Dialectical Behaviour Therapy (DBT)

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Dialectical Behaviour Therapy (DBT)

• Dr Amanda Wildgoose
• Consultant Clinical Psychologist/
• DBT Lead (MAP CAG)

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The Evidence Base

• DBT currently has 16 RCTs and numerous published
  quasi experimental and uncontrolled studies.
• All studies demonstrate that DBT reduces suicidal
  behaviour, self-harm and hospitalisations and
  leads to an increase in global functioning. Many
  studies also demonstrate a reduction in comorbid
  substance misuse, eating difficulties, anger,
  hopelessness, impulsivity and depression.
• NICE Guidelines recommend DBT in the first
  instance for clients with BPD, for whom reducing
  self-harm is a priority.

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Efficiency costs of DBT v TAU

• Studies looking at health economic data have
  determined that the cost for DBT is approximately
  50 of TAU
• Significantly fewer inpatient days
• Fewer and less severe episodes of intentional
  self-injury
• Fewer AE attendances
• Less therapy dropout

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Bio-Social Theory

• DBT views BPD as resulting from a pervasive
  dysfunction of the emotion regulation system

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BIOSOCIAL THEORY
Biological component
BIOLOGICAL DYSFUNCTION in the EMOTION REGULATION
SYSTEM
Social component
INVALIDATING ENVIRONMENT
PERVASIVE EMOTION DYSREGULATION
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Emotion Dysregulation

• Emotional
• Vulnerability
• Inability to
• Modulate Emotions

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Emotion dysregulation
Intense Intense Response to ES
Emotional Stimuli
High sensitivity to ES
Slow return to baseline
Emotional Response
Cannot up-regulate physiological arousal when
needed
Cannot turn away from ES
Cannot control impulsive behaviour related to
strong negative affects
Cannot work towards non mood dependent activity
Information processing distorted/ dysregulated
SHUTS DOWN
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What is DBT?
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5 Functions of Comprehensive Treatment

1. Enhance capabilities
2. Improve motivational factors
3. Assure generalisation to natural environment
4. Enhance therapist capabilities and motivation to
   treat effectively
5. Structure the environment

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Enhancing capabilities

• Function
• Acquisition of new cognitive, emotional/
  physiological and overt behavioural response
  repertoires
• Integration of response repertoires for effective
  performance
• DBT Modes
• Skills training
• Psychoeducation (individual therapy)

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Improving Motivation

• Function
• Contingency clarification and strengthening of
  clinical progress
• Reduction of inhibiting and/or interfering
  emotions/physiological responses,
  cognitions/cognitive style, overt behaviours
  and/or environmental events
• Modes
• Individual therapy
• Contingency management, extinction,
  exposure/response prevention, cognitive
  modification etc.

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Ensuring Generalisation to Natural Environment

• Function
• Transfer of skilful response repertoire to
  natural environment
• Integration of skilful responses within changing
  natural environments to achieve effective
  performance
• Modes
• Telephone consultation
• In vivo interventions
• Systemic interventions (e.g. 12-week Family
  Connections group for carers/family)

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Enhancing Therapist Capabilities and Motivation

• Function
• Acquisition, integration and generalisation of
  cognitive, emotional, and behavioural repertoires
  for effective application of treatment
• Strengthening of therapeutic responses and
  reduction of responses that inhibit and/or
  interfere with effective application of treatment
• Modes
• Weekly therapist consultation meetings
• Supervision (incl. adherence and competency
  rating)
• Continuing professional development/training

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Structuring the Environment

• Function
• Contingency management within the treatment
  program as a whole
• Contingency management within the community
• Modes
• Care coordination(environmental intervention)
• System interventions (e.g. couples work, staff
  training and support in hostels)

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Structuring the Treatment
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Pre-Treatment Goals and Targets

• Agreement on goals
• Commitment to change
• Initial targets of treatment
• Agreement to recommended treatment
• Client agreements
• Therapist agreements
• 3. Agreement to therapist-client relationship

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Pre-treatment

• 3-6 sessions
• Identify goals (be specific)
• Assess past behaviour (target relevant behaviours
  parasuicide, substance misuse, therapy
  interfering behaviour etc)
• Weave in orienting (biosocial theory, targets,
  modes, diary card etc)
• Weave in commitment strategies throughout
• Develop relationship throughout
• Orient to treatment (behavioural analysis,
  solution rehearsal taster session, personal
  limits)
• Commitment strengthening (re treatment and goals)

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Therapy Target HierarchySevere Behavioural
Dyscontrol Behavioural Control

• Decrease
• Life-threatening behaviours
• Therapy-interfering behaviours
• Quality-of-life interfering behaviours
• Increase behavioural skills
• Core mindfulness
• Interpersonal effectiveness
• Emotion regulation
• Distress tolerance
• Self-management

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Criteria for PE protocol for comorbid PTSD

• Not at imminent risk of suicide/life threatening
  behaviour (no self-harm for 8 weeks)
• No serious TIB client and therapist are
  actively engaged in treatment
• Ability to experience intense emotion without
  functional or dysfunctional escaping
• Ability to come into contact with cues for
  higher-priority behaviours (e.g.
  self-harm/suicide attempt) without engaging in
  those behaviours
• Knows and uses sufficient skills
• It is the clients goal to target PTSD now

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Individual Session Structure

• Review diary card
• Check in on other aspects of treatment
• Set agenda according to target hierarchy
• Identify a specific instance of a target relevant
  problem behaviour (topography, frequency,
  intensity and duration)
• Do a behavioural chain analysis
• Perform a solution analysis
• Rehearse some new behaviour, plan generalization
  and ask for commitment to it, troubleshoot
  obstacles
• Notify of session ending, plan for next session,
  wind down

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Skills Group Structure

• Weekly 2 hour group
• Homework reviewround robin with skills leader
  taking feedback
• Break
• New skill taught
• Use of active teaching style
• Provide rationale for skills
• Get buy in and examples of how new skills might
  be useful
• Teach skills
• Pull out new behaviour
• Set homework
• Get a commitment to do homework, troubleshoot any
  difficulties

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Goals of Skills Training

• Behaviours to Increase Behaviours to Decrease
• Mindfulness skills Identity confusion
• Emptiness
• Cognitive dysregulation
• Interpersonal skills Interpersonal chaos
• Fears of abandonment
• Emotion Regulation skills Labile affect
• Difficulties with anger
• Distress Tolerance Impulsive behaviours
• Suicide threats
• Parasuicide

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Function of weekly consultation team

• Help with formulation and difficulties
  encountered in applying the treatment adherently
• Education
• Empathy and support
• To keep team motivated and away from burnout
• For validation
• As your own treatment community to deal with your
  own process issues arising in the relationship
• To help you use your own DBT skills
• To share SUCCESSES!!!

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Any questions?