EMPOWER: Enabling and Motivating People (with a Personality Disorder) in Occupation, Wellbeing, Education and Responsibility

Background: 38% of those on incapacity benefit have a mental disorder (Layard, 2006), of these at least 10% will have a personality disorder (PD). PD is characterised by difficulties with emotional regulation, interpersonal difficulties and poor self management (including impulsivity and substance abuse), all of which affect employment. In standard treatment for PD, vocational status remains poor even after symptom reduction. Two pilot studies in the USA have indicated that Dialectical Behavioural Therapy (DBT) is effective for increasing employment and wellbeing (Koons et al., 2006; Comtois et al., 2010). Aims: The aim of this research programme is to evaluate Dialectical Behavioural Therapy Skills for Employment (DBT-SE) for individuals with a PD in the UK employment context. Objectives: To increase understanding of the specific challenges which face individuals with a PD in obtaining and retaining employment (WP1) and finalise the treatment manual. To develop and evaluate a Preparedness for Employment Scale for individuals with PD (PES-PD), for use in treatment planning and outcome measurement (WP2). To evaluate the effectiveness of DBT-SE with a feasibility study (WP3) followed by a full Randomised Control Trial (WP4). To identify if DBT-SE is cost effective compared to existing interventions (WP4). To develop an implementation plan to facilitate the dissemination DBT-SE (WP5). Hypotheses: It is predicted that at 16 month follow up the results of the RCT of DBT-SE, as compared to usual care, will show (compared to the 16 months prior to treatment): an increase in hours of employment. improvements in wellbeing as measured by the mood and social functioning measures. a reduction in use of physical health, mental health, criminal justice, and social services. Following the development and psychometric evaluation of the PES-PD it is predicted that: those in DBT-SE will show a significant improvement on the Preparedness for Employment Scale (PES-PD) by end of treatment. Improvement on the PES-PD will be associated with an increase in employment seeking activity. Methods: The first step (WP1) will be to further elucidate the barriers and challenges for individuals with PD in negotiating employment through additional focus groups and qualitative interviews across the stakeholders (clients, families, employers, and employment services). An initial consensus meeting of experts in DBT, employment, and the PPI committee will then finalise the draft treatment manual. This manual will then be distributed to a wider group of clinicians (NHS and non-NHS), service users, families, managers, and commissioners to broaden the consensus process. Using the existing literature on readiness for employment and data from WP1, we will draft the Preparedness for Employment Scale for PD (PES-PD) (WP2). The development and psychometric evaluation will include: systematic literature review of existing scales and the literature on PD and employment to identify domains and items; piloting of the scale for readability, completeness, and applicability; a small pilot a preliminary factor analysis to identify items to be removed; a formal reliability study for the identification of means and standard deviations, internal consistency, and factor structure; validation of the measure through comparison with scales related to the concepts (e.g. well being, activity, beliefs); test-retest reliability; and evaluation of sensitivity to change after treatment. The scale will be evaluated to consider movement on the path to employment. We will commence with a non-randomised feasibility study (WP3) to consider: acceptability of the intervention (good attendance, low drop out rate, qualitative feedback); rates of recruitment (from clinicians, GPs, and self referral), retention rates (both non-starters and drop outs); ability of staff deliver the treatment (adherence ratings of tapes; practice logs); acceptab