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Fi Conington

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Title: Fi Conington


1
DIALECTICAL BEHAVIOUR THERAPY
  • Fi Conington
  • Clinical Lead OASIS

2
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

3
DSM 5
  • The Fifth Edition of the Diagnostic and
    Statistical Manual of Mental Disorders (DSM-5)
    was released at the American Psychiatric
    Associations (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.

4
DSM 5 ICD-10
Cluster A The odd eccentric Paranoid Distrust and suspiciousness Paranoid Distrust and sensitivity
Cluster A The odd eccentric Schizoid Socially and emotionally detached Schizoid Emotionally cold and detached
Cluster A The odd eccentric Schizotypal difficulty in establishing and maintaining close relationships with others. No equivalent
Cluster B The dramatic erratic Antisocial Violation of the rights of others Dissocial Callous disregard of others, irresponsibility and irritability
Cluster B The dramatic erratic Borderline Instability of relationship, self-image and mood Emotionally Unstable Borderline type unclear self-image and intense unstable relationships Impulsive type inability to control anger, quarrelsome and unpredictable
Cluster B The dramatic erratic Histrionic Excessive emotionality and attention-seeking Histrionic Dramatic, egocentric and manipulative
Cluster B The dramatic erratic Narcissistic Grandiose, lack of empathy, need for admiration No equivalent
Cluster C The anxious fearful Avoidant Socially inhibited, feelings of inadequacy, hypersensitivity Avoidant Tense, self-conscious and hypersensitive
Cluster C The anxious fearful Dependent Clinging and submissive Dependent Subordinates, personal need, seeking constant reassurance
Cluster C The anxious fearful Obsessive compulsive Perfectionist and inflexible Anankastic Indecisive, pedantic and rigid
5
DBTs 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

6
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).

7
Historical Context
  • Marsha Linehan Working with women with a
    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

8
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.
9
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.

10
Conceptual Framework
  1. Stage Theory of Treatment
  2. Bio-social theory of the etiology and maintenance
    of BPD
  3. Learning principles and ideas from behaviour
    therapy
  4. BPD behavioural patterns and Dialectical Dilemmas
  5. Dialectical Orientation to change

11
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12
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 behaviour
  4. Deficits in behavioural capabilities needed to
    make life changes

13
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.

14
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

15
3. Theory of change
  • Principles of learning and ideas from behaviour
    therapy.
  • Analysis of antecedents and consequences
  • Functional analysis/behaviour chain analysis.

16
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17
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)

18
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

19
Dialectical Dilemmas
20
Dialectical Dilemmas
  • Dilemma
  • Emotional Vulnerability vs. Self-invalidation
  • Treatment Target
  • Increasing emotional modulation
  • Decreasing emotional reactivity
  • Increasing self-validation

21
Dialectical Dilemmas
  • Active Passivity vs. Apparent Competence
  • Treatment Target
  • Increasing active problem solving
  • Decreasing active passivity
  • Increasing accurate communication
  • Decreasing mood dependency of behaviour.

22
Dialectical Dilemmas
  • Unrelenting Crisis vs. Inhibited Grieving
  • Treatment Target
  • Increasing realistic decision making and judgment
  • Decreasing crisis-generating behaviours
  • Decreasing inhibited grieving

23
DIALECTICAL BEHAVIOUR THERAPY
  • THE PRACTICE

24
Outline of Treatment Programme Functions and Modes
  • Functions
  • Enhanced Capabilities
  • Improve Motivational factors
  • Assure generalisation to natural environment
  • Structure the environment
  • Enhance therapists capabilities motivation to
    treat effectively
  • Modes
  • Skills Training Group
  • Individual therapy
  • Telephone, Milieu coaching
  • Organisational interactions (consult-to-client)
  • Team consultation to hold therapists inside the
    treatment

25
DBT - Overview
  • Structure
  • Behaviour Therapy
  • Validation
  • Dialectics
  • Mindfulness

26
Structure the Treatment
  • Outpatient individual Psychotherapy
  • Outpatients Group Skills Training
  • Telephone Consultation
  • Therapist consultation meeting
  • Uncontrolled Ancillary Treatments
  • Pharmacotherapy
  • Acute-inpatient admissions

27
Structure of sessions
  • Individual Sessions
  • Diary cards
  • Hierarchy of treatment goals
  • Chain analysis
  • Solution analysis

28
  • Programme Outline Stage 1
  • One year period to include
  • Weekly Group consisting of the following 6 month
    modules (run twice)

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
29
Structure of Group
  • Mindfulness exercise
  • Diary cards/ homework feedback
  • Skills training
  • Setting homework

30
Structure of DBT service
  • Group training
  • Each patient has an individual therapist
  • Group skills taught by 2 therapists
  • DBT consultation group
  • Case management strategies

31
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.

32
Case Management Strategies
  • Consultation-to-the patient strategy
  • Environment intervention strategy

33
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

34
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.

35
Chain analysis
36
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.

37
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

38
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.

39
The Therapeutic Relationship
  • Trust and attachment are augmented
  • Through warmth (e.g., Rogerian stance)
  • Through appropriate self-disclosure
  • By Validating the patients experience.
  • Including negative feelings about therapy
  • Explicitly identifying such feelings
  • Anticipating therapy-interfering behaviours
  • Being available by phone between sessions

40
Dialectics
41
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.

42
Pre- treatment phase
  • Pre treatment assessment
  • Introduction to the model
  • Engagement and Commitment
  • Pros and cons of engaging in therapy
  • Identifying Target behaviours to decrease
  • Identifying aims for therapy
  • Introduction to tools
  • Contracting

43
Mindfulness
44
DIALECTICAL BEHAVIOUR THERAPY
  • THE SKILLS

45
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46
Mindfulness
  • WHAT skills
  • Observe
  • Describe
  • Participate
  • HOW skills
  • Without judgment
  • In the moment (one mindfully)
  • Effectively

47
Distress Tolerence
  • Wise mind ACCEPTS
  • Self-soothing
  • IMPROVE the moment
  • Pros and Cons

48
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

49
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50
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

51
Radical Openess
  • Turning the mind
  • Radical Acceptance
  • Practice Willingness
  • Notice Willfulness

52
DBT - Adaptions
  • Different Client Groups
  • Individual DBT
  • DBT light
  • Pros and Cons of Adapting the model

53
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

54
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.

55
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 n31.
  • Conclusion 50 of female patients who
    completed the programme improved at a clinically
    relevant level.

56
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.

57
Research local evaluation procedures
  • Outcomes of Treatment
  • Outcome measures
  • Behavioural measures
  • Number of visits to AE
  • 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

58
Discussion
  • Diagnosis of BPD
  • DBT in the context of the wider Psychiatric
    system
  • Strengths, limitations of DBT
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