Research Unit, The Cassel Hospital, Richmond, Surrey
Correspondence: Dr M. Chiesa, Research Unit, The Cassel Hospital, I Ham Common, Richmond, Surrey TW107JF. e-mail: marco{at}cassel.ftech.co.uk
Declaration of interest This study was funded by a grant from the Sir Jules Thorn Charitable Trust.
See editorial, pp. 93-94,
this issue.
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ABSTRACT |
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Aims Investigation of early discontinuation of specialised in-patient psychosocial treatment in a sample of people with personality disorder.
Method Out of 134 consecutive admissions to the Cassel Hospital, 42 early drop-outs and 92 patients who remained were compared on demographic and clinical variables. Early drop-outs were invited for in-depth interviews, to explore their hospital experiences.
Results The early drop-out group and the group which remained showed significant differences in occupational status, borderline personality disorder (BPD) and the treatment programme to which they were allocated. All three independent variables predicted early discontinuation of treatment. The qualitative analysis of interview transcripts identified significant problems in institutional dimensions.
Conclusions Important subjects and process variables contributing to early drop-out in people with personality disorder were identified, with potential implications for clinical practice.
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INTRODUCTION |
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Previous studies
The literature on personality disorder shows high drop-out rates (44-66%)
in hospital-based treatments (Skodol
et al, 1983;
Gunderson et al,
1989; Kelly et al,
1992). These comparative studies found that attrition in
borderline personality disorder (BPD) is significantly higher than in
non-borderline personality disorder (NBDP), but some of their findings were
contradictory. While Skodol et al
(1983) found that drop-outs
have had significantly more prior treatment, and had more severe symptoms at
baseline, Gunderson et al
(1989) and Kelly et
al (1992) showed opposite
findings in their samples.
Systematic analysis of data which takes into account the views of the users of the service is included in only three studies of generic psychotherapy out-patient populations (Acosta, 1980; Hynan, 1990; Pekarik, 1992). To our knowledge, attrition studies that include a qualitative analysis have not yet been carried out in specialised in-patient psychotherapy units. We feel that this is a considerable gap in the literature, and that more studies in this area are needed to achieve a better understanding of early drop-out.
Hospital setting
The Cassel Hospital is renowned for employing a psychodynamically based
approach to the treatment and management of personality disorder in adults,
adolescents and whole families. Medium-term residential treatment in
in-patient psychotherapy units may be indicated for personality disorder for
which previous general psychiatric and out-patient psychotherapeutic treatment
has failed. The advantages of in-patient treatment include better compliance
with treatment, fostering of the therapeutic alliance, a systematic challenge
to destructive behaviour, and containment of suicidal gestures
(Wallerstein, 1986;
Norton & Hinshelwood,
1996). The combination of a specific sociotherapeutic programme
(Chapman, 1984), and individual
twice-weekly psychotherapy delivered by medical and non-medical
psychotherapists is the cornerstone of treatment at the Cassel. The hospital
functions according to modified therapeutic community principles based on a
culture of enquiry (Main,
1989). Patients are admitted to two different programmes, based on
geographical considerations: those residing within the Greater London Area
(GLA) are allocated to a two-stage model (6 months in hospital followed by 18
months' psychosocial outreach work), while subjects residing outside the GLA
are allocated to a one-stage model (1-year hospital stay, with no out-patient
follow-up). Most patients admitted are on psychotropic medication; this is
continually monitored and gradually withdrawn as treatment progresses.
Although some components of treatment are unique, the hospital programme shares core structural and cultural dimensions with other therapeutic communities and in-patient psychotherapy units. In these settings, the impact of high dropout rates is considerable for various reasons. First, there is evidence that the longer the patient stays in treatment the more likely they are to benefit from it (Waldinger & Gunderson, 1984; Kelly et al, 1992). Second, the high demand made on health and social services (Chiesa et al, 1996; Dolan et al, 1996) by these patients would continue if specialised treatment failed. Third, the higher turnover resulting from patients terminating their treatment prematurely is considered to be unsettling for the stability of the milieu, the cohesion of the patients' group and their sense of belonging. A high incidence of early drop-out leads to low staff morale and a sense of worthlessness of the treatment offered, and to insecurity in the larger patients' community.
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METHOD |
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Study sample
Out of 134 consecutive patients admitted to the Cassel Hospital from
January 1993 to July 1997, 42 (32%) left the hospital within 14 weeks. Only 14
patients (11%) dropped out of treatment after 14 weeks (but before completion
of the course), two (1.5%) committed suicide while still in hospital and 76
(57%) completed the course of treatment.
Quantitative data collection
As part of a prospective outcome study
(Chiesa & Fonagy, 2000) systematic information on all patients was obtained at intake, and at 6, 12
and 24 months. The following instruments were used: the Structured Clinical
Interview for DSM-III-R (Spitzer et
al, 1990); the Symptom Checklist-90
(Derogatis, 1983); the Social
Adjustment Scale (Weissman,
1975) and the Global Assessment Scale
(Endicott et al,
1976).
Statistical analysis
The statistical analyses were performed in SPSS for Windows (release 6.1).
Chi-square was used to compare categorical variables between the early
drop-out group and the group remaining; when the expected frequencies were
below five, Fisher's exact test was used. Means were compared using the
t-test for independent samples, except when distribution was not
normal; then the Mann-Whitney U-test was performed. Logistic
regression was used to determine the independent contribution of variables to
early termination of treatment. Significance rested on a log likelihood test
between the full model and one in which the main effect was removed.
Qualitative data collection
The 42 patients who left the hospital within 14 weeks were invited for a
meeting with one of the researchers, to explore their experiences during their
contact with the hospital. Nine patients refused the offer of a meeting, two
were no longer alive, and nine could not be traced, while four declined to be
interviewed on the grounds that they felt that they had little to contribute
to the study. Eighteen patients (43%) accepted the invitation to meet with one
of two researchers (C.D. and S.L.).
The method used was one of semi-structured in-depth interviews. The interviews were immediately dictated and subsequently transcribed. The three researchers subjected each transcription to content analysis, modelled on the method described by Miles & Huberman (1994), which consists of highlighting sentence fragments that may indicate the presence of significant problem areas which the subject encountered during their stay at the hospital. Highlighted passages were subsequently organised according to problem area themes, which in turn were grouped into six general problem area categories. These categories represent a list of structural, cultural and process dimensions characteristic of the Cassel Hospital psychosocial approach. The transcripts were finally scored separately by two raters (C.D. and S.L.). An average 91% interrater agreement was reached.
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RESULTS |
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Qualitative analysis
The analysis of the 18 available transcripts resulted in 50 positive scores
on the area categories experienced as problematic
(Table 3). Of these, 41 (82%)
applied to three categories: institutional culture and structure, organisation
of treatment and relationship with other patients. The main problems as
perceived by patients can be summarised as follows.
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Cultural and structural set-up and general treatment approach
Treatment organisation and delivery
Dimensions of living together in a therapeutic community
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DISCUSSION |
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Borderline personality disorder and early drop-out
The superior in-patient treatment compliance showed by subjects with
borderline personality disorder in the two-stage programme is an interesting
finding. Since geographical factors and differences in the two populations
have been excluded in two recent studies
(Chiesa, 1997;
Chiesa & Fonagy, 2000),
considerations of the treatment model may provide a possible explanation. A
two-phase model may allow a better working-through of emotionally laden
conflicts to do with termination and separation from treatment, which is
established as a crucial feature in the treatment of BPD. The prospect of a
shorter in-patient stay and an assured longer-term continuation of treatment
as an out-patient may render more tolerable the claustrophobic and persecutory
anxieties stirred by the intensely challenging and confrontational nature of
the hospital psychosocial approach.
Clinical implications of qualitative analysis
The results from the analysis of the patients' experience of the hospital
setting may have implications for clinical practice in therapeutic community
settings. Most of the problem areas identified implicated the dimensions of
the prevailing institutional culture, the way treatment was delivered and
aspects of the patients' living together. A too uniform application of the
treatment programme, which does not take into account individual differences,
a rigidity in applying the rules and an excessive confrontational attitude at
the expense of containment and understanding, constitute the main findings.
This emerging pattern seems opposed to the declared hospital philosophy of
treatment, which stresses understanding, enquiry into patient and staff
dynamics, flexibility, constant dialogue and creative thinking. In therapeutic
community and group settings, the coexistence of an unacknowledged (hence
difficult to modify) authoritarian, moralistic and rigid culture with the
therapeutic treatment philosophy is a constant danger
(Main, 1967;
Chiesa, 1990). The presence of
a patients' subculture that involves ganging-up on individual patients,
bullying, scapegoating and back-biting may not be addressed sufficiently by
the staff. Indeed, published material only stresses the therapeutic dimension
of living together in a group. This subculture also has anti-therapeutic
effects, and may be an important contributing factor to patients leaving
treatment prematurely.
Patients on the whole did not find their relationship with the individual therapist or key nurse a source of difficulties. The belief system developed over the years in hospital staff places the relationship between the psychotherapist and the patient's key nurse at the centre of the treatment strategy (James, 1984). Specific supervisory arrangements to monitor the working relationship between nurse and therapist have been set up over the years. This study shows that those are not the problem areas as experienced by patients, and that the establishment of a non-problematic relationship between patient, psychotherapist and primary nurse does not ensure continuation in treatment. A change of focus may be needed, in the direction of reviewing and improving treatment structures, and the cultural attitudes and expectations of the staff.
Methodological considerations
Although we feel that this study makes an original contribution to the
literature on early discontinuation of psychotherapeutic treatment, some
limitations ought to be borne in mind when interpreting the results. First,
the study was carried out on a selected sample of individuals with personality
disorder admitted to a specialised in-patient setting from a wide geographical
area. Although other therapeutic communities, which share a similar treatment
philosophy and modality, may benefit from the results of this study, the
generalisability of the findings to wider settings is limited.
Qualitative results are based on in-depth interviews conducted with a drop-out sample. To obtain a more comprehensive picture, data on the hospital experiences of the group remaining in hospital, for comparison with those of the drop-out group, are also needed. Preliminary results from a survey of treatment satisfaction of those who remained shows a significant degree of convergence of findings between them and the drop-outs. These results make a strong argument in favour of initiating a process of revision of the structural, cultural and organisational set-up of the hospital.
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CLINICAL IMPLICATIONS AND LIMITATIONS |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication December 18, 1998. Revision received October 18, 1999. Accepted for publication October 18, 1999.