FI CONINGTONCLINICAL LEAD OASIS

DIALECTICAL BEHAVIOUR THERAPY

DSM-IV Criteria

• frantic efforts to avoid real or imagined abandonment.

• a pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization 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 (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in Criterion v.

• recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

• 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

• Inappropriate intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)

• Transient, stress-related paranoid ideation or severe dissociative symptoms

DSM 5 • 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.

• 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.

DSM 5 ICD-10Cluster AThe odd & eccentric

ParanoidDistrust and suspiciousness

ParanoidDistrust and sensitivity

Schizoid Socially and emotionally detached

Schizoid Emotionally cold and detached

Schizotypal :difficulty in establishing and maintaining close relationships

with others.

No equivalent

Cluster BThe

dramatic & erratic

AntisocialViolation of the rights of others

DissocialCallous disregard of others, irresponsibility and

irritability

BorderlineInstability of relationship, self-image and

mood

Emotionally UnstableA) Borderline type: unclear self-image and intense

unstable relationshipsB) Impulsive type: inability to control anger,

quarrelsome and unpredictable

HistrionicExcessive emotionality and

attention-seeking

HistrionicDramatic, egocentric and manipulative

NarcissisticGrandiose, lack of empathy, need for

admiration

No equivalent

Cluster CThe anxious

& fearful

AvoidantSocially inhibited, feelings of inadequacy,

hypersensitivity

AvoidantTense, self-conscious and hypersensitive

DependentClinging and submissive

DependentSubordinates, personal need, seeking constant

reassurance

Obsessive compulsivePerfectionist and inflexible

AnankasticIndecisive, pedantic and rigid

DBT’s Reorganisation of Diagnostic Criteria for BPD

Emotional Dysregulation – criteria 6 and 8Interpersonal Dysregulation – criteria 1 and 2Behavioural Dysregulation – Criteria 4 and 5Cognitive Dysregulation – Criterion 9Dsyregulation of the self – Criteria 3 and 7

•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).

Presentation within care settings

Historical Context

Marsha Linehan – Working with women with a diagnosis of BPD. (1993)

Work standardised in treatment manualsDeveloped and adaptedBlends Cognitive-behavioural interventions

with Eastern meditation practicesShares 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 re-evaluate 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

1. Stage Theory of Treatment2. Bio-social theory of the etiology and

maintenance of BPD3. Learning principles and ideas from

behaviour therapy4. BPD behavioural patterns and Dialectical

Dilemmas5. Dialectical Orientation to change

1. Stages of Treatment: Behaviours to target in DBT

1. Suicidal/homicidal or other imminently life-threatening behaviour

2. Therapy interfering behaviour – client and therapist

3. Quality of life interfering behaviour4. Deficits in behavioural capabilities needed

to make life changes

2. Bio-social Theory

Emotional vulnerability

Genetic/biological/neurological developmentEmotional Dysregulation

High sensitivity, Strong reactions, slow return to baseline.Invalidating environment

Fails to confirm, corroborate or verify individual.

Examples of invalidating environment

Dismiss or disregardCriticism and punishmentReject self-description as inaccurateReject response to events as incorrect or

ineffectivePathologize normative responsesReject 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 consequencesFunctional analysis/behaviour chain analysis.

4. Dialectic - A World View

Fundamental interrelatedness or wholeness of reality.

The fundamental nature of reality is changeReality 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

Dialectical Dilemmas

Dialectical Dilemmas

Dilemma Emotional

Vulnerability vs. Self-invalidation

Treatment Target Increasing emotional

modulation Decreasing emotional

reactivity Increasing self-

validation

Dialectical Dilemmas

Active Passivity vs. Apparent Competence

Treatment Target Increasing active

problem solving Decreasing active

passivity Increasing accurate

communication Decreasing mood

dependency of behaviour.

Dialectical Dilemmas

Unrelenting Crisis vs. Inhibited Grieving

Treatment Target Increasing realistic

decision making and judgment

Decreasing crisis-generating behaviours

Decreasing inhibited grieving

THE PRACTICE

DIALECTICAL BEHAVIOUR THERAPY

Outline of Treatment Programme Functions and Modes

NorthDevonDBTProgramme2011

Functions1. Enhanced Capabilities2. Improve Motivational

factors3. Assure generalisation

to natural environment

4. Structure the environment

5. Enhance therapist’s capabilities & motivation to treat effectively

Modes1. Skills Training

Group2. Individual therapy

3. Telephone, Milieu coaching

4. Organisational interactions (consult-to-client)

5. Team consultation to hold therapists inside the treatment

DBT - Overview

StructureBehaviour TherapyValidationDialecticsMindfulness

Structure the Treatment

Outpatient individual PsychotherapyOutpatients Group Skills TrainingTelephone ConsultationTherapist consultation meeting

Uncontrolled Ancillary Treatments Pharmacotherapy Acute-inpatient admissions

Structure of sessions

Individual Sessions Diary cards Hierarchy of treatment goals Chain analysis Solution analysis

Distress Tolerance 6 weeks

Mindfulness 2 weeks

Interpersonal Effectiveness 6 weeks

Mindfulness 2 weeks

Mindfulness 2 weeks

Emotion Regulation 6 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

Programme Outline – Stage 1One year period to include:

Weekly Group consisting of the following 6 month modules (run twice):

Structure of Group

Mindfulness exerciseDiary cards/ homework feedbackSkills trainingSetting homework

Structure of DBT service

Group trainingEach patient has an individual therapistGroup skills taught by 2 therapistsDBT consultation groupCase management strategies

Structure - Rules

Clients who drop out of therapy are out of therapyEach client has to be in on-going individual

therapyClients are not to attend groups under the

influence of drugs/alcoholClients are not allowed to discuss past self-harm

with other clients outside of sessions.Clients may not form private relationships outside

of the groupClients 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 strategyEnvironment intervention strategy

Behaviour Therapy

Chain analysis.Emphasis on learning theory – practice and

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

ContractsRules governing attendance to group and

individual sessions – strict boundariesRules surrounding self-harm and admission to

inpatient wardSpecific tools – exposure, response

prevention, opposite action, reparation and repair.

Chain analysis

Case illustration

Role play – behavioural analysisOn 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 observingLevel 2 – ReflectionLevel 3 – Mind ReadingLevel 4 – Validation in terms of the pastLevel 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-disclosureBy Validating the patient’s experience.

Including negative feelings about therapy Explicitly identifying such feelings

• Anticipating therapy-interfering behaviours

• Being available by phone between sessions

Dialectics

Mindfulness

What is it?

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 assessmentIntroduction to the modelEngagement and CommitmentPro’s and con’s of engaging in therapyIdentifying Target behaviours to decreaseIdentifying aims for therapyIntroduction to toolsContracting

Mindfulness

THE SKILLS

DIALECTICAL BEHAVIOUR THERAPY

Mindfulness

WHAT skills Observe Describe Participate

HOW skillsWithout judgmentIn the moment (one mindfully)Effectively

Distress Tolerence

Wise mind ACCEPTSSelf-soothingIMPROVE the momentPros 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 RelationshipsBalancing Priorities and DemandsBalancing the wants-to-shouldsBuilding mastery and self-respect

Objectiveness effectiveness Relationship effectiveness Self-respect effectivness

Radical Openess

Turning the mindRadical AcceptancePractice WillingnessNotice Willfulness

DBT - Adaptions

Different Client GroupsIndividual 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) hasrecommended the following for people with BorderlinePersonality 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 TreatmentOutcome measuresBehavioural 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 BPDDBT in the context of the wider Psychiatric

systemStrengths, limitations of DBT