Transcript Slide 1

DIALECTICAL BEHAVIOURAL
THERAPY
THE STORY SO FAR . . . 7 Years of DBT
Presenter: Gay Boaden BSS, BC
DBT Coordinator
Dialectical Behavioural Therapy Program
“Moving Forward” in the Manning
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Institutional Context for DBT
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In 2004, 30 clinicians from Taree Community Health were trained in Dialectical
Behavioural Therapy, by Rachel Rossiter and Jennifer Koorey from The Centre for
Psychotherapy, James Fletcher Psychiatric Hospital, Newcastle.
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Gay Boaden was appointed DBT Coordinator and commenced work on a business
plan and implementation of the program in the Manning and Great Lakes area.
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Based on empirical evidence from the Centre for Psychotherapy and the Hunter
Valley Mental Health Service, DBT was found to be a cost effective approach for
managing multiple, acute presentations of individuals with Borderline Personality
Disorder.
•
Our program is a community, outpatient program within a rural setting, in the Mid
North Coast of NSW.
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Organisational Diagram
HUNTER NEW ENGLAND AREA HEALTH SERVICE
MANNING MENTAL HEALTH SERVICE
MANAGEMENT TEAM
MANNING RURAL REFERRAL HOSPITAL
WARDS / EMERGENCY DEPARTMENT
MENTAL HEALTH
ACCESS LINE
CONSULTATION LIAISON
AREA
HEALTH
REFERRAL
MANNING
ALLIED
HEALTH
REFERRAL
ACUTE MENTAL HEALTH
SERVICE
MANNING MENTAL HEALTH
INPATIENT UNIT
MAYO
HOSPITAL
REFERRAL
PRIVATE
PROVIDER
REFERRAL
MENTAL HEALTH ALLOCATION & ACCESS MEETING
DIALECTICAL BEHAVIOUR THERAPY
PROGRAM COORDINATOR
SUPERVISION
CENTRE FOR
PSYCHOTHERAPY
DBTSKILLS
GROUP
DIALETICAL BEHAVIOUR THERAPY
CONSULT GROUP
INDIVIDUAL DBT
THERAPIST
DBT PHONE
COACHES
DBT INTENSIVE
GROUP
MHIPU
MINDFULNESS
DBT SHORT
COURSE
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Rationale for DBT
• The Dialectical Behaviour Therapy Program for treating Borderline
Personality Disorder, was developed by Marsha Linehan during the early
90's and has been shown to reduce costs to services by an average of
50% (Behavioral Technology Transfer Group 2002).
• This costing advantage is being replicated in Australian DBT program
outcomes within the Hunter Valley Mental Health Service (HVMHS).
• Based upon these results, we anticipate similar outcomes for our services.
(2004 Business Plan:Boaden,G & Macauslane,S)
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Business Case for Implementing BPD
Treatment Program
• One of the main aims of introducing a specific treatment program for BPD
was to reduce the frequency of interactions and the associated costs to
each of the service providers across the range below:
• Ambulance / Police / GP
• Admissions to both MBH A&E & Taree Psychiatric Inpatient Unit
• Crisis Interventions – Sexual Assault, Community Mental Health & Acute
Inpatient Unit, Alcohol & Other Drugs Teams
• Ongoing Counselling sessions through each of the teams listed above,
without any structured clinically tested framework.
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Background to Dialectical Behaviour
Therapy
• Dialectical Behaviour Therapy (DBT) can be described as a cognitivebehavioural therapy for BPD. It combines problem solving, informed by
behaviour principles and techniques, with an attitude of acceptance
characterised by validation of, and empathy for the individual with BPD
(Linehan 1993).
• The treatment model for DBT typically involves a combination of individual
therapy, skills training, between session telephone support and an
ongoing therapist consultation & support group. The treatment can extend
for 12 - 18 months and involves a pre-treatment stage, and four main
stages of therapy
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4 Stages of DBT
1 During the pre-treatment phase a comprehensive mental health
assessment is conducted, with particular emphasis on the individual's
potential ability to commit to such a demanding program.
2 The next stage of therapy concentrates on reducing suicidal ideation &
behaviours that interfere with the therapy process and to their quality of
life.
3 The third stage addresses problems associated with post traumatic stress,
as many BPD clients have experienced physical, emotional & sexual
abuse.
4 The fourth stage of the therapy deals with self esteem and individual
treatment goals. The final stage is concerned with building the individual's
capacity to experience joy. (Kiehn & Swales 2001).
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5 Program Components & Their Interrelationships
Our Program “Moving Forward” includes all Five components of DBT:
1
DBT Individual Therapy.
2
DBT Skills Group Training.
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After hours DBT Phone Coaching.
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Consultation to all DBT therapists. Clinical Supervision is provided
within our team as well as accessed externally by videoconference
through the Centre for Psychotherapy
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Supportive Ancillary treatments such as; Pharmacotherapy and Acute
Inpatient Liaison are provided.
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Patient Characteristics of BPD
• More generally, Linehan (1993) suggests that clients with BPD tend to
demonstrate:• Emotional Dysregulation
• Interpersonal Dysregulation
• Behavioural Dysregulation
• Cognitive Dysregulation
• Dysregulation of the self
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Characteristics Of BPD
This translates into what she describes as 6 typical patterns of behaviour.
1. Emotional Vulnerability - Inability to label & understand ones feelings
2. Self Invalidation - having unrealistic goals & expectations
3. Unrelenting Crisis - each crisis following another without being resolved
4. Inhibited Grieving - unable to face negative feelings of loss and grief
5. Active passivity - active in finding others to solve their problems
6. Apparent competence - have learned to give the impression of being competent
in response to an invalidating environment
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Diagnostic Criteria For BPD
DSM IV TR
A pervasive pattern of instability of interpersonal relationships, self image, and affects as well as
marked impulsivity beginning by early adulthood and present in a variety of contexts, as
indicated by five or more of the following:1.
2.
3.
4.
5.
6.
7.
8.
9.
frantic efforts to avoid real or imagined abandonment
a pattern of unstable and intense personal relationships characterised by alternating
between extremes of idealisation and devaluation
identity disturbance: markedly and persistently unstable self image or sense of self
impulsivity in at least two areas that are potentially self damaging (eg. Spending, sex,
substance abuse, reckless driving, binge eating Note: Suicidal or self harming behaviour in
criterion 5
recurrent suicidal behaviour, gestures or threats or self mutilating behaviour
affective instability due to marked reactivity in mood (eg. Intense episodic dysphoria,
irritability or anxiety usually lasting a few hours and only rarely more than a few days)
chronic feelings of emptiness
inappropriate intense anger or difficulty controlling anger (eg frequent displays of temper,
constant anger, recurrent physical fights)
transient, stress related paranoid ideation or severe dissociative symptoms
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Personality Disorders
DSM IV TR
CLUSTER A – Odd & Eccentric
• Paranoid – distrust & suspiciousness such that others motives are considered malevolent
• Schizoid – detachment from social relationships & restricted range of emotional expression
• Schizo typal * – acute discomfort in close relationships, cognitive or perceptual distortions,
eccentricities of behaviour
CLUSTER B – Dramatic, Emotional & Erratic
• Antisocial * – disregard for, & violation of the rights of others
• Borderline * – instability in interpersonal relationships, self image & affects, marked impulsivity
• Histrionic – excessive emotionality & attention seeking
• Narcissistic – grandiosity, need for admiration, lack of empathy
CLUSTER C - Anxious & Fearful
• Avoidant *– social inhibition, feelings of inadequacy, & hypersensitivity to negative evaluation
• Dependent – submissive & clinging behaviour related to an excessive need to be taken care of
• Obsessive Compulsive * – preoccupation with orderliness, perfectionism & control
Personality Disorder Not Otherwise Specified – traits of several PD’s, or one not classified eg Passive
Aggressive PD
* Proposed DSM V Personality Disorders plus PD Trait Specified
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Definition of Program Components
• Individual therapy (1 Hour each week) is provided by one of our eight
therapists. This process addresses clients’ personal needs, developing a
strong therapeutic relationship, which will hold them throughout times of
heightened distress in their lives. This relationship is often reported as the
first long term, stable relationship that has not “blown up”.
• DBT Skills Group (2½ hours each week) provides a teaching
environment, where skills acquisition, development and generalisation
occurs. Home work is given and reviewed combined with mindfulness
exercises. The function of the group is to inform, clarify DBT teaching, as
well as to engender a culture of respect, validation and advanced vicarious
learning. The group is lead by two skills group leaders who use the power
of the group to inform, cheerlead and validate participants.
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DBT Phone Coaching
• DBT Phone Coaching is provided by individual therapists and skills group
leaders, who are all members of the Consult Group.
• The function of the after hours phone coaching is to decrease suicide
crisis behaviours and to increase generalisation of skills, in times of high
emotional distress.
• The phone coaching line provides an opportunity to cheerlead and validate
our clients in their environment as well as providing acute care for selfharming and or suicidal clients.
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DBT Consult Group
• DBT Consult Group is the engine that drives the program or the oil that
keeps the machine running smoothly.
• One function of the Consult Group is to enhance therapist capabilities and
motivation to treat patients effectively.
• As in the Client Skills Group our Consult Group provides ongoing
teaching, generalization of skills acquisition, cheerleading and validation
for its members. Clinical Supervision is an integral component of our
consult group
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Nature and Numbers of Personnel Offering DBT
• Our Consult Group consists of a team of nine Mental Health Professionals.
• We have five registered Mental Health Nurses one Clinical Nurse
Specialist, one Intern Psychologist, one Social Welfare Counsellor and
one Clinical Psychotherapist.
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Therapist's Agreements
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We adhere to standard DBT agreements. We attend and participate in weekly
Consult Meetings (90 minutes)
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We agree to make every reasonable effort to conduct competent and effective
therapy.
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We agree to obey standard ethical and professional guidelines
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We agree to be available to our client for weekly therapy sessions and provide
therapy backup if unavailable.
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We agree to respect the integrity and rights of the client.
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We agree to maintain confidentiality.
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We agree to obtain consultation when needed.
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Clients' Agreements
• Clients' Agreements in standard DBT are an integral part of the pretreatment phase. Clients as do Therapists sign off on their respective
agreements early in treatment. Clients agree to:
• Stay in therapy for a minimum of twelve months.
• Agree to work towards reducing self-harming behaviours.
• Work on problems that interfere with therapy.
• Attend weekly individual sessions.
• Participate in weekly skills groups.
• Complete Diary Cards and homework assignments.
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ENTRY CRITERIA
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Patients in “Moving Forward” DBT Program.
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Entry criteria depends on a diagnosis of Borderline Personality Disorder, with at least one
serious suicide attempt in the past twelve months, with intent to die.
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To maintain consistency in diagnoses we engage our own DBT treating Psychiatrists.
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Our patients come to us from many referral sources and locations. We receive referrals
from Hospitals, Probation and Parole Justice Departments, Psychiatrists, General
Practitioners, Social Workers, Psychologists within our area, as well as out of area.
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We have had contact with more than one hundred and fifty clients since our program
commenced during the past seven years. It is anticipated that this number will continue to
grow as our service gains greater exposure and the number of successful outcomes are
more widely known.
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Modifications of Standard DBT
• We also provide a 10 week Skills Group Program “Life Matters'" for the
general population who do not meet the criteria for the comprehensive
program. This is a stand alone program.
• The rationale for this program is to meet the needs of people who are
experiencing problems with interpersonal relationships, difficulty in
regulating emotions and tolerating distressful situations, but without
serious self-harming behaviour
• This group is run by two experienced DBT therapists / Skills Group
Leaders. This is a useful introduction and training ground for new
members of our team, to gain knowledge and practise their acquisition and
development of DBT Skills. Students on placement enjoy being part of
this group.
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DBT Coordination
• Patients in our comprehensive program, “Moving Forward”, are aware that
they are in a well coordinated DBT Program. Many have expressed
sincere thanks for the opportunity given to them, to be included in this
valuable, life changing program.
• Some participants have researched DBT on the net and have discovered
that our program delivers a comprehensive program, one that includes all
the necessary components of DBT. Some have looked into private
services and have found that not all the components are offered and
without private health insurance it is unavailable to them.
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DBT Coordination
• Our process in providing a coordinated, comprehensive service, was
guided by Marsha Linehan’s research clearly showing that life changing
outcomes, can occur for clients who participate in the full program.
• My determination to implement a model as close to Marsha's model, came
with this knowledge and the belief that our patients deserve the greatest
opportunity to access this successful program, even in a rural setting, with
limited resources.
• I have been encouraged by our local team of mental health professionals,
who have willingly changed the way that they work, embracing this
Dialectical Behavioural Therapy model.
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Outcomes so far . . .
AVERAGE DIFFICULTIES IN EMOTION REGULATION FACTOR
SCORES BEFORE AND AFTER DBT
Nonacceptance
40
Goal Directed Behaviour
35
Impulse Control
30
Emotional Aw areness
25
Emotion Reg Strategies
AVERAGE
SCORES 20
15
Emotional Clarity
Emotion Reg Strategies
10
Impulse Control
Nonacceptance
AFTER
0
BEFORE
5
TIME
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Pre and Post Testing
MH HOSPITAL PRESENTATIONS BEFORE AND AFTER
INTRODUCTION OF DBT IN 2005
66
70
60
50
CUMMULATIVE 40
PRESENTATIONS 30
20
10
8
0
BEFORE
TIME
AFTER
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Self Report K10
SELF REPORT K10 REDUCTIONS DURING DBT PROGRAM
5
4
3
ITEM SCORES
2
Apr-10
Feb-10
Dec-09
Jun-10
TIME PERIODS
Oct-09
Aug-09
Jun-09
0
Apr-09
1
Item 10
Item 7
Item 4
ITEMS
Item 1
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Our demographic data
• In six years we have had 30 participants successfully graduating after 12
months program
• 87% female, 13% male
• 100% unemployed (entry), 27% employed (exit)
• 100% BPD, 13% BPD only diagnosis
• 87% BPD plus at least one other co-morbidity
• Age range 18 – 52 years, Average age 36
• 50% graduated from the full program
• 27% discontinued group prior to graduation
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Our successes
• We have celebrated with clients who have:
– graduated after completing DBT program
– completed Stage 2 therapy
– returned to complete DBT after dropping out
– returned for a ‘refresher’ short course
– achieved all of their DBT goals
– gone on to marry their life partner
– moved into or back into the workforce
– started their own business
– teaching DBT behaviours to others
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Professional Reflections
“ …. one of the glaring impacts of the DBT Programme, as it is delivered
across the Manning Mental Health Cluster, would be the impact on the
admission rate/frequency of those clients that attract a diagnosis of
Borderline Personality Disorder, that is to say it is extremely rare for
anyone from this diagnostic group to be admitted to the Inpatient Unit as
opposed to the previous high levels of frequent and very short admissions
that still occur in other mental Health Services.
The benefits to the client, and their family, is less disruption to their day to
day living and the development of healthy ways to communicate and
handle their distresses.
At the risk of sounding mercenary this extremely low admission rate
equates to significant savings to the Health budget and funding.”
Ron Haigh
Manager Mental Health
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Professional Reflections
Prior to the introduction of DBT, treatment of clients presenting with a BPD
were largely crisis management and time consuming. I remember feeling
powerless to help clients, apart from short term strategies, which often were hit
and miss or sabotaged if the client felt it wasn’t what they wanted.
Post DBT, there is now the scope to offer a tangible hope to sufferers, from a
clinicians perspective, we can now focus more on offering hope for the future
than simple managing the immediate crisis. From a consumers perspective
the knowledge that things don’t have to stay the same, that there is an
alternative, often allows them to gain control in the immediate sense and hold
hope in their situation in the long term.
Stuart Perks
Clinical Nurse Consultant in Consultation Liaison Psychiatry
Professional Reflections
“In the Emergency Department, we used to have people
presenting very regularly, highly distressed, overdosing,
cutting and other self-harming behaviours, such as overuse of
alcohol and drugs, high speed driving and dangerous sexual
activities to name a few……..after DBT was introduced, I
noticed an amazing reduction in the number of presentations
of these people.”
Robyn Rooney
Emergency Department Nurse
Professional Reflections
“DBT is an invaluable program for people wanting to work on longstanding dysfunctional patterns of behaviour (e.g. emotional dysregulation,
suicidal/self-harm ideation) who otherwise will find it quite difficult to get
help.”
Dr. Rahul Gupta
Acting Clinical Director, Manning Mental Health Service
Reference List
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APA (2000) Diagnostic Skills Manual IV TR
Behavioral Tech (2010) DBT Intensive Training Notes Seattle: Behavior Tech
Boaden,G & Macauslane,S (2004) Dialectical Behaviour Therapy- Project Overview:
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Centre for Psychotherapy (2005) The Dialectical Behaviour Therapy Approach to
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Dimeff, L., Koerner, K. & Linehan, M.M. (2002) Summary of Research on DBT.
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Macauslane,S. (2010) DBT Intensive Poster Presentation
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