Dialectical Behavior Therapy Made Easy: Integrating DBT Skills in Everyday Practice

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Dialectical BehaviorTherapy Made Easy
Integrating DBT Skills in Everyday Practice

• 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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Why Intensive Training?The Function of
theIntensive is to- Motivate therapists to
use empiricallysupported therapies (ESTs) to
treat clients with severe psychiatric
problems- Teach effective use of DBT
strategies - Facilitate development of
DBT consultationteams
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The Overarching DBT Goal is...
A LIFE Worth Living
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Dialectal Philosophy of Treatment

• Dialectics As...
• Persuasion
• World View

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Balance Core Strategies
PROBLEM SOLVING
VALIDATION
Dialectics
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DIALECTICAL
Communication
Change
Acceptance
Reciprocal
Irreverent
Problem Solving
Validation
Core
Consultation- to-the-Patient
Environmental Intervention
Team Consultation
Case Management
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DBT Consultation Agreements 1/2

• To accept a dialectical philosophy
• To consult with the patient on how to interact
  with other therapists and not to tell other
  therapists how to interact with patient
• That consistency of therapists with one another
  (even across the same patient) is not necessarily
  expected

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DBT ConsultationAgreements 1/2

• That all therapists are to observe their own
  limits without fear of judgmental reactions from
  other consultation group members
• To search for non-pejorative, phenomenological
  empathic interpretation of patients behavior
• That all therapists are fallible

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In DBT,the therapist acting from WiseMind

• PRACTICES
• Observing (Just Notices)
• Describing (Puts Words On)
• Participating (Acts Intuitively from Wise Mind)
• AND IS
• Non Judgmental (Neither Good nor Bad)
• One Mindful (In the Moment)
• Effective (Focus on What Works)

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Commitment Strategies

• Selling commitment evaluating the pros and cons
• Playing the devils advocate
• Foot-in-door and door-in-the-face techniques
• Connecting present commitment to prior
  commitments
• Highlighting freedom to choose and absence of
  alternatives
• Shaping

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Why Learn a New Treatment?

• Old one doesnt work
• New one has better outcomes
• New one has same outcomes, but
• - is more efficient
• - is preferred by providers
• - is more humane

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Before You Start Decide

• Whom you will serve
• What they need
• Theory of psychopathology

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Before You Start

• Decide Whom
• You Will Serve

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DBT

• Was developed in a context of
• treating specific problems and
• problem behaviors within an
• overall diagnostic group

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DSM IV Diagnostic Criteria For Borderline
Personality Disorder

• A pattern of intense and unstable interpersonal
  relationships
• Frantic efforts to avoid real or imagined
  abandonment
• Identity disturbances or problem with self
• Impulsivity that is potentially self-damaging

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DSM-IV Criteria cont

• Recurrent suicidal or parasuicidal behavior
• Affective instability
• Chronic feelings of emptiness
• Inappropriate intense or uncontrollable anger
• Transient stress related paranoid ideations or
  severe dissociative symptoms

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Diagnosing BPD

• Questionnaires
• Use for initial screening
• Structured Interview
• Use when reliable diagnosis is essential
• Clinical Interview
• Use in clinical settings where rigorous
• diagnosis is not essential
• See Appendix II Diagnosis

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Borderline Personality Disorder(Re-Organized)

• Emotion Dysregulation
• Affective lability
• Problems with anger
• Interpersonal Dysregulation
• Chaotic relationships
• Fears of abandonment
• Self Dysregulation
• Identify disturbance/difficulties
• Sense of self/Sense of emptiness

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Borderline Personality Disorder(Re-Organized)
Contd.

• Behavioral Dysregulation
• Parasuicidal behavior
• Impulsive behavior
• Cognitive Dysregulation
• Dissociative responses/
• paranoid ideation

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BorderlinePersonalityDisorder isassociated
withfatal and non-fatalsuicidal behaviors
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BPD Can Be Fatal

• Among SUICIDES
• 40-65 have PD
• Among PDs
• BPD is most associated with suicidal
• behavior
• Among BPD
• 8-10 commit suicide
• Up to 75 attempt suicide
• 60-80 self-mutilate
• See Appendix III BPD SUICIDE

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Before You Start

• Decide What
• Treatment Your Patients
• Will Need

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• Treatments for BPD
• DBT
• Object relations partial hospitalization
• Pharmacology

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DBT

• Research
• Findings
• to Date

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Randomized Controlled Trial

• DBT vs. Treatment-As-Usual
• With Chronically Suicidal
• BPD Women
• (University of Washington)
• Linehan, et al., 1991, 1992, 1993,1994

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DBTltTreatment As Usual (TAU)

• with parasuicidal
• Parasuicidal
• Medical risk of parasuicidal
• Treatment drop-outs
• Psychiatric inpatient days
• Anger
• DBTgtTAU
• Social adjustment
• Global adjustment

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Initial DBT Outcome TrialOne-Year
Follow-Up(Linehan, Heard Armstrong, 1993)

• Statistically Significant Findings
• DBT Ss had higher GAS scores throughout follow-up
• DBT Ss had less parasuicidal behaviors, less
  anger, and better social adjustment during
  initial 6 months of follow-up
• DBT Ss had fewer psychiatric inpatient days and
  better interviewer-rated social adjustment during
  final six months

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Efficiency Costsof DBT vs. TAU

• Cost for DBT is approximately 50 of treatment as
  usual
• -significantly fewer inpatient days
• -fewer and less severe parasuicidal
• behaviors
• -fewer emergency medical visits
• -less therapy dropout

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One Year Health Care Costs Per Patient

• DBT TAU
• Individual Psychotherapy 3,885 2,915
• Group Psychotherapy 1,514 147
• Day Treatment 10 876
• Emergency Room Visits 226 569
• Psychiatric Inpatient Day 2,612
  12,079
• Medical Inpatient Days 360 1,096
• Total 8,607 17,682

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Randomized Controlled Trial

• DBT vs. Treatment-as-Usual
• With BPD Substance Abusers
• University of Washington
• Linehan, Schmidt, Kanter, Craft,
• Dimeff, Comtois, McDavid, 1999

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Design RCT

• Conditions Dialectical Behavior Therapy
• (DBT)
• Treatment-As-Usual
• (TAU)
• Time Frame 1 year treatment
• 4 month follow-up
• Assessments Pre-Treatment
• 4 month
• 8 month
• 12 month (post-treatment)
• 16 month

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Subjects n28

• BPD
• SUD for opiates, cocaine, amphetamines,
• sedatives, hypnotics or anxiolytics or
• Polysubstance Use Disorder
• Female
• Did not meet criteria for
• -Schizophrenia or other Psychotic
• Disorder
• -Bipolar Disorder
• -Mental Retardation

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Matching Variables

• Age
• Severity of Highest Drug Dependence
• Readiness to Change
• Global Adjustment (Axis V, DSM-IV)

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DBTltTAU- Drop Use- Drop Out

• DBTgtTAU (at 16 month)
• Global Adjustment
• Social Adjustment
• DBT gains continued at follow-up

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Proportion of Urinalyses DIRTY by Condition
Mean Proportion Dirty
plt.10 plt.05 plt.01
Time
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Interviewer-Assessed Proportion of DAYS USING
Drugs and Alcohol by Condition
Proportion of Days Using
plt.10 plt.05 plt.02
Time
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Percent Treatment Drop-Outs
plt.05
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Mean Number of Treatment Sessions During the Year
by Condition
Individual Psychotherapy Sessions
Psychotherapy Sessions Counseling with a Case
Manager
plt.05
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DBT vs. Treatment as usual

• Pre-Treatmentgt12 month
• Parasuicidal Episodes
• Anger

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Object Relations

• Research findings to date

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Bateman Fonagys 18-MonthPartial
Hospitalization Program (PHP)

• PHP Treatment
• - 3x/week group psychotherapy
• - 1x/week individual psychotherapy, expressive
  therapy and community meeting
• - 1x/month meeting with psychiatrist and cast
  administrator
• Control Standard Psychiatric Care
• - 2x/month meeting with psychiatrist and
  visiting psychiatric nurse

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Bateman Fonagys 18-MonthPartial
Hospitalization Program (PHP)

• PHPltControl
• Frequency of suicide attempts and self-
• mutilation
• Number and duration of inpatient admissions
• Use of psychotropic medications
• Self-report measures of depression, anxiety
• PHPgtControl
• Improvements on self-report measures of social
  and interpersonal functioning

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Critique of Bateman Fonagys PHP

• Methodological Confounds
• - PHP patients received considerably more
  treatment per week (6hours) compared to TAU (3
  hrs/month)
• No treatment manual currently exists limiting
  further investigation by others.
• No studies have replicated original findings.
• PHP may be more expensive than DBT.
• -18 month vs. 12 months PHP vs. outpatient

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Pharmacotherapy

• Research Findings to Date

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Medication Enhance Hardware capacity
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Software Skills learning DBT
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PharmacotherapyTreatments for BPD Paul Soloff,
MDSoloff, P.H (2000) Psychopharmacology of
Borderline Personality Disorder Psychiatric
Clinics of North America 23 (1), 169-92

• Medications Algorithm Rules
• - Target specific problem area
• ? Cognitive/perceptual
• ? Affective
• ? Impulsive dyscontrol
• - Strong empirical support
• - Safe
• -Act rapidly

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Soloffs Medication AlgorithmTreating Impulsive
Symptoms

• START with SSRI (if rapid response is needed, a
  low-dose conventional neuroleptic)
• If response to SSRI monotherapy inadequate,
  ADD/SWITCH to low dose neuroleptic
• If response remains poor, ADD/SWITCH to lithium
  or MAOI
• SWITCH to carbamazepine or valproate, if no
  response
• If necessary, ADD atypical neuroleptic

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Soloffs Medication AlgorithmTreating Affective
Symptoms

• START with SSRI or related and antidepressant
• If responsible inadequate, SWITCH to different
  SSRI or related antidepressant
• If response still poor, AUGMENT with a
  benzodiazepine or a low dose neuroleptic
• If response remains inadequate, SWITCH to MAOI
• FINALLY, add/switch to lithium or mood stabilizer

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Soloffs Medication AlgorithmTreating
Cognitive/Perceptual Symptoms?START with low
dose typical neuroleptic?If poor/partial
response, INCREASE dose?If response still poor,
RECONSIDER DIAGNOSIS.If symptoms are mood
congruent, treat for affective symptoms?If
symptoms do NOT have a major mood
component,SWITCH to Clozapine or another
atypicalantipsychotic
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Consensus By Experts onPharmacotherapy for BPD

• No magic bullet medication for BPD patients
• Soloffs algorithm is method of choice where
  drugs target domain of dysfunction
• Pharmacotherapy alone is insufficient to treat
  BPD must be combined with psychosocial treatment

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Before you start

• Agree on the best theoretical
• Understanding of
• Psychopathology you are
• treating

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DBT Bio-Social TheoryFUNCTIONS OF BIO-SOCIAL
THEORY IN DBT

• Engenders an attitude of effective compassion
• Compassion Know empathetically the
• person is (involuntarily) in hell
• Effective Get them out of hell and make
• sure they can stay out
• Tells what to do when interacting with the person
• Defines relationship between treatment and data
• explicit accounting for current data open to
  influence by new data

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Reduction in Mean Number of Parasuicide Acts
Over Time for Each Condition Analyzed Separately
plt.10
Koons, Robins, et al. (1998)
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Percent Treatment Drop-Outs
plt.05
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Opiate Use Across Year
DBT CVT12S
Positive
Weeks
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Psychiatric Hospitalizations During Treatment
DBT vs. TAU
p.04
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Suicide Attempts DBT vs. TAU
ns
Miller, A. L., Rathus, J. H. (1996)
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Pre-post comparison and group vs. time
differences Depression
BDI
HAMD
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Pre-post comparison and group vs. time
differences Anxiety
STAI
HAMA
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Pre-post comparison and group vs. time
differences Anger
STAXI
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Pre-post comparison and group vs. time
differences Social Integration
GAF
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Pre-post comparison and group vs. time
differences Dissociation
DES
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Effect Sizes TAU-DBT
large
medium
small
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GAF
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Therapy Response Effect sizes
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DBT vs. Treatment-as-Usualfor Incarcerated
Juvenile Offenders Echo Glen Childrens Center
Trupin, Stewart, Boesky, McClung, Beach

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DBTgtTAU ns

• Pre-treatment gt 12-Month
• Depression
• Hopelessness
• Suicide Ideation

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Significant Changes

• DBT 80 hours training
• Reduced sever behavior problems ( para-suicide,
  aggression, class disruptions)
• Reduced staff use of punitive actions ( compared
  to previous year)

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Significant issue

• DBT 16 hours training
• No reduction in behavior problems
• Increased staff use of punitive actions.

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DBT

• Case
• Conceptualization

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BPD is a Pervasive Disorderof the Emotion
Regulation System

• BPD criterion behaviors function to regulate
  emotions or are a natural consequence of emotion
  dysregulation

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BPD

• How criterion
• Behaviors relate to
• Emotion dysregulation
• picture

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Biosocial Theory of BPD

• Biological Dysfunction in the Emotion Regulation
  System
• ?
• Invalidating
• Environment
• ?
• Pervasive Emotion Dyregulation

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Emotion Dysregulation

• Emotional Vulnerability
• ? ?
• Inability to Modulate Emotions

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Emotion Vulnerability

• High sensitivity
• - Immediate reactions
• - Low threshold for emotional reaction
• High reactivity
• - Extreme reactions
• - High arousal dysregulates cognitive
• processing
• Slow return to baseline
• - Long lasting reactions
• - Contributes to high sensitivity to next
• emotional stimulus

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Tasks in EmotionModulation

• Decrease (or increase) physiological arousal
  associated with emotion
• Re-orient attention
• Inhibit mood dependent action
• Organize behavior in the service
• of external, non mood dependent
• goals