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Chanen, A., 2000. Prevention and Early Intervention for Borderline Personality Disorder in Young People. Reformulation, ACAT News Autumn, p.x.
Borderline Personality Disorder (BPD) has long been a neglected mental health problem. The social and economic costs of BPD have been severely underestimated and it is associated with an extraordinary litany of misery, suffering, morbidity and mortality. Suicide rates for people diagnosed with this problem are around 10%. Despite this, little attention has been paid to the development of prevention and early intervention strategies for BPD.
Thinking in this area has been hampered by a wide range of issues. These include reluctance to use the diagnosis in young people, difficulties identifying those who should receive an intervention and the lack of an obvious choice for an appropriate intervention. There has been no evaluated trial of prevention in BPD despite the potential benefits, the fact that there is often a long period between first symptoms and actual diagnosis of disorder and despite the fact that psychotherapy is more likely to be effective for less severely borderline patients. Nevertheless, there has been a recognition that young people, their families and the community at large have expressed a desire to participate in prevention and early intervention strategies.
As reported in ACAT News (CAT In Australia, Spring 2000), a randomised, controlled trial of a CAT intervention is currently underway in Australia for prevention of and early intervention for borderline personality disorder in young people. The study is taking place at Mental Health Services for Kids and Youth (MH SKY), the regional mental health service for young people in Western metropolitan Melbourne. It caters for 130 000 people aged 15-24 years spread over a geographical area approx-imately the size of Greater London. MH SKY offers a comprehensive service including various outpatient services, a community treatment team and inpatient units. We have established a clinic within this service called Helping Young People Early (HYPE) which sees young people with emerging BPD.
In this clinic, we have asked the following research questions: 1) Can an intervention reduce the risk, delay the onset or reduce the severity of subsequent disorder and establish a ‘healthier’ developmental trajectory? 2) Is a complex intervention more effective than a simple one?
We are investigating this through a randomised, controlled trial comparing routine assertive case management ("Standardised Treatment") with CAT. Participants in the clinic receive 24 sessions of either treatment, with follow-up reviews over the subsequent six months. We have three therapists who are delivering both treatments on a random assignment basis.
One of the strengths of this study is its careful attention to the issue of "treatment integrity". This involves ensuring that the treatments we intend to deliver are actually delivered and that they are done with the highest possible level of competency. This has only been possible with the extraordinary level of support which we have received from Tony Ryle, Ian Kerr, the CAT unit at Guy’s Hospital and ACAT. Their input has ensured that the CAT intervention will be of the highest possible quality and (we hope) a true test of the therapy. This is no mean feat, given the thousands of miles that separate us. We have had to develop a distance learning and supervision process to overcome the problem that there is no CAT expertise or training in Australia. This involves a combination of email, telephone conferencing, transmission of recordings over the Internet and face-to-face intensive workshops. Recently, the team flew to London for a very successful intensive (and exhausting!) one-week workshop, organised by Ian Kerr.
Following a long period of development of the project, we are now ready to commence allocating cases to the study proper. We hope to recruit 80 young people into the study over the next 18 months. I hope to provide regular updates on the progress of the study and our experience of using CAT with young people.
Dr Andrew Chanen
Department of Psychiatry, University of Melbourne and Mental Health Services for Kids and Youth, Melbourne, Australia.