Presentation on theme: "DIALECTICAL BEHAVIOUR THERAPY"— Presentation transcript:
1DIALECTICAL BEHAVIOUR THERAPY Fi ConingtonClinical Lead OASIS
2DSM-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 behaviouraffective 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 emptinessInappropriate 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 symptomsDBT is fundamentally a treatment for those given the diagnosis of BPD. Criteria to orientate us to the diagnosis of BPD.Now DSM 5 – but DBT’s reorganisation of diagnostic criteria is linked to DSM 1VWould question – abandonment – rejection instead
3DSM 5The 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.Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States and contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system.Personality disorders are associated with ways of thinking and feeling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life. They fall within 10 distinct types: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder.
4DSM 5 ICD-10 Cluster A The odd & eccentric Cluster B ParanoidDistrust and suspiciousnessDistrust and sensitivitySchizoidSocially and emotionally detachedEmotionally cold and detachedSchizotypal :difficulty in establishing and maintaining close relationships with others.No equivalentCluster BThe dramatic & erraticAntisocialViolation of the rights of othersDissocialCallous disregard of others, irresponsibility and irritabilityBorderlineInstability of relationship, self-image and moodEmotionally UnstableBorderline type: unclear self-image and intense unstable relationshipsImpulsive type: inability to control anger, quarrelsome and unpredictableHistrionicExcessive emotionality andattention-seekingDramatic, egocentric and manipulativeNarcissisticGrandiose, lack of empathy, need for admirationCluster CThe anxious & fearfulAvoidantSocially inhibited, feelings of inadequacy, hypersensitivityTense, self-conscious and hypersensitiveDependentClinging and submissiveSubordinates, personal need, seeking constant reassuranceObsessive compulsivePerfectionist and inflexibleAnankasticIndecisive, pedantic and rigidPersonality disorders are associated with ways of thinking and feeling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life. They fall within 10 distinct types: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder.The proposed revisions that were not accepted for the main body of the manual were approved as an alternative hybrid dimensional-categorical model that will be included in a separate chapter in Section III of DSM-5. This alternative model is included to encourage further study on how this new methodology could be used to assess personality and diagnose personality disorders in clinical practice.DSM-5 moves from the multiaxial system to a new assessment that removes the arbitrary boundaries between personality disorders and other mental disorders.This slide can be used to highlight the different diagnoses of personality disorder, however facilitators should emphasise that this programme is not focused on this in great detail and that the focus is more on exploring individual needs and working effectively in response to these.DSM 1V: Diagnostic and Statistical Manual of Mental DisordersOCD-10: International Classification of DiseasesCluster A: The Odd, Eccentric ClusterCluster B: The Dramatic, Emotional, Erratic ClusterCluster C: The Anxious, Fearful ClusterCluster A personality disordersA person with a cluster A personality disorder tends to have difficulty relating to others and usually shows patterns of behaviour most people would regard as odd and eccentric. Others may describe them as living in a fantasy world of their own.An example is paranoid personality disorder, where the person is extremely distrustful and suspicious.Cluster B personality disordersA person with a cluster B personality disorder struggles to regulate their feelings and often swings between positive and negative views of others. This can lead to patterns of behaviour others describe as dramatic, unpredictable and disturbing.An example is borderline personality disorder, where the person is emotionally unstable, has impulses to self-harm, and intense and unstable relationships with others.Cluster C personality disordersA person with a cluster C personality disorder struggles with persistent and overwhelming feelings of anxiety and fear. They may show patterns of behaviour most people would regard as antisocial and withdrawn.An example is avoidant personality disorder, where the person appears painfully shy, socially inhibited, feels inadequate and is extremely sensitive to rejection. The person may want to be close to others, but lacks confidence to form a close relationship.Schizotypal personality disorder is characterized by someone who has great difficulty in establishing and maintaining close relationships with others. A person with schizotypal personality disorder may have extreme discomfort with such relationships, and therefore have less of a capacity for them.4
5DBT’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 7As a means of understanding problems from a behavioural perspective. Prioritising difficulties into a hierachy
6Presentation within care settings Frequent admissionsSelf harm / suicide attemptsDrugs / alcohol often a featureFrequent crisisMultiple agencies involvedSplitting – 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).Discussion – Experience of dealing with this client group – what are the issuesManipulation – Marsha Linehan
7Historical ContextMarsha 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 approachesCBT – Invalidating -Asking people to change too quickly-Brought in validation and mindfulnessLinehan was born in Tulsa, Oklahoma. In March 1961 she was diagnosed with schizophrenia at the Institute of Living in Hartford, Connecticut where she was an inpatient. Linehan was subjected to electroconvulsive therapy, seclusion, as well as Thorazine and Librium as treatment. She has said that she feels that she actually had borderline personality disorder.[Bhudist practitioner
8Why 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.Individuals not having the skills to deal with emotional trauma. Fire fighting each session or decompensating – admission to hospital
9Traditional 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.
10Conceptual Framework Stage Theory of Treatment Bio-social theory of the etiology and maintenance of BPDLearning principles and ideas from behaviour therapyBPD behavioural patterns and Dialectical DilemmasDialectical Orientation to change
11Stage 1 Moving from Being out of control of one’s behaviour to being in control - Stage 2 – Moving from being emotionally shit down to experiencing emotions fully. The main target of this stage is to help clients experience feelings without having to shut down by dissociating, avoiding life, or having symptoms of PTSD. In DBT we say that clients are now in more control but are in ‘quiet desperation’. To begin the trauma work whilst emotionally aware.Stage 3 – Building an ordinary life, solving Ordinary life problems – clients work on ordinary problems such as marital conflict, job dissatisfaction, career goals. Some clients choose to continue with the same therapist, some take a long break from therapy and others work on these goals without a therapist.Stage 4 – Moving from incompleteness to completeness and connection – recognition that most people struggle with “existential” problems despite having competed therapy. They can still feel somewhat empty or incomplete. Although research on this stage is lacking, Marsha Linehan added it after realizing that may clients go on to seek meaning through spiritual paths.Is this about endings? Discussion point.
121. Stages of Treatment: Behaviours to target in DBT Suicidal/homicidal or other imminently life-threatening behaviourTherapy interfering behaviour – client and therapistQuality of life interfering behaviourDeficits in behavioural capabilities needed to make life changes
132. Bio-social Theory Emotional vulnerability Genetic/biological/neurological developmentEmotional DysregulationHigh sensitivity, Strong reactions, slow return to baseline.Invalidating environmentFails to confirm, corroborate or verify individual.Valuable clinical features of this theory are: 1) it avoids blaming the patient 2) it facilitates psycho education by identifying inadequate learning experiences 3) It helps patients acquire skillsInvalidating environment
14Examples 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
153. Theory of changePrinciples of learning and ideas from behaviour therapy.Analysis of antecedents and consequencesFunctional analysis/behaviour chain analysis.In general, persistent disordered behaviours is viewed as a result of deficits in capabilities as well as problems of motivations.Principles of learning and ideas from behaviour therapy are used to analyse behaviour and influence change.DBT case formulation relies on functional analysis or behavioural chain analysis.Careful analysis of antecedents and consequences is particularly important due to the central role of emotion dysregulation in BPD. Also important to distinguish between behaviours that are consistent across the board (traits) and behaviours that are difficult in some contexts.
16Chain analysis begins with a clear definition of problem behaviour Chain analysis begins with a clear definition of problem behaviour. Then vulnerability factors – then prompting event.Behavioural Analysis worksheet
174. 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)Learning psychosocial skills is particularly hard when a person’s immediate environment or larger culture do not support such learning. The individual must learn not ony self-regulations skills, but also better skills for influencing her environment.Thesis and antithesis out of whose synthesis evolves a new set of opposing forcesDiachotomous and extreme thinking behaviour and emotions are seen as dialectical failures
185. Dialectics – A treatment approach Working towards synthesis of opposing polarities:-Acceptance V changeChange V consequences of changeMaintaining personal integrity V learning new skillsWorking towards flexibility and management of change whilst developing stabilityLearn to accept what cannot change from what you can change.Similar to the alcoholic’s creed that asks for the strength to change what can be changed, to accept what cannot be changed, and to know the differenceHowever also – more complex – eg dieting – acceptance can lead to changeDialectical tension and resolution (synthesis) between accepting things the way they are(thesis) and working for change (antithesis)
20Dialectical Dilemmas Dilemma Treatment Target Emotional Vulnerability vs. Self-invalidationTreatment TargetIncreasing emotional modulationDecreasing emotional reactivityIncreasing self-validationBPD individuals frequently jump from a behavioural pattern that under regulates to another that over regulates emotion, the discomfort of each extreme triggering oscillation between response patternsEmotional vulnerability is an extreme sensitivity to emotional stimuli. This is the person who has strong and persistent emotional reactions to even small events. Emotionally vulnerable people have difficulty with such things as modulating facial expressions, aggressive action and obsessive worries. On the other end of the dialectical pole is self-invalidation. Self invalidation involves discounting one’s own emotional experiences, looking to others for accurate reflections of reality and over-simplifying problems and their solutions. The combination of these two characteristics leads to oversimplifying problems and how to achieve goals and extreme shame, self-criticism and punishment when goals are not met.
21Dialectical Dilemmas Active Passivity vs. Apparent Competence Treatment TargetIncreasing active problem solvingDecreasing active passivityIncreasing accurate communicationDecreasing mood dependency of behaviour.Active passivity is the tendency to approach life’s problems helplessly. Under extreme stress, an individual will demand that the environment and people in the environment solve his or her problems. Apparent competence, on the other hand, is the ability to handle many everyday life problems with skill. Often, people with BPD are appropriately assertive, able to control emotional responses and successful in coping with problems. These competencies, however, are extremely inconsistent and dependent on circumstances. The dilemma of active passivity and apparent competence leaves the individual feeling helpless and hopeless with unpredictable needs for assistance and fear of being left alone to fail
22Dialectical Dilemmas Unrelenting Crisis vs. Inhibited Grieving Treatment TargetIncreasing realistic decision making and judgmentDecreasing crisis-generating behavioursDecreasing inhibited grievingWith unrelenting crisis, repetitive stressful events and an inability to recover fully from one before another occurs results in urgent behaviors such as suicide attempts, self-injury, drinking, spending money and other impulsive behaviors. Inhibited Grieving is the tendency to avoid painful emotional reactions. Constant crisis leads to trauma and painful emotions, which the individual frantically attempts to avoid.These three common dialectical dilemmas are intended to help the therapist understand and relate to the individual’s experience. Although the concept of these dilemmas was originally developed by Linehan in her work with people with BPD, DBT is currently used successfully with people with a wide variety of issues. It is likely that these dilemmas a relevant for a wide variety of people.
24Outline of Treatment Programme Functions and Modes Enhanced CapabilitiesImprove Motivational factorsAssure generalisation to natural environmentStructure the environmentEnhance therapist’s capabilities & motivation to treat effectivelyModesSkills Training GroupIndividual therapyTelephone, Milieu coachingOrganisational interactions (consult-to-client)Team consultation to hold therapists inside the treatmentNorthDevonDBTProgramme2011
26Structure the Treatment Outpatient individual PsychotherapyOutpatients Group Skills TrainingTelephone ConsultationTherapist consultation meetingUncontrolled Ancillary TreatmentsPharmacotherapyAcute-inpatient admissions
27Structure of sessions Individual Sessions Diary cards Hierarchy of treatment goalsChain analysisSolution analysisHierarachy – life threatening, therapy interfering, quality of life interfering
28Programme Outline – Stage 1 One year period to include: Weekly Group consisting of the following 6 month modules (run twice):Distress Tolerance6 weeksMindfulness2 weeksInterpersonal EffectivenessEmotion RegulationThe 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
29Structure of Group Mindfulness exercise Diary cards/ homework feedback Skills trainingSetting homework
30Structure of DBT service Group trainingEach patient has an individual therapistGroup skills taught by 2 therapistsDBT consultation groupCase management strategiesProcedures designed to help patients manage their physical and social environment (including their health professional networks) so that their overall funtioning is enhanced, achievement of their goals is facilitated, and their progress in therapy is supported.
31Structure - Rules Clients who drop out of therapy are out of therapy Each 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.What about prescribed medication?Rules around telephone consultation.
32Case Management Strategies Consultation-to-the patient strategyEnvironment intervention strategyDominant case management strategy. Consistent with the assumption that consulting with patients about how to interact effectively with their environment takes priority over consulting with the environment on how to interact with the patient.Involves coaching, providing the patient with information and skills.2. When the immediate outcome is more important than long-term learning, the patient does not have the skills or motivation. Eg risk to life, environment is too powerful. Discussion - SAFTI
33Behaviour 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
34Behaviour Therapy Contracts Rules 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.
35Chain analysisChain analysis begins with a clear definition of problem behaviour. Then vulnerability factors – then prompting event.Case illustration – role play.
36Case 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.
37Validation Level 1 – Active observing Level 2 – Reflection Level 3 – Mind ReadingLevel 4 – Validation in terms of the pastLevel 5 – Validation in terms of the presentListening and observing what the patient is thinking, feeling and doing in and attentive, non-biased and open mannerReflection of thoughts, feelings and behaviours as expressed and observed within the therapy relationship. Through discussion the therapist helps the patient identify, describe and label their own behavioural patterns.The therapist articulates thoughts, memories, assumptions and feelings that hte patient is not verbalising. The therapist appears to be on the same wavelength as the patient.Therapist identifies the essential learning experiences whilst still identifying the behaviour as dysfunctional in the momentThe therapist acknowledges the inherent difficulty of the patient’s current life and therapuetic tasks
38Validation 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.
39The 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 therapyExplicitly identifying such feelingsAnticipating therapy-interfering behavioursBeing available by phone between sessionsFreudian therapists would never do this
41MindfulnessWhat 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.
42Pre- treatment phase Pre treatment assessment Introduction to the modelEngagement and CommitmentPro’s and con’s of engaging in therapyIdentifying Target behaviours to decreaseIdentifying aims for therapyIntroduction to toolsContracting
45DBT is NOT a suicide prevention strategy – it is about finding a live worth living
46Mindfulness HOW skills Without judgment In the moment (one mindfully) WHAT skillsObserveDescribeParticipateHOW skillsWithout judgmentIn the moment (one mindfully)Effectively
47Distress Tolerence Wise mind ACCEPTS Self-soothing IMPROVE the moment Pros and Cons
48Emotion Regulation Emotion –focused work Labelling emotions Understanding their effectReducing the chances of being controlled by emotionsReducing vulnerability to negative emotions – PLEASE MASTERIncreasing positive emotions through experienceLetting go of emotional suffering‘Acting opposite’Emotion focused work – Invalidating environment – emotions are often not understood, not contained or fed back in a confusing way. Often in the mental health system we are speaking a language that patients don’t understand. Individuals learn how to label and express emotions.Emotional suffering – Acceptance and commitment therapy – the difference between pain and suffering. Trying to stop feelings often make them bigger.Acting opposite – exposure therapy, taking risks.
49Breaking down of emotional components Breaking down of emotional components. Psycho-educational aspects can be empowering.Prompting event can be thoughts feelings behaviour physical reactions. 1 prompting event can trigger another.Events do not prompt emotions – interpretation of events doConcentration on facial muscles – research indicates they have a powerful effect on emotions – Exercise – half smile.BPD individuals have learnt better than most to hide their emotions. This is a natural result of social learning in an invalidating environment. Hiding is usually automatic – individuals do not intend it or are not aware of it. (NOTE also able to read others expressions minutely – from learned experience – getting cues of how to behave from others – external validation – research experiment)
50Interpersonal Effectiveness Attending to RelationshipsBalancing Priorities and DemandsBalancing the wants-to-shouldsBuilding mastery and self-respectObjectiveness effectivenessRelationship effectivenessSelf-respect effectivness
51Radical Openess Turning the mind Radical Acceptance Practice WillingnessNotice Willfulness
52DBT - Adaptions Different Client Groups Individual DBT DBT light Pros and Cons of Adapting the modelDiscussion
53National Research Evidence Based on various research findings, the Department of Health(NICE Guidelines CG78 to be updated in 2012) hasrecommended the following for people with BorderlinePersonality Disorder:treatment that lasts at least monthsdialectical behaviour therapy for people who really struggle with self-harming behavioursmentalisation-based therapy, which is a mixture of group and individual reflectiontherapeutic communities and structured group therapy programmes
54Research FindingsLinehan et al., 1991, 1993, 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.
55Research FindingsBohus et al., 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.
56Research FindingsComtois et al., 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.
57Research local – evaluation procedures Outcomes of TreatmentOutcome measuresBehavioural measures:Number of visits to A&ENumber of admissions to inpatient wardsLength of time of admission to inpatient wardsNumber of suicide attemptsNumber 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 stylesCORE - Global functioningClient FeedbackClient programme evaluation
58Discussion Diagnosis of BPD DBT in the context of the wider Psychiatric systemStrengths, limitations of DBT