Integrating DBT into Community Mental Health Setting: being flexible and creative

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Integrating DBT into Community Mental Health
Settingbeing flexible and creative

• Safdar I. Chaudhary, MD
• Medical Director
• S'eclairer

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Additional Information other teaching /
educational resources

• You can reach Safdar I. Chaudhary, MD at the
  following
• Office 341 Story Road, Export, PA 15632
• Tel [phone]
• Email safdar3_at_gmail.com
• Web www.seclairer.com
• Fax [phone]

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The Treatment is designed flexibly

• As the treatment progresses, changes are made in
  the treatment application.
• Patient have psychic bleeding
• The emotional state of both the patients and the
  therapists deteriorate when these individual
  enter psychotherapy

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Manipulative ?
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Manipulative ?
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Burn or cancer patients, No different than
Borderline Patients

• If we withhold pain medicine from them, they
  would vacillate in exactly the same manner as
  borderline individuals
• Too needy

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Pejorative terms

• Create emotional distance, anger and frustration
  among therapists

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Community Mental Health Centers

• Scarce Resources in community
• Patient may not have adequate means to get care
  they need
• Other obligations and demands on the therapists
  time
• Our time, attention and care are brief and
  rationed hours of the week.

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Accepting the patients

• As they are

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Butterfly
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The Most Fundamental Dialectic

• Accepting the patients just as they are within
  the context of trying to teach them to change.
• The tension between patient's alternating,
  excessively high and low aspirations and
  expectations relative to their own capabilities
  offers a formidable challenge to therapists

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Mindfully being present with patient

• No longer present with patient not being
  mindful of patients agenda

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Moment to moment

• It requires moment to moment changes in the use
  of supportive acceptance verses confrontation and
  change strategies
• Like a dance
• Therapist needs to be matter of fact, irreverent,
  outrageous verses warm flexibility,
  responsiveness.

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The Vehicle of change

• The relationship between the therapist and
  patient
• Movement and timing as critical as context and
  technique

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Balance Core Strategies
PROBLEM SOLVING
VALIDATION
Dialectics
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In DBT

• The therapist channels change in the patient,
  while at the same time recognizes that the change
  engendered is also transforming the therapy and
  therapist.
• Thus there is an ever present dialectical tension
  within the therapy itself between the process of
  change and the outcome of change

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At each moment

• There is a temporary balance between the
  patients attempts to maintain herself as she is
  without changing, and her attempts to change
  herself regardless of the constraints of her
  history and current situation.

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Role Play
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The transition to each new temporary stability

• Is often experienced as painful crisis
• Any real resolution of the crises must
  ultimately involve a new way of being in the
  world.
• Yet resistance to doing so is great and will not
  occur in the absence of repeated and varied
  encounters in natural experiences
• Self preservation vs. self-transformation

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The opposition between and person is maintained

• Borderline seek sense of unity and integration by
  suppression and or non development of self
  identity- beliefs, likes, desires, attitudes,
  independence skills.
• The paradox that one can be different but yet
  part of the whole is not grasped.

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Dialectal and Transactional Model

• Individual functioning and environmental
  conditions are mutually and continuously
  interactive, reciprocal and interdependent.
• Although individual is surely affected by the
  environment, the environment is also affected by
  the individual

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Stages of Disorder

• Level 1 Severe Behavioral Dyscontrol goal is
  behavioral control
• Level 2 Quite desperation goal is Emotional
  Experiencing
• Level 3 Problem in Living goal is Ordinary
  happiness and unhappiness
• Level 4 Incompleteness goal is Capacity for joy
  and freedom

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Its applicability to your setting

• Acute care hospital
• Partial
• Respite
• Out patient clinic
• Your office
• What ever

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New admission to the unit

• Extremely suicidal and very demanding of staff
  time
• Patient who takes up most of the nursing / staff
  time
• The environment are stressed and stretched in
  their ability to respond well to further stress.
• Other people may invalidate or blame the victim
  if further demands are made on the system.

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Inpatient Primary Treatment Targets

• Hosptalizable behavior just Community Ready
• Decrease behaviors prompting / prolonging
  hospitalization
• Suicidal and life threatening crisis
• Treatment destroying behaviors
• Other behaviors
• Egregious and parasuicidal behaviors on the unit

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Inpatient Treatment Target

• Increase
• Skills for getting and staying out of the
  hospital
• Distress tolerance
• Interpersonal Effectiveness
• Emotion Regulation
• Mindfulness
• Self-Management
• Troubleshooting post-discharge problem and
  solutions

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Inpatient Pre-Treatment Targets

• 1. Commitment to Change
• -Agreement on goals of treatment
• 2. Agreement to inpatient treatment plan
• - Patient agreements
• -Therapist agreements

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Inpatient Treatment Goals Hosptalizable
behaviors

• Just Community Ready
• Control of life threatening behaviors
• Adequate discharge plan
• continuity of necessary care
• Just adequate living arrangement
• Discharge

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DBT Path to Clear Mind

• Decrease substance abuse
• Decrease urges to use drugs
• Decrease Physical discomfort from abstaining
• Decrease apparently unimportant behaviors e.g.
  selling drugs, socializing with drug users or
  dealers
• Decrease keeping options open to use drugs
  lying about drug use, keeping drug dealers phone
  numbers

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Dialectal Dilemmas for adolescents families

• Excessive Leniency vs. Authoritarian control
• Fostering dependence vs. Forcing Autonomy
• Normalization pathology vs. pathologizing
  normative behaviors

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Adult borderline patient

• Adopt the characteristic of the invalidating
  environment
• Thus they invalidated their own emotional
  experiences, look to others for accurate
  reflections of external reality and oversimplify
  the ease of solving lifes problems.
• This oversimplification leads to unrealistic
  goals, inability to use rewards instead of
  punishment for small steps towards final goals
  and self hate following failure to achieve these
  goals.

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The DBT treatment process is tricky

• Requires enormous amount of therapist tolerance
• Therapists willingness to experience emotional
  pain
• And requires therapist flexibility
• Therapists often become invalidating themselves
  when patient are not getting better ( after
  therapists re-doubling their efforts to alleviate
  suffering is not seemingly helpful)

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Selection of patients

• Depends
• Inpatient acute care unit may not have much of a
  choice
• Out patient individual therapist may get cases
  assigned according to case load
• May have choices of implementing program in
  gradual increment

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Crucial steps in treatment

• Therapist creates a environment of validation
  rather than blaming the patient and within that
  context the therapist blocks or extinguish bad
  behaviors, drags good behaviors out of patient
  and figures out a way to make good behaviors so
  reinforcing that the patient continuous good one
  and stops bad ones.

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Ancillary Treatment Strategies

• Recommend ancillary treatment when needed
• There is nothing in DBT that prohibits use of
  ancillary mental health treatments as long as
  these programs are clearly ancillary to DBT and
  not primary treatment

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Ancillary Services

• Inpatient care, day treatment
• Residential substance abuse programs
• Take Psychotropic medications
• See a physician, nurse or other pharmacotherapist
  
• Attend group meetings,
• Case management, marriage counseling, vocational
  counseling

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Any attempt to stop ancillary care

• Leads to dishonesty or open rebellion by
  patients.
• So the mental healthcare can be large and
  complex.
• Therapist is a consultant to patient and not
  ancillary services
• Patient need to work through conflicting advise

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Medication Protocols

• Anti depressant
• Anti psychotics
• Anxiolytics
• Mood stabilizer
• Combination strategies

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Consulting to the patient on pharmacotherapy
consumer issues

• Therapist helps patient how to interact
  effectively with medical personnel
• How to communicate what her needs can be heard
• How to obtain information about various
  medications
• How to comply with treatment, request change when
  needed.

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Treating Prescription Abuse

• When patient is abusing medications this is
  treated as suicidal behavior, if the abuse is
  potentially life threatening or instrumental to
  parasuicidal
• Therapy interfering if medication is part of
  treatment plan
• Quality of life interfering if it is not
• DBT diary card elicits information on meds both
  illicit and licit. Primary therapist should
  review this information
• Lethal drugs should not be given to lethal people

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Hospital Protocol

• Avoiding acute psychiatric inpatient admission
  whenever possible
• In a crisis DBT says now is the time to learn new
  behaviors strike when the iron is hot.

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DBT recommend admission when

• Patient is psychotic and threatening suicide
• Very high risk of suicide, therapist needs a
  vacation- sever burn out.
• The relationship between the patient and
  therapist is severely strained
• History of serious overdose and has meds
• Needing protection in the early phases of
  exposure treatment of PTSD
• Sever substance abuse issues

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Treatment Targets

• Commitment even if it is half hearted is a
  request for DBT
• Characteristic of therapist compassion,
  persistence, patience, a belief in efficacy of
  DBT treatment that will outlast patients believe
  that it will not work

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Setting the stage

• Getting patient attention agreeing on goals and
  orienting patient to treatment
• Agreeing on goals of treatment and general
  treatment procedures is crucial first step

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Stages of Disorder

• Level 1 Severe Behavioral Dyscontrol goal is
  behavioral control
• Level 2 Quite desperation goal is Emotional
  Experiencing
• Level 3 Problem in Living goal is Ordinary
  happiness and unhappiness
• Level 4 Incompleteness goal is Capacity for joy
  and freedom

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Patient who do not agree for these goals

• Are not suitable for DBT

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Applying core strategies

• Validation
• Problem solving Moment to moment behavioral
  analysis is critical to decode the individual
  issues and therefore maladaptive behaviors
• Does the patient have the capability to engage in
  more adaptive responses to construct a life worth
  living ? If not what behavioral skills are
  needed.

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What are reinforcement contingencies ?

• To reinforce positive behaviors, negative
  behaviors to be extinguished
• If adaptive problem solving behaviors exist is
  their application inhabited by excessive fear or
  guilt ?
• Faulty believes and assumptions ?

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Modes of treatment

• Individual
• Group skills training
• Telephonic consultation
• Case consultation

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Individual Outpatient Psychotherapy

• Each patient has an individual therapist
• All other modes of therapy revolve around the
  individual therapy
• Therapist pays attention to motivational issues,
  including personal and environmental factors that
  inhibit effective behaviors

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Individual Outpatient Psychotherapy

• Once per week, may be increased to twice per week
  during crisis- for time limited only
• Session 50-60 minutes- 90-110 minutes
• Can shorten or lengthen session on the spot to
  reinforce therapeutic working if needed and able
  to do so.
• May plan phone consultation if needed
• Schedule patient at the end of the day if needing
  long session.

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Skills training

• All patient must be in structured skills training
  during the first year of therapy.
• Skills training is very difficult in the context
  of individual therapy oriented to reduce
  motivation for suicide
• Open group 2- 2.5 hours/ week or two one hour
  groups
• 6-8 members / group

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Case Consultation for Therapist

• Quick burn out
• Blaming the victim
• Meeting attended by all therapist group and
  individual
• Weekly meetings

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Agreement of Patient

• One year therapy agreement. At the end of each
  year treatment, progress is evaluated and the
  question of whether to continue working together
  is discussed.
• DBT conducted in inpatient unit may be very time
  limited.

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Circumstance of unilateral termination

• Patient who miss 4 weeks of scheduled therapy in
  a row either required skills training or
  individual therapy are out of program.
• They can not return to therapy until end of the
  current contract period and then return as a
  matter of negotiation.
• There is no circumstances under which this rule
  is broken.
• Even a mothers love is not unconditional

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Patient agreements

• Attendance agreement
• Suicidal behaviors agreement
• Therapy interfering behaviors agreement
• Skills training agreement
• Research and payment agreement

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Therapist Agreements

• Every reasonable effort agreement therapist as
  a guide
• Ethics agreement
• Personal contact agreement
• Respect for patient agreement
• Confidentiality agreement
• Consultation

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Assessment of Suicide

• Context
• Hand out
• Role Play
• Resources