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: “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, “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 emotion 2.Exploration of attempts to avoid distressing thoughts and feelings 3.Identification of recurring thoughts and patterns in the patient’s ideas 4.Discussion of past experience and development 5.Focus on interpersonal relations 6.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: 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

Attachment and Outcome

Attachment & Outcome

Attachment and Outcome

Process: improvement in emotional processing

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

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

Additional slide – HoNOS-LD factor scores with waiting list [n=6] & follow up [n=8] data

Additional slide: Dose effect