Transcript DIALECTICAL BEHAVIOUR THERAPY

DIALECTICAL BEHAVIOUR
THERAPY
FI CONINGTON
CLINICAL LEAD OASIS
DSM-IV Criteria
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frantic efforts to avoid real or imagined abandonment.
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a pattern of unstable and intense interpersonal relationships characterised by alternating
between extremes of idealization and devaluation.
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identity disturbance: markedly and persistently unstable self-image or sense of self.
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impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating). Note: Do not include suicidal or selfmutilating behaviour covered in Criterion v.
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recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
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affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
chronic feelings of emptiness
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Inappropriate intense anger or difficulty controlling anger (e.g. frequent displays of temper,
constant anger, recurrent physical fights)
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Transient, stress-related paranoid ideation or severe dissociative symptoms
DSM 5
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The Fifth Edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) was released at the American Psychiatric
Association’s (APA) Annual Meeting in May 2013.
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During the development process of the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5), several
proposed revisions were drafted that would have significantly
changed the method by which individuals with these disorders are
diagnosed. Based on feedback from a multilevel review of proposed
revisions, the APA Board of Trustees ultimately decided to retain the
DSM-IV categorical approach with the same 10 personality disorders.
Cluster A
The odd &
eccentric
Cluster B
The dramatic
& erratic
Cluster C
The anxious
& fearful
DSM 5
ICD-10
Paranoid
Distrust and suspiciousness
Paranoid
Distrust and sensitivity
Schizoid
Socially and emotionally detached
Schizoid
Emotionally cold and detached
Schizotypal :difficulty in establishing and
maintaining close relationships with others.
No equivalent
Antisocial
Violation of the rights of others
Dissocial
Callous disregard of others, irresponsibility and
irritability
Borderline
Instability of relationship, self-image and
mood
Emotionally Unstable
A) Borderline type: unclear self-image and intense
unstable relationships
B) Impulsive type: inability to control anger,
quarrelsome and unpredictable
Histrionic
Excessive emotionality and
attention-seeking
Histrionic
Dramatic, egocentric and manipulative
Narcissistic
Grandiose, lack of empathy, need for
admiration
No equivalent
Avoidant
Socially inhibited, feelings of inadequacy,
hypersensitivity
Avoidant
Tense, self-conscious and hypersensitive
Dependent
Clinging and submissive
Dependent
Subordinates, personal need, seeking constant
reassurance
Obsessive compulsive
Perfectionist and inflexible
Anankastic
Indecisive, pedantic and rigid
DBT’s Reorganisation of Diagnostic Criteria for
BPD
 Emotional Dysregulation – criteria 6 and 8
 Interpersonal Dysregulation – criteria 1 and 2
 Behavioural Dysregulation – Criteria 4 and 5
 Cognitive Dysregulation – Criterion 9
 Dsyregulation of the self – Criteria 3 and 7
Presentation within care settings
•Frequent admissions
•Self harm / suicide attempts
•Drugs / alcohol often a feature
•Frequent crisis
•Multiple agencies involved
•Splitting – differing points of view within the care network being reinforced by the
client.
•Helplessness / frustration amongst the staff group. Sometimes blaming. “Something
must be done!”
•Misdiagnosis / failure to assess Axis II, relying purely on a variable clinical
presentation (Axis I).
Historical Context
 Marsha Linehan – Working with women with a
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diagnosis of BPD. (1993)
Work standardised in treatment manuals
Developed and adapted
Blends Cognitive-behavioural interventions with
Eastern meditation practices
Shares elements in common with psychodynamic,
client-centred, Gestalt and paradoxical approaches
Why not traditional Therapy?
The term “Borderline” grew out of observations within the Psychoanalytic
community that there was a group of clients who did not respond well to
therapy and yet did not present as being psychotic.
Marsha Linehan (1993), suggests that traditional therapy is problematic
because it essentially creates the conditions under which someone with this
presentation will struggle i.e. trust issues, discussing emotive material and
requiring the client to then modulate their emotions enough for them to reevaluate their experience.
As a consequence such clients often decompensate within therapy and the
treatment creates a crisis.
Traditional Therapy or DBT?
 DBT takes a different approach. It recognises that
there is a skills deficit and focuses on teaching skills
that enable the client to regulate their emotions,
tolerate distress, regulate relationships and make
mindful decisions. It also directly challenges self
harm as a strategy for regulating emotions. Once
these skills have been fully adopted, it then becomes
possible for the client to engage with the more
explorative therapies.
Conceptual Framework
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Stage Theory of Treatment
Bio-social theory of the etiology and maintenance
of BPD
Learning principles and ideas from behaviour
therapy
BPD behavioural patterns and Dialectical
Dilemmas
Dialectical Orientation to change
1. Stages of Treatment: Behaviours to
target in DBT
Suicidal/homicidal or other imminently lifethreatening behaviour
2. Therapy interfering behaviour – client and
therapist
3. Quality of life interfering behaviour
4. Deficits in behavioural capabilities needed to make
life changes
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2. Bio-social Theory
 Emotional vulnerability
Genetic/biological/neurological development
 Emotional Dysregulation
High sensitivity, Strong reactions, slow return to
baseline.
 Invalidating environment
Fails to confirm, corroborate or verify individual.
Examples of invalidating environment
 Dismiss or disregard
 Criticism and punishment
 Reject self-description as inaccurate
 Reject response to events as incorrect or
ineffective
 Pathologize normative responses
 Reject response as attributable to socially
unacceptable characteristic (e.g., over-reactive
emotions, paranoia manipulation, negative
attitude
3. Theory of change
 Principles of learning and ideas from behaviour
therapy.
 Analysis of antecedents and consequences
 Functional analysis/behaviour chain analysis.
4. Dialectic - A World View
 Fundamental interrelatedness or wholeness of
reality.
 The fundamental nature of reality is change
 Reality is not seen as static – comprised of internal
opposing forces that are in constant
flux.(Psychodynamic)
5. Dialectics – A treatment approach
 Working towards synthesis of opposing polarities: Acceptance V change
 Change V consequences of change
 Maintaining personal integrity V learning new skills
Working towards flexibility and
management of change whilst developing
stability
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Dialectical Dilemmas
Dialectical Dilemmas
 Dilemma
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Emotional Vulnerability
vs. Self-invalidation
 Treatment Target
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Increasing emotional
modulation
Decreasing emotional
reactivity
Increasing self-validation
Dialectical Dilemmas
 Active Passivity vs.
Apparent Competence
 Treatment Target
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Increasing active problem
solving
Decreasing active
passivity
Increasing accurate
communication
Decreasing mood
dependency of behaviour.
Dialectical Dilemmas
 Unrelenting Crisis vs.
Inhibited Grieving
 Treatment Target
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Increasing realistic
decision making and
judgment
Decreasing crisisgenerating behaviours
Decreasing inhibited
grieving
DIALECTICAL BEHAVIOUR
THERAPY
THE PRACTICE
Outline of Treatment Programme
Functions and Modes
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Functions
Enhanced Capabilities
Improve Motivational
factors
Assure generalisation
to natural environment
Structure the
environment
Enhance therapist’s
capabilities &
motivation to treat
effectively
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5.
Modes
Skills Training Group
Individual therapy
Telephone, Milieu
coaching
Organisational
interactions (consultto-client)
Team consultation to
hold therapists inside
the treatment
NorthDevonDBTProgramme
2011
DBT - Overview
 Structure
 Behaviour Therapy
 Validation
 Dialectics
 Mindfulness
Structure the Treatment
 Outpatient individual Psychotherapy
 Outpatients Group Skills Training
 Telephone Consultation
 Therapist consultation meeting
 Uncontrolled Ancillary Treatments
Pharmacotherapy
 Acute-inpatient admissions
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Structure of sessions
 Individual Sessions
 Diary cards
 Hierarchy of treatment goals
 Chain analysis
 Solution analysis
Programme Outline – Stage 1
One year period to include:
Weekly Group consisting of the following 6 month
modules (run twice):
Distress Tolerance
6 weeks
Mindfulness
Mindfulness
2 weeks
2 weeks
Interpersonal Effectiveness
6 weeks
Emotion Regulation
6 weeks
Mindfulness
2 weeks
The modular rotation allows for new clients to be taken on within an 8
week period. The groups will run for 2 ½ hours. Total client capacity
to include group = 8
Structure of Group
 Mindfulness exercise
 Diary cards/ homework feedback
 Skills training
 Setting homework
Structure of DBT service
 Group training
 Each patient has an individual therapist
 Group skills taught by 2 therapists
 DBT consultation group
 Case management strategies
Structure - Rules
 Clients who drop out of therapy are out of therapy
 Each client has to be in on-going individual therapy
 Clients are not to attend groups under the influence of
drugs/alcohol
 Clients are not allowed to discuss past self-harm with
other clients outside of sessions.
 Clients may not form private relationships outside of
the group
 Clients who call one another for help when feeling
suicidal must be willing to accept help from the person
called.
Case Management Strategies
 Consultation-to-the patient strategy
 Environment intervention strategy
Behaviour Therapy
 Chain analysis.
 Emphasis on learning theory – practice and
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repetition.
Focus on behaviour and acquisition of new skills.
NOT being “seduced by interest”.
Focus on the hear and now.
Use of the body/posture
Behaviour Therapy
 Contracts
 Rules governing attendance to group and individual
sessions – strict boundaries
 Rules surrounding self-harm and admission to
inpatient ward
 Specific tools – exposure, response prevention,
opposite action, reparation and repair.
Chain analysis
Case illustration
 Role play – behavioural analysis
 On returning home from a party Mary made several
lacerations to her arm. Whilst at the party, after a
few drinks she had felt more confident and relaxed
and had begun chatting animatedly with her friends
boyfriend. Her friend had become angry and
accused her of flirting.
Validation
 Level 1 – Active observing
 Level 2 – Reflection
 Level 3 – Mind Reading
 Level 4 – Validation in terms of the past
 Level 5 – Validation in terms of the present
Validation
 Feelings, thoughts or behaviour.
 Soothes and encourages the patient through difficult
times.
 Enhances the therapeutic relationship.
 Strengthens the therapists empathy.
 Teaches the patient to trust and validate his or her
own behaviour.
The Therapeutic Relationship
 Trust and attachment are augmented:
 Through warmth (e.g., Rogerian stance)
 Through appropriate self-disclosure
 By Validating the patient’s experience.
 Including negative feelings about therapy
 Explicitly identifying such feelings
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Anticipating therapy-interfering behaviours
Being available by phone between sessions
Dialectics
Mindfulness
 What is it?
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A state in which one is highly aware and focused on the reality
of the present moment, accepting and acknowledging it,
without getting caught up in thoughts that are about the
situation or in emotional reactions to the situation.
Pre- treatment phase
 Pre treatment assessment
 Introduction to the model
 Engagement and Commitment
 Pro’s and con’s of engaging in therapy
 Identifying Target behaviours to decrease
 Identifying aims for therapy
 Introduction to tools
 Contracting
Mindfulness
DIALECTICAL BEHAVIOUR
THERAPY
THE SKILLS
Mindfulness
 WHAT skills
 Observe
 Describe
 Participate
 HOW
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skills
Without judgment
In the moment (one mindfully)
Effectively
Distress Tolerence
 Wise mind ACCEPTS
 Self-soothing
 IMPROVE the moment
 Pros and Cons
Emotion Regulation
 Emotion –focused work
 Labelling emotions
 Understanding their effect
 Reducing the chances of being controlled by emotions
 Reducing vulnerability to negative emotions – PLEASE
MASTER
 Increasing positive emotions through experience
 Letting go of emotional suffering
 ‘Acting opposite’
Interpersonal Effectiveness
 Attending to Relationships
 Balancing Priorities and Demands
 Balancing the wants-to-shoulds
 Building mastery and self-respect
 Objectiveness effectiveness
 Relationship effectiveness
 Self-respect effectivness
Radical Openess
 Turning the mind
 Radical Acceptance
 Practice Willingness
 Notice Willfulness
DBT - Adaptions
 Different Client Groups
 Individual DBT
 DBT light
 Pros and Cons of Adapting the model
National Research Evidence
Based on various research findings, the Department of Health
(NICE Guidelines 2009 - CG78 to be updated in 2012) has
recommended the following for people with Borderline
Personality Disorder:
 treatment that lasts at least 12-18 months
 dialectical behaviour therapy for people who really
struggle with self-harming behaviours
 mentalisation-based therapy, which is a mixture of
group and individual reflection
 therapeutic communities and structured group
therapy programmes
Research Findings
 Linehan et al., 1991, 1993, 1994. Similar findings
with all studies suggested significant reductions in
self-harm & suicide attempts, length and frequency
of hospitalisation, treatment dropouts and improved
anger management, global and interpersonal
functioning.
Research Findings
 Bohus et al., 2004. Effectiveness of Inpatient DBT –
3 months treatment vs TAU. Significant reduction in
self-injurious behaviour and in clinical symptoms
such as depression/anxiety. Increase in
interpersonal functioning, social adjustment and
global psychopathology n=31.
Conclusion – 50% of female patients who completed
the programme improved at a clinically relevant
level.
Research Findings
 Comtois et al., 2007. Effectiveness of DBT in a
community mental health centre. I year treatment
programme. Results indicated significant reductions
in number and severity of self-harm, impatient
admissions and A & E visits. N = 38.
 Limitation – non-randomised sample so open to
selection bias.
Research local – evaluation procedures
• Outcomes of Treatment
Outcome measures
Behavioural measures:
• Number of visits to A&E
• Number of admissions to inpatient wards
• Length of time of admission to inpatient wards
• Number of suicide attempts
• Number of self-harm acts (without intent to die)
Psychometric measures – assessment, six-month, and twelve month
periods:
• Clinical symptoms (SCL-R)
• Personality Profile and clinical symptoms (Millon)
• IIP-32 – Interpersonal relating styles
• CORE - Global functioning
Client Feedback
• Client programme evaluation
Discussion
 Diagnosis of BPD
 DBT in the context of the wider Psychiatric system
 Strengths, limitations of DBT