Autonomous37%

Approx. proportion of attachment style in literature [not ID: Steele, 2002]

Hostile

Unresolved

Preoccupied

Autonomous

Conclusions: outcome of psychodynamic therapy and people with ID

• Psychodynamic therapy has efficacy generally.

• Psychodynamic therapy worked for people with ID in our service effectiveness.

• Effect sizes were good [for total HoNOS-LD scores d=0.85].

• Therapy was efficient with a median of 8 sessions, though some people need much more than this.

Conclusions: therapist rated attachment style

• Attachment representations rated by clinician predicted initial severity

• On some aspects of outcome, the attachment representations rated by clinician indicate a different course [sharper improvement]

• The number of sessions has some relationship to the amount of change – i.e. there was a possible effect of ‘dose’

Conclusions – group in detail

For our group examined more detail

• Progress coincides with less paranoid-schizoid rating on the PRP

• Progress coincides with more depressive ratings on the PRP to be confirmed – data awaiting analysis

• The group measure showed increasing levels of involvement, empathic comments about each other, affection and cohesion towards each other.

• But not coherent attendance. Discussion point: “internal model of the group” may be more important than actual attendance.

Control analyses

Outcome & age – no relationship [r=0.09].

Attachment & gender – no relationship[chi-square (1,54) =0.5, ns].

Outcome & gender – no relationship[e.g for HoNOS-LD total score:

F(1,53)=0.06, ns].

Free use of the QuERRS for hcpc registered psychologists

allan.skelly@ntw.nhs.uk

Additional slide – HoNOS-LD factor scores with waiting list

[n=6] & follow up [n=8] data

0

1

2

3

4

5

6

7

Time 0 Time 1 Time 2 Follow up

BMR

ADAPT

INT DYS

Additional slide: Dose effect

Is there a relationship of number of sessions and amount of change?

0

10

20

30

40

50

60

70

80

-15 -10 -5 0 5 10 15 20 25 30

change on HoNOS-Ld total scores

no

of

se

ss

ion

s

rho=.44