Transcript DBT for Looked After Children

Dialectical
Behaviour Therapy
(DBT)
Dr A James
2008. (Ms K Alfoadari).
Age of onset of depression.
Zisook et al, AJP 2007
Deliberate self-harm in Oxfordshire.
Hawton et al, JCPP 2003,44:1191-1198.
Increase in DSH with antidepressants (5-18%of all DSH). 1990-2000.
Rates of suicide and open verdicts in England & Wales
in 15-19 year-olds, 1993 – 2005 Hawton 2007
10
9
Rate/100,000
8
Males
7
6
Both
sexes
5
4
3
Females
2
1
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Aggregated Risk for Adolescent Suicide. Brent et al, JCPP
2005
Risk
Males
Females
Total
Any psychiatric
disorder
8.7 (2.9–26.7)
6.9 (2.7–17.4)
9.4 (3.7–23.9)
Mood disorder
10.0 (5.3–18.9)
16.4 (5.4–49.7) 9.8 (6.0–16.1)
SUD
9.2 (4.4–19.2)
3.1 (.1–68.6)
7.2 (3.7–13.9)
CD
4.9 (2.4–10.3)
1.9 (.4–8.4)
4.6 (2.6–7.9)
Any previous
attempt
42.7 (10.2–179) 50.4 (6.3–403)
67.4 (16.3–280)
Methods of suicide in 15-19 year-olds,
2005
(Hawton
Males
(N=74) 2007)
Females (N=28)
Overdose
Gas
Hanging
Drowning
Firearm
Fire
Jumping from
height
Jumping in front of
moving object
Other
Treatment of Self-Harm (SH).
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The NICE guidelines for repeated SH in
adolescents (National Institute for Clinical
Excellence, 2004) recommends developmental
group psychotherapy, based upon just one
randomised controlled trial (Wood et al, 2001).
For adults, the NICE guidelines (National
Institute for Clinical Excellence, 2004;2009), a
Cochrane review (Hawton et al, 2000) and the
American Psychiatric Association (2001)
recommend Dialectical Behavioural Therapy
(DBT) for SH.
Dialectic Behavioural Therapy
Originally developed for treatment of parasuicidal women with
Borderline Personality Disorder in an outpatient setting.
Adapted for -Inpatient Adult (Springer et al, 1996)
-Inpatient Adolescents (Katz et al, 2004)
-Outpatient Adolescents (Miller et al, 2007)
-Adolescents with Bipolar Disorder (Goldstein et al, 2007)
-Substance Misuse (Lineham et al, 1999,2002; Dimef et al, 2008)
-Eating Disorders (Safer et al, 2001)
-Elderly (>60 years) PD and MDD( Lynch et al, 2007)
--Treatment Resistant depression (Harley et al, 2008)
.
Psychosocial Treatments.
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Cognitive Behavioural Treatments
-Cognitive Behavioural Therapy (CBT)
-Problem Solving Therapy (PST)
-Interpersonal Therapy (IPT)
-Dialectic Behavioural Therapy (DBT)
- Schema-Focused Therapy (SFT)
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Psychodynamic
-Psychodynamic Therapy
-Mentaiisation therapy
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Combination
-Multisystemic Therapy (MST).
Dialectic Behavioural Therapy
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Partly manual based
Linehan 1993 Cognitive-Behavioral Therapy of Borderline Personality
Disorder.
Linehan 1993 Skills Training Manual for Treating Borderline Personality
Disorder.
Miller, Rathus & Linehan 2007. Dialectic Behavior Therapy for Suicidal
Adolescents.
DBT Studies
Author
Year
N
Sample
Linehan et al 1991,93, 94
44
Parasuicidal Women with
BPD
Linehan et al 1999
28
Women with BPD and
drug dependence
Turner et al
2000
24
BPD and suicidal
behaviour
Koons et al
2000
20
Women with BPD
Safer et al
2001
29
Women with Bulimia
Nervosa
Telch et al
2004
44
Females with binge
eating disorder
Linehan et al 2002
24
Women with BPD and
opiate dependence
DBT Studies
Author
Year
N
Sample
Lynch et al
2003,2006
35
Elderly depressed with
and without PD
Verheul et al
Van den Bosch
2002,2003,
2006
56
Parsuicidal women with
BPD.
Linehan et al
2006
100
Women with BPD and
suicidal behaviour
DBT-A.
Rathus, Miller 2002; Miller, Rathus & Linehan 2007
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Decreased treatment length (52 to 16 weeks).
Involving family members in skills training format
(multifamily group format).
Involving family members in individual sessions when
necessary.
Adaptation of skills to adolescence.
Use of age-appropriate language in handouts.
DBT-A
Method
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Outpatient Therapy 1 hour weekly.
Multifamily therapy skills therapy (2 hour weekly).
Telephone consultations between sessions with
individual therapist
skills therapist(s)
Therapists’ consultation meeting weekly.
Ancillary treatments as necessary
Pharmacotherapy
Psychiatric admission
Duration of treatment
16 weeks.
Borderline Personality Disorder
(BPD)
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DMS-IV diagnostic Criteria for Borderline
Personality Disorder pervasive pattern of
instability of interpersonal relationships,
self-image, and affects and marked
impulsivity beginning by early adulthood
and present in variety of context as
indicated by five or more of the diagnostic
criteria
Nine Criteria for BDP
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A pattern of intense and unstable interpersonal and unable to
interpersonal relationship
Frantic efforts to avoid real or imagined abandonment
Identity disturbance or problems with sense of self
Impulsivity that is potentially self damaging
Recurrent suicidal or parasuicidal behaviour
Chronic feeling of emptiness
Affective instability
Chronic feelings of emptiness
Inappropriate intense or uncontrolled anger
Transient stress-related paranoid ideation or severe dissociation
symptoms
DBT Organisation of BPD
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In DBT practitioners view these difficulties
in more behavioural terms, thus allowing
the use of behavioural interventions
based upon a skills deficit model:
DBT Organisation of BPD
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Emotional Dysregulation: Affective lability, problems
with anger
Interpersonal Dysregulation: chaotic relationships,
fears of abandonment
Self Dysregulation: identity disturbance/ difficulties
sense of self/ sense of emptiness
Behavioural Dysregulation: parasuicidual behaviour
impulsive behaviour
Cognitive Dysregulation: dissociation responses/
paranoid ideation
Dialectical Behaviour Therapy
(DBT)
Dialectical behaviour therapy is a broad
based cognitive behaviour therapy that
has been specifically designed for patients
with Borderline Personality Disorder.
 DBT conceptualises a biosocial theory of
borderline personality disorder with a skills
deficit and problem solving model.
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What is Dialectics?
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Dialectics is a cooperative exercise between two
people with opposing views.
Instead of battling it out until one view is taken to
be the right one, the aim of dialectics is for both
parties to search for an ‘answer’ that satisfies
the problem from both points of view.
It’s about finding the Both/And and not the
And/Or
Biosocial Model
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Biological Principals
Linehan's theory is based on emotional
dysregulation which is produced by an
emotional vulnerability and maladaptive
and inadequate emotional modulation
strategies.
Biosocial model (Linehan, 1993)
Emotional
Vulnerability
Invalidating
Environment
Pervasive Emotional
Dysregulation
Biological Principals (Cont.)
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A person who is emotionally vulnerable is
someone whose automatic nervous system
reacts excessively to relatively low levels of
stress and takes longer to return to normal levels
of arousal once the stressor has been removed.
Emotion dysregulation is seen as a result in the
transaction between the biological disposition
and the environment.
7
6
Intensity 5
4
3
normal
BPD
2
1
0
1 2 3 4
5 6 7
8 9 10
normal
11 12 13
14 15 16
Time
17
Environmental principles
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Invalidating Environment refers essentially to the
situation where personal experiences and
responses of the growing child are “invalidated”
by care givers in their life. The child’s personal
communications are not accepted as an
accurate indication of her true feelings. The
invalidating environment contributes to emotion
dysregulation by failing to teach the child to label
and moderate arousal, to tolerate distress, or
trust her own emotion responses as valid
interpretations of events.
Biological Principles cont…
Emotion vulnerability
+
maladaptive, inadequate emotion
regulation strategies
=
EMOTION DYSREGULATION
Components of DBT
1:1
SESSIONS
TELEPHONE
SUPPORT
9am-9pm
OTHER
PROFESSIONALS
DBT
SKILLS
TRAINING
TEAM
MEETING
Individual Therapy
Pre-treatment:
To gain commitment and agreement to
stay in treatment using dialectic skills,
validation and commitment strategies
and an away weekend to enhance group
cohesion. There is a strong emphasis on
how difficult treatment is.
1:1 work cont….
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Stage 1:
Decide on treatment hierarchy (starting
with most life threatening behaviours)
Decrease life threatening behaviour
Decrease therapy interfering behaviour
Decrease quality of life interfering
behaviour
Skills Training in DBT
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There are 4 skills taught in DBT skills
training:
Mindfulness
Interpersonal effectiveness
Distress tolerance
Emotion regulation
Skills Training in DBT
Skills training has two primary goals;
1)
2)
Communicate information about particular
coping strategies to group members
Elicit from group members rules and
strategies for effective coping that they
have learned in the particular situation they
encounter
Mindfulness skills
Mindfulness is central for DBT
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It is the first skill taught and listed on the diary card
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Mindfulness skills are taught at the beginning of each
module
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The skills are a psychological and behavioural version of
Eastern meditation that has been drawn from ZEN.
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Mindfulness DBT looks at three primary states of mind
Mindfulness skills cont…
Wise mind
Emotional mind
Reasonable mind
Mindfulness Skills cont….2
What skills
How skills
Observe
Describe
Participate
Non- judgmental
One mindfully
Effectively
Interpersonal Effectiveness
Skills
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DBT Interpersonal Effectiveness skills are similar to
those skills taught in assertiveness training and
interpersonal problem solving classes.
The skills taught assist group members in:
ASKING WHAT ONE NEEDS TO SAY NO TO;
COPING WITH CONFLICTS.
The term “effectiveness” in DBT means obtaining
changes that one wants, maintaining the relationship and
maintaining your self respect.
Emotion Regulation skills
The first step in emotional regulation is learning to identify
emotions. To do this group members have to learn to observe
and describe:
1)The event prompting the emotion
2) The interpretation of the event that prompted the emotion
3) The phenomenological experience (including physical
sensations)
4) The behaviour expressing emotion
5) The after effects of the emotion on others types of functioning
Emotion Regulation skills cont…
Skills covered:
 identify obstacles to changing emotions
 reducing vulnerability to “Emotional Mind”
 increasing positive emotional events
 increasing mindfulness to current emotions
 taking the opposite action
 applying distress tolerance techniques
Distress Tolerance skills
The distress tolerance behaviours targeted in DBT
skills training are concerned with tolerating and
surviving crisis and with accepting life as it is in that
moment
Four sets of skills are taught;
1)
Distraction
2)
Self soothing
3)
Improve the moment
4)
Thinking of pro’s and con’s
Phone Coaching
The aim of telephone coaching is to help
patients refocus and use skills
 Problem solve
 Highlight shame
 Validate
 Use radical acceptance
Team Meetings & Group
Supervision
These focus on:
 keeping the therapist motivated and “true” in
order to reflect on the statement given to
patients
 encouraging the therapist to accept the
dialectics synthesis
 encouraging the therapist to adopt a none
judgmental/blaming stance
Case Presentation
Emily Smith is a 17 year old white female, she
lives in supported accommodation in Oxfordshire.
Emily’s presenting problems are:
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Deliberate self harm
Mood instability
Inability to tolerate distress
Restriction of diet
Periods of excessive drinking
Poor relationship with family
History
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Emily was also born with a nut allergy. She is the
eldest of three siblings and has two brothers
aged 15 and 9. She is academically bright and
attended grammar schools until 3 months prior
to her first admission.
Emily’s mum describes Emily as being very
emotionally needy and sensitive. Emily’s mother
also suffers from depression and suffered from
post-natal depression after Emily’s birth.
History
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Emily has had two admissions to Highfield Adolescent inpatient unit following referrals for DSH and low mood
over an 18 month period. During admission Emily
disclosed she was sexually abused by her brother.
These allegations were not investigated by social
services and her parents did not believe her.
Emily turned 16 and was supported in finding
independent accommodation.
Initially the independent living went well and Emily
reported a decrease in her symptoms. Her mood soon
began to fluctuate and she has began to struggle with
her self harm.
Behaviour Analysis
Vulnerability factors:
 The support she is offered is inconsistent and
dependent on which member of staff is working.
 There are a large number of males in the house
who have come from prison and probation
services. At first Emily was happy to be living
there she now feels that it is a punishment as
her brother and family have a much higher
standard of living. She is very blaming of her
family for her situation.
Stages of Treatment
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Emily’s target behaviors are:
1. Decreasing
self-hraming behaviours
2. Decreasing therapy interfering behaviours
3. Decreasing
quality of life interfering
behaviour
4. Increasing skills.
Treatment
Increase
Distress
tolerance
Interpersonal skills
Self-respect and self
worth
Acceptance
Decrease
Self-harm
Inability
to tolerate
distress
Poor interpersonal
relationships with family
Restriction of diet
Excessive drinking
Behaviour Analysis Diagram
Vulnerability (disrupted eating/sleeping and low in mood)
Precipitating Events
House mate playing loud music
Environmental invalidation
Telephone call from mum
can not visit today with
younger brother
Effective behaviours
phoned a friend/made plans
Active Passivity
Asked housing staff
to sort out house mate
Self-validation
I don’t diverse to be
cared for.
Interpersonal skills
Did not use
Friend cancelled.
Emotional dysregulation
Panic/fear
Impulsive
thoughts
Self-invalidation
Even my friends hate me
Emotional dysregulation
Loneliness/anxiety
Targeted behaviour
Cuts with razor.
Regulation and
Communication of
distress
Consequence: feels embarrassment/shame
and feels she has let herself and others down.
Negative reinforcer.
But tells a member of staff who then suggests they go for a coffee together.
Behaviour Analysis
Vulnerability factors:
 The support she is offered is inconsistent and
dependent on which member of staff is working.
 There are a large number of males in the house
who have come from prison and probation
services. At first Emily was happy to be living
there she now feels that it is a punishment as
her brother and family have a much higher
standard of living. She is very blaming of her
family for her situation.
Behaviour Analysis
Precipitating Events
 When Emily’s house mate started playing loud
music she felt angry and invalidated as her
house mate had been playing loud music till
3am the previous night.
 Emily approached staff in the house to complain,
the only response she got was that he was on
his last warning and would be given an eviction
notice. Emily felt too tired and weak to approach
him directly and did not want to get into a
confrontation.
Behaviour Analysis
Further Vulnerability factors:
 Emily’s anti-depressant medication was being
reduced and she was experiencing low mood.
When she is low in mood her cognitions are
often self-invalidating.
 Emily ruminates and becomes negative about
herself, which leads to her reducing her diet as a
means of punishing herself or cutting.
 The loud music in her accommodation has led to
Emily experiencing a disturbed sleep pattern
and at times gets very little sleep.
Behaviour Analysis
Self-invalidation:
 The dysfunctional cognitions serve to support
Emily's view that no one cares for her and she
does not deserve to be cared for.
 Due to vulnerability factors Emily was highly
aroused, making the consideration of applying
skills more difficult.
 After trying effective behaviours that did not work
due to environmental factors Emily returns to
self-invalidation.
Behaviour Analysis
Dysfunctional Links (cont)
 EMOTIONAL REGULATION DEFICIT
- Emily has a skills deficit in mindfulness,
emotional regulation, and distress tolerance.
She was unable to use mindfulness skills
(observing, non-judgmental stance and
description of her current emotional state).
- As Emily’s skills were limited in use, it served to
reinforce Emily’s belief of being unable to cope
without self-harm. This was reinforced by her
actions/behaviour.
Behaviour Analysis
Dysfunctional Links (cont)
 DISTRESS TOLERANCE DEFICIT:
 After trying distress tolerance skills in the form of
distraction (phoning a friend) the environment factors
stopped it from working (friend couldn't get money).
Consequently the positive reinforcement was removed.
 Emily reports feeling angry because she tried and it did
not work. This resulted in self punishment and a
reduction in more functional behaviour.
 Emily then experienced negative thoughts about not
being able to use skills.
Treatment Plan
Target behaviour: Self-harm
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Decrease vulnerability factors
Skills generalisation
Increase dialectic thinking
Behaviour rehearsal
Cognitive restructuring
Validation and addressing self-invalidation
Exposure treatment
Responses to specific clues
Address excessive dependence
Contingency management
Interventions
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Decrease vulnerability factors. Therapy sessions
focused on decreasing vulnerability through
Cognitive restructuring of invalidation and using
cheerleading to motivate.
Reviewing diary cards focusing on regaining sleep
pattern and eating meals three times day.
Increasing dialectical behaviour thought and
behaviour patterns.
Skills generalisation: Using behaviour rehearsal,
validation, exposure and reviewing responses to
specific cues in both individual and group skills
training.
Outcome Three months into treatment.
Changes after three months;
 Increase in dialectical thinking
 Reduction in DSH
 Increase recognition of normative behaviours
 Problem solving
 Increase of skills
 First month: reduction in DSH in first two weeks treatment.
Incidences 4 per week.
 Second month: Decrease in DSH 3 per week increase in excessive
drinking and not using skills
 Third month: Decrease in drinking, DSH the same three per week
but more use of skills
Other treatments.
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An RCT of a skills-based treatment versus a supportive
relationship treatment of 35 adolescent suicide attempters
(Donaldson et al, 2005) produced significant decreases in suicidal
ideation and depressed mood at 3- and 6-month follow-up, with no
differences between treatment groups.
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A recent, relatively large scale RCT of cognitive analytic therapy
versus ‘good’ treatment as usual for adolescents with borderline
personality disorder found both were equally effective at 24 months
follow-up (Chanen et al, 2008)
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Mentalisation Therapy (Bateman et al, 2004; Gibson 2006),
DBT for Adolescents
in the Looked After
Care System.
A.James.
Hon Senior Lecturer
University of Oxford.
Adolescents in the Looked After
Care System (LAC).
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The rates of emotional and behavioural
problems in children in care range from 40 % to
nearly 60%, depending on the sample
Minnis et al, (2004) found that over 90% of the
children in foster care had previously been
abused or neglected and 60% had evidence of
mental health problems including conduct
problems, emotional problems, hyperactivity and
problems with peer relations.
Adolescents in the Looked After
Care System (LAC).
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A Swedish study (Vinnerljung et al, 2007) found
former children in the care system were four to
five times more likely than the general
population to have been hospitalised following
suicide attempts. Individuals who had been in
long-term foster care tended to have the most
dismal outcome. Even adjusting for birth parents’
hospitalizations with a psychiatric diagnosis, and
for birth-home-related socio-economic factors, a
twofold elevated risk remained.
Adolescents in the Looked After
Care System (LAC).
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In the UK, children looked after by local authorities are
recognised by the children’s National Service Framework
(Department of Health, 2004) and Every Child Matters
(Chief Secretary to the Treasury, 2003) as a group who
are particularly vulnerable to psychological difficulties
and are often denied access to services.
Even so some studies indicate service utilization by this
group as comparatively high with 36% having been
assessed in Child and Adolescent Mental Health
Services (CAMHS) and 25% having seen a child
psychiatrist (Stanley et al, 2005; Rodriquez et al, 2004).
Adolescents in the Looked After
Care System (LAC).
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For children in the care system DSH
represents a major health concern. In the
UK, the rate of adolescent DSH in the
general population is high with 11.2% of
females and 3.2% of males reporting an
episode of DSH within the previous year
(Hawton et al, 2002). Young females who
engage in repeated DSH are at particular
risk of suicide (Zahl et al, 2004).
Reduction in DSH with DBT.
4
3.5
3
2.5
2
Episodes DSH per
Week
1.5
1
0.5
0
T1
T2
T3
F = 23.95 d.f. = 2 ,
p < 0.001
Improvement in Functioning (GAF
Score)
90
80
70
60
50
GAF Score
40
30
20
10
0
T1
T2
T3
DBT
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The treatment package was based upon the community
model already being used within CAMHS (James et al.
2008). This had been adapted from the manualised
treatment developed for adults (Linehan 1993a, 1993b)
and the 12 week package developed by Miller and
Rathus (Rathus et al, 2002).
In this study, DBT was delivered in the community.
Stage 1 - The treatment package consisted of pretreatment, a once-weekly skills training group, a onceweekly hour-long individual session, telephone support,
carers training and outreach components.
Participants
Young people were referred to the service
from all areas: social services teams
(Looked After and Leaving Care), CAMHS,
Forensic CAMHS and Youth Offending
Teams. The capacity of the DBT team
was 8 clients as recommended for the
group skills training (Linehan 1993b).
Participants.
To be included in the study subjects had to have a
history of more than six months of persistent SH, defined
after Hawton et al. (2002) as: an act with a non-fatal
outcome in which an individual deliberately did one or
more of the following: self cutting; jumping from a height
which they intended to cause harm; ingesting a
substance in excess of the prescribed or generally
recognised therapeutic dose; ingesting a recreational or
illicit drug that was an act that the person recognised as
self harm; ingesting a non-ingestible substance or object.
Exclusion criteria included a diagnosis of schizophrenia,
bipolar disorder, autism, autistic spectrum disorder and
those with moderate and severe mental impairment.
Participants
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Twenty young people agreed to engage in DBT, four young men
and 16 young women.
The mean age at treatment onset was 15.3 years (sd = 1.4), the
youngest being 13, the oldest 17 years of age.
Of those 20, 14 engaged in full DBT, with 6 disengaging after the
pre-treatment motivation stage. Nine completed two full cycles of
the group (2 male, 7 female), and 5 dropped out of full DBT within
the first skills module of group.
Of those that began DBT 7 were in full-time education, 2 were in
partial supported education and 5 were unemployed.
When they started DBT 2 young people were in a secure unit, 3
were living in local authority children’s homes, 3 were living with
foster carers, 3 were living independently, 2 were living with family
members and 1 was living in homeless sheltered housing. Five
young people were prescribed medication- all serotonin re-uptake
inhibitors (SSRIs) antidepressants - fluoxetine (2), sertraline (1)
citalopram (1).
Procedures
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The Structured Clinical Interview for DSM-IV 11 (SCID-II) was used
to assess and quantify borderline personality traits.,.
Independent audit outcome measures were carried at the start of full
treatment and end of treatment. These were Beck Depression
Inventory (BDI), (Beck, 1979), Beck Hopelessness Scale (BHS),
(Beck et al., 1974), Attachment Style (Attachment Style
Questionnaire (ASQ), (Feeney et al, 1993), Negative Automatic
Thoughts (Childrens Automatic Thoughts Scale (CATS), (Schniering
& Rapee, 2002),) and a Global Assessment of Functioning (GAF),
(DSM-IV-TR, APA 2000).
The number of episodes of DSH per week was determined by
clinical interview.
Results.
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For those who completed treatment (n = 9)
there was a significant reduction in
depression scores (t = 2.83, d.f. = 8, p =
0.025,); hopelessness scores (t = 2.49,
d.f. = 8, p = 0.038,) and a significant
reduction in frequency of self harm (t =
4.051, d.f. = 8 p = 0.004,). There was also
a significant increase in global functioning
scores (t = 6.11, d.f. = 8 p < 0.001).
Results.
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Of note at the end of treatment 7 had totally stopped
DSH, one still cut superficially approximately once a
month, compared to daily cutting and ligature tying, and
one enrolled in drug rehabilitation to treat heroin
addiction, but showed no other kinds of DSH.
At the end of treatment there were no significant
changes in negative automatic thoughts (CATS), or
quality of life scores (Adolescent Comprehensive Quality
of Life Scale) scores. All participants were rated
according to the Attachment Style (ASQ) as being
insecurely attached.
Results.
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Of the nine who completed treatment, four where
already in education and remained in school or moved to
further education,
Three were supported back into education, one was
supported to get a job and one went into a drug
rehabilitation centre.
By the end of treatment two young people were moved
from secure units, one returned back to their family and
the other moved to supported lodgings.
Two young people moved from foster care, one into
independence and the other back to their family.
Results.
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Fity-five percent (11/20) of young people who
agreed to start the programme dropped out after
pre-treatment or within the first module of group.
Those who dropped out had significantly higher
scores of depression on the BDI (t = 2.26, d.f. =
12, p = 0.045) and hopelessness on the BHS (t
= 2.71, d.f, = 12, p = 0.025), but achieved higher
positive ratings on the Global Assessment of
Functioning (t = 2.545, d.f. = 12, p = 0.026).
There was no significant difference in scores on
any other measure.
Discussion.
Problems – High drop out rate.
 Other treatments available.
 Treatment of depression
 Time for a multi-centre randomised
controlled trial (RCT) (Fleischhaker et al,
2006).
