Does your mental health service need Dialectical Behaviour Therapy?

S.Fox

L.Gauld

C.Lamza

E. Malcomson

How it all begins....

From the service users’ point of view

Getting the patient ready

Consider: • Do you use a formal assessment for the patient who describes impulsive, chaotic, self-damaging behaviours • Do you discuss and diagnose your patient with Borderline Personality Disorder (BPD) • What treatment options are available for patients with BPD

The Treatment Options?

• Discharged/GP only follow up • Medication • In-patient care/Respite admission • A&E • Counselling • Standard out-patient follow up • Psychotherapy........

Psychological Therapy choices

• Acceptance and Commitment Therapy • Cognitive Analytic Therapy • Cognitive Behaviour Therapy • Dialectical Behaviour Therapy • Interpersonal Psychotherapy • Psychodynamic Psychotherapy/Mentalisation • Solution Focused Therapy • STEPPS, REBT, FAP, PCT, EMDR........

Referring a patient for DBT

Ideally, • Ensure that the diagnosis of BPD is confirmed and that the patient has a clear understanding of the therapy • Provide a detailed referral, completed jointly with the patient.

Highlight problematic behaviours.

• Include background information

The Assessment

• Welcome and orientate the patient to the treatment • Explore patient’s views on diagnosis • Confirm and update referral information • Assess commitment • Complete a diagnostic examination using validated instruments • Offer a prompt and solution focused outcome

Assessment Instruments

• Structured Clinical Interview for DSM IV Axis II Personality Disorder (SCID II) (First

et al,

1995) Assesses personality disorders categorically or dimensionally using DSM IV either - It is a semi-structured clinical interview.

• Diagnostic Interview for Borderlines DIB R(Revised Version) (Zanarini

et al,

1989)

Pre-treatment

Preparing your patient for therapy • The structure and the theory of the DBT • The targets – DBT’s and the patient’s • The contract and consenting to treatment • The rules – telephone, individual and group • Chain analysis • The diary card

Full DBT

The manualised therapy consists of • Weekly individual therapy session (with DBT therapist) for 1 year • Weekly Skills Group training (with DBT trained facilitators) a 6 month programme, repeated.

• Arranged telephone consultation • Consultation group supervision (for therapists all DBT)

The Individual therapy session

• Always based on the diary card • Attends to the treatment targets in a hierarchical way • Is the combination of the core strategies of validation and problem solving plus Dialectical, Irreverent, Reciprocal communication and Case management strategies • Maintains a balance between acceptance and change

Date of Session Urge to Quit Therapy Misery Suicidal Ideation Urge to Self Harm Action on Self-Harm Urges Did I have a structured routine Misuse of medication (and how many tablets) Probs with sleep (how many hours) Anx Starving/ Bingeing Use of Laxatives (if yes, how many)

2011

Mon: Tues: Wed: Thur: Fri: Sat: Sun:

0 - 5 0 - 5 0 - 5 0 - 5 YES/ NO 0 - 5 YES/NO YES/NO 0 - 5 YES/NO YES/NO

• • • •

The Skills Group

Mindfulness - teaches the individual how to balance the mind (2 sessions, repeated after each module) Emotion Regulation Skills - helps to regulate or balance painful emotions (8 sessions) Interpersonal Effectiveness Skills helps the individual to ask effectively for what they need and to cope with interpersonal conflict (8 sessions) Distress Tolerance - promote acceptance in a non judgemental way of the individual and the situation (4 sessions) = 26 weeks, then repeated again.

Telephone Consultation

• All calls must be

before

a patient engages in self-harming/suicidal behaviours • The patient does not require to be suicidal to initiate telephone consultation; patient has to be in crisis/unable to cope with problems in living • Telephone consultation is designed to teach the patient how to apply DBT skills • Should be brief, skills based and in line with the telephone strategy checklist

Consultation Group Supervision

• All therapists must attend regularly • Requires a structured agenda • Mindfulness exercise to begin • Feedback on both individual and skills group is essential • Provides an opportunity for Cheerleading • Ensures dialectical balance • Helps identify further DBT training needs

The DBT patient experience

• From the service users point of view.....