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Dialectical Behaviour Therapy (DBT) Dr A James 2008. (Ms K Alfoadari).

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Presentation on theme: "Dialectical Behaviour Therapy (DBT) Dr A James 2008. (Ms K Alfoadari)."— Presentation transcript:

1 Dialectical Behaviour Therapy (DBT) Dr A James 2008. (Ms K Alfoadari).

2 Age of onset of depression. Zisook et al, AJP 2007

3 Deliberate self-harm in Oxfordshire. Hawton et al, JCPP 2003,44:1191-1198. Increase in DSH with antidepressants (5-18%of all DSH). 1990-2000.

4 Rates of suicide and open verdicts in England & Wales in 15-19 year-olds, 1993 – 2005 Hawton 2007 Males Both sexes Females

5 Aggregated Risk for Adolescent Suicide. Brent et al, JCPP 2005 Risk MalesFemalesTotal Any psychiatric disorder 8.7 (2.9–26.7)6.9 (2.7–17.4)9.4 (3.7–23.9) Mood disorder10.0 (5.3–18.9)16.4 (5.4–49.7)9.8 (6.0–16.1) SUD9.2 (4.4–19.2)3.1 (.1–68.6)7.2 (3.7–13.9) CD4.9 (2.4–10.3)1.9 (.4–8.4)4.6 (2.6–7.9) Any previous attempt 42.7 (10.2–179)50.4 (6.3–403)67.4 (16.3–280)

6 Methods of suicide in 15-19 year-olds, 2005 (Hawton 2007) Males (N=74)Females (N=28)

7 Treatment of Self-Harm (SH). The NICE guidelines for repeated SH in adolescents (National Institute for Clinical Excellence, 2004) recommends developmental group psychotherapy, based upon just one randomised controlled trial (Wood et al, 2001). For adults, the NICE guidelines (National Institute for Clinical Excellence, 2004;2009), a Cochrane review (Hawton et al, 2000) and the American Psychiatric Association (2001) recommend Dialectical Behavioural Therapy (DBT) for SH.

8 Dialectic Behavioural Therapy Originally developed for treatment of parasuicidal women with Borderline Personality Disorder in an outpatient setting. Adapted for - -Inpatient Adult (Springer et al, 1996) -Inpatient Adolescents (Katz et al, 2004) -Outpatient Adolescents (Miller et al, 2007) -Adolescents with Bipolar Disorder (Goldstein et al, 2007) -Substance Misuse (Lineham et al, 1999,2002; Dimef et al, 2008) -Eating Disorders (Safer et al, 2001) -Elderly (>60 years) PD and MDD( Lynch et al, 2007) --Treatment Resistant depression (Harley et al, 2008).

9 Psychosocial Treatments. Cognitive Behavioural Treatments -Cognitive Behavioural Therapy (CBT) -Problem Solving Therapy (PST) -Interpersonal Therapy (IPT) -Dialectic Behavioural Therapy (DBT) - Schema-Focused Therapy (SFT) Psychodynamic -Psychodynamic Therapy -Mentaiisation therapy Combination - Multisystemic Therapy (MST).

10 Dialectic Behavioural Therapy Partly manual based Linehan 1993 Cognitive-Behavioral Therapy of Borderline Personality Disorder. Linehan 1993 Skills Training Manual for Treating Borderline Personality Disorder. Miller, Rathus & Linehan 2007. Dialectic Behavior Therapy for Suicidal Adolescents.

11 AuthorYearNSample Linehan et al1991,93, 9444Parasuicidal Women with BPD Linehan et al199928Women with BPD and drug dependence Turner et al200024BPD and suicidal behaviour Koons et al200020Women with BPD Safer et al200129Women with Bulimia Nervosa Telch et al200444Females with binge eating disorder Linehan et al200224Women with BPD and opiate dependence DBT Studies

12 AuthorYearNSample Lynch et al2003,200635Elderly depressed with and without PD Verheul et al Van den Bosch 2002,2003, 2006 56Parsuicidal women with BPD. Linehan et al2006100Women with BPD and suicidal behaviour DBT Studies

13 DBT-A. Rathus, Miller 2002; Miller, Rathus & Linehan 2007 Decreased treatment length (52 to 16 weeks). Involving family members in skills training format (multifamily group format). Involving family members in individual sessions when necessary. Adaptation of skills to adolescence. Use of age-appropriate language in handouts.

14 DBT-A Method Outpatient Therapy 1 hour weekly. Multifamily therapy skills therapy (2 hour weekly). Telephone consultations between sessions with individual therapist skills therapist(s) Therapists’ consultation meeting weekly. Ancillary treatments as necessary Pharmacotherapy Psychiatric admission Duration of treatment 16 weeks.

15 Borderline Personality Disorder (BPD) DMS-IV diagnostic Criteria for Borderline Personality Disorder pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity beginning by early adulthood and present in variety of context as indicated by five or more of the diagnostic criteria

16 Nine Criteria for BDP A pattern of intense and unstable interpersonal and unable to interpersonal relationship Frantic efforts to avoid real or imagined abandonment Identity disturbance or problems with sense of self Impulsivity that is potentially self damaging Recurrent suicidal or parasuicidal behaviour Chronic feeling of emptiness Affective instability Chronic feelings of emptiness Inappropriate intense or uncontrolled anger Transient stress-related paranoid ideation or severe dissociation symptoms

17 DBT Organisation of BPD In DBT practitioners view these difficulties in more behavioural terms, thus allowing the use of behavioural interventions based upon a skills deficit model :

18 DBT Organisation of BPD Emotional Dysregulation: Affective lability, problems with anger Interpersonal Dysregulation: chaotic relationships, fears of abandonment Self Dysregulation: identity disturbance/ difficulties sense of self/ sense of emptiness Behavioural Dysregulation: parasuicidual behaviour impulsive behaviour Cognitive Dysregulation: dissociation responses/ paranoid ideation

19 Dialectical Behaviour Therapy (DBT) Dialectical behaviour therapy is a broad based cognitive behaviour therapy that has been specifically designed for patients with Borderline Personality Disorder. DBT conceptualises a biosocial theory of borderline personality disorder with a skills deficit and problem solving model.

20 What is Dialectics? Dialectics is a cooperative exercise between two people with opposing views. Instead of battling it out until one view is taken to be the right one, the aim of dialectics is for both parties to search for an ‘answer’ that satisfies the problem from both points of view. It’s about finding the Both/And and not the And/Or

21 Biosocial Model Biological Principals Linehan's theory is based on emotional dysregulation which is produced by an emotional vulnerability and maladaptive and inadequate emotional modulation strategies.

22 Biosocial model (Linehan, 1993) Emotional Vulnerability Invalidating Environment Pervasive Emotional Dysregulation

23 Biological Principals (Cont.) A person who is emotionally vulnerable is someone whose automatic nervous system reacts excessively to relatively low levels of stress and takes longer to return to normal levels of arousal once the stressor has been removed. Emotion dysregulation is seen as a result in the transaction between the biological disposition and the environment.

24 Time Intensity

25 Environmental principles Invalidating Environment refers essentially to the situation where personal experiences and responses of the growing child are “invalidated” by care givers in their life. The child’s personal communications are not accepted as an accurate indication of her true feelings. The invalidating environment contributes to emotion dysregulation by failing to teach the child to label and moderate arousal, to tolerate distress, or trust her own emotion responses as valid interpretations of events.

26 Biological Principles cont… Emotion vulnerability + maladaptive, inadequate emotion regulation strategies = EMOTION DYSREGULATION

27 Components of DBT

28 Individual Therapy Pre-treatment: To gain commitment and agreement to stay in treatment using dialectic skills, validation and commitment strategies and an away weekend to enhance group cohesion. There is a strong emphasis on how difficult treatment is.

29 1:1 work cont…. Stage 1: Decide on treatment hierarchy (starting with most life threatening behaviours) Decrease life threatening behaviour Decrease therapy interfering behaviour Decrease quality of life interfering behaviour

30 Skills Training in DBT There are 4 skills taught in DBT skills training: Mindfulness Interpersonal effectiveness Distress tolerance Emotion regulation

31 Skills Training in DBT Skills training has two primary goals; 1) Communicate information about particular coping strategies to group members 2) Elicit from group members rules and strategies for effective coping that they have learned in the particular situation they encounter

32 Mindfulness skills Mindfulness is central for DBT It is the first skill taught and listed on the diary card Mindfulness skills are taught at the beginning of each module The skills are a psychological and behavioural version of Eastern meditation that has been drawn from ZEN. Mindfulness DBT looks at three primary states of mind

33 Mindfulness skills cont…

34 Mindfulness Skills cont….2 What skills How skills Observe Non- judgmental Describe One mindfully Participate Effectively

35 Interpersonal Effectiveness Skills DBT Interpersonal Effectiveness skills are similar to those skills taught in assertiveness training and interpersonal problem solving classes. The skills taught assist group members in: ASKING WHAT ONE NEEDS TO SAY NO TO; COPING WITH CONFLICTS. The term “effectiveness” in DBT means obtaining changes that one wants, maintaining the relationship and maintaining your self respect.

36 Emotion Regulation skills The first step in emotional regulation is learning to identify emotions. To do this group members have to learn to observe and describe: 1)The event prompting the emotion 2) The interpretation of the event that prompted the emotion 3) The phenomenological experience (including physical sensations) 4) The behaviour expressing emotion 5) The after effects of the emotion on others types of functioning

37 Emotion Regulation skills cont… Skills covered: identify obstacles to changing emotions reducing vulnerability to “Emotional Mind” increasing positive emotional events increasing mindfulness to current emotions taking the opposite action applying distress tolerance techniques

38 Distress Tolerance skills The distress tolerance behaviours targeted in DBT skills training are concerned with tolerating and surviving crisis and with accepting life as it is in that moment Four sets of skills are taught; 1) Distraction 2) Self soothing 3) Improve the moment 4) Thinking of pro’s and con’s

39 Phone Coaching The aim of telephone coaching is to help patients refocus and use skills Problem solve Highlight shame Validate Use radical acceptance

40 Team Meetings & Group Supervision These focus on: keeping the therapist motivated and “true” in order to reflect on the statement given to patients encouraging the therapist to accept the dialectics synthesis encouraging the therapist to adopt a none judgmental/blaming stance

41 Case Presentation Emily Smith is a 17 year old white female, she lives in supported accommodation in Oxfordshire. Emily’s presenting problems are: Deliberate self harm Mood instability Inability to tolerate distress Restriction of diet Periods of excessive drinking Poor relationship with family

42 History Emily was also born with a nut allergy. She is the eldest of three siblings and has two brothers aged 15 and 9. She is academically bright and attended grammar schools until 3 months prior to her first admission. Emily’s mum describes Emily as being very emotionally needy and sensitive. Emily’s mother also suffers from depression and suffered from post-natal depression after Emily’s birth.

43 History Emily has had two admissions to Highfield Adolescent in-patient unit following referrals for DSH and low mood over an 18 month period. During admission Emily disclosed she was sexually abused by her brother. These allegations were not investigated by social services and her parents did not believe her. Emily turned 16 and was supported in finding independent accommodation. Initially the independent living went well and Emily reported a decrease in her symptoms. Her mood soon began to fluctuate and she has began to struggle with her self harm.

44 Behaviour Analysis Vulnerability factors: The support she is offered is inconsistent and dependent on which member of staff is working. There are a large number of males in the house who have come from prison and probation services. At first Emily was happy to be living there she now feels that it is a punishment as her brother and family have a much higher standard of living. She is very blaming of her family for her situation.

45 Stages of Treatment Emily’s target behaviors are: 1. Decreasing self-hraming behaviours 2. Decreasing therapy interfering behaviours 3. Decreasing quality of life interfering behaviour 4. Increasing skills.

46 Treatment IncreaseDecrease Distress tolerance Interpersonal skills Self-respect and self worth Acceptance Self-harm Inability to tolerate distress Poor interpersonal relationships with family Restriction of diet Excessive drinking


48 Behaviour Analysis Vulnerability factors: The support she is offered is inconsistent and dependent on which member of staff is working. There are a large number of males in the house who have come from prison and probation services. At first Emily was happy to be living there she now feels that it is a punishment as her brother and family have a much higher standard of living. She is very blaming of her family for her situation.

49 Behaviour Analysis Precipitating Events When Emily’s house mate started playing loud music she felt angry and invalidated as her house mate had been playing loud music till 3am the previous night. Emily approached staff in the house to complain, the only response she got was that he was on his last warning and would be given an eviction notice. Emily felt too tired and weak to approach him directly and did not want to get into a confrontation.

50 Behaviour Analysis Further Vulnerability factors: Emily’s anti-depressant medication was being reduced and she was experiencing low mood. When she is low in mood her cognitions are often self-invalidating. Emily ruminates and becomes negative about herself, which leads to her reducing her diet as a means of punishing herself or cutting. The loud music in her accommodation has led to Emily experiencing a disturbed sleep pattern and at times gets very little sleep.

51 Behaviour Analysis Self-invalidation: The dysfunctional cognitions serve to support Emily's view that no one cares for her and she does not deserve to be cared for. Due to vulnerability factors Emily was highly aroused, making the consideration of applying skills more difficult. After trying effective behaviours that did not work due to environmental factors Emily returns to self-invalidation.

52 Behaviour Analysis Dysfunctional Links (cont) EMOTIONAL REGULATION DEFICIT - Emily has a skills deficit in mindfulness, emotional regulation, and distress tolerance. She was unable to use mindfulness skills (observing, non-judgmental stance and description of her current emotional state). - As Emily’s skills were limited in use, it served to reinforce Emily’s belief of being unable to cope without self-harm. This was reinforced by her actions/behaviour.

53 Behaviour Analysis Dysfunctional Links (cont) DISTRESS TOLERANCE DEFICIT:  After trying distress tolerance skills in the form of distraction (phoning a friend) the environment factors stopped it from working (friend couldn't get money). Consequently the positive reinforcement was removed.  Emily reports feeling angry because she tried and it did not work. This resulted in self punishment and a reduction in more functional behaviour.  Emily then experienced negative thoughts about not being able to use skills.

54 Treatment Plan Target behaviour: Self-harm Decrease vulnerability factors Skills generalisation Increase dialectic thinking Behaviour rehearsal Cognitive restructuring Validation and addressing self-invalidation Exposure treatment Responses to specific clues Address excessive dependence Contingency management

55 Interventions Decrease vulnerability factors. Therapy sessions focused on decreasing vulnerability through Cognitive restructuring of invalidation and using cheerleading to motivate. Reviewing diary cards focusing on regaining sleep pattern and eating meals three times day. Increasing dialectical behaviour thought and behaviour patterns. Skills generalisation: Using behaviour rehearsal, validation, exposure and reviewing responses to specific cues in both individual and group skills training.

56 Outcome - Three months into treatment. Changes after three months; Increase in dialectical thinking Reduction in DSH Increase recognition of normative behaviours Problem solving Increase of skills First month: reduction in DSH in first two weeks treatment. Incidences 4 per week. Second month: Decrease in DSH 3 per week increase in excessive drinking and not using skills Third month: Decrease in drinking, DSH the same three per week but more use of skills

57 Other treatments. An RCT of a skills-based treatment versus a supportive relationship treatment of 35 adolescent suicide attempters (Donaldson et al, 2005) produced significant decreases in suicidal ideation and depressed mood at 3- and 6-month follow-up, with no differences between treatment groups. A recent, relatively large scale RCT of cognitive analytic therapy versus ‘good’ treatment as usual for adolescents with borderline personality disorder found both were equally effective at 24 months follow-up (Chanen et al, 2008) Mentalisation Therapy (Bateman et al, 2004; Gibson 2006),

58 DBT for Adolescents in the Looked After Care System. A.James. Hon Senior Lecturer University of Oxford.

59 Adolescents in the Looked After Care System (LAC). The rates of emotional and behavioural problems in children in care range from 40 % to nearly 60%, depending on the sample Minnis et al, (2004) found that over 90% of the children in foster care had previously been abused or neglected and 60% had evidence of mental health problems including conduct problems, emotional problems, hyperactivity and problems with peer relations.

60 Adolescents in the Looked After Care System (LAC). A Swedish study (Vinnerljung et al, 2007) found former children in the care system were four to five times more likely than the general population to have been hospitalised following suicide attempts. Individuals who had been in long-term foster care tended to have the most dismal outcome. Even adjusting for birth parents’ hospitalizations with a psychiatric diagnosis, and for birth-home-related socio-economic factors, a twofold elevated risk remained.

61 Adolescents in the Looked After Care System (LAC). In the UK, children looked after by local authorities are recognised by the children’s National Service Framework (Department of Health, 2004) and Every Child Matters (Chief Secretary to the Treasury, 2003) as a group who are particularly vulnerable to psychological difficulties and are often denied access to services. Even so some studies indicate service utilization by this group as comparatively high with 36% having been assessed in Child and Adolescent Mental Health Services (CAMHS) and 25% having seen a child psychiatrist (Stanley et al, 2005; Rodriquez et al, 2004).

62 Adolescents in the Looked After Care System (LAC). For children in the care system DSH represents a major health concern. In the UK, the rate of adolescent DSH in the general population is high with 11.2% of females and 3.2% of males reporting an episode of DSH within the previous year (Hawton et al, 2002). Young females who engage in repeated DSH are at particular risk of suicide (Zahl et al, 2004).

63 Reduction in DSH with DBT. F = 23.95 d.f. = 2, p < 0.001

64 Improvement in Functioning (GAF Score)

65 DBT The treatment package was based upon the community model already being used within CAMHS (James et al. 2008). This had been adapted from the manualised treatment developed for adults (Linehan 1993a, 1993b) and the 12 week package developed by Miller and Rathus (Rathus et al, 2002). In this study, DBT was delivered in the community. Stage 1 - The treatment package consisted of pre- treatment, a once-weekly skills training group, a once- weekly hour-long individual session, telephone support, carers training and outreach components.

66 Participants Young people were referred to the service from all areas: social services teams (Looked After and Leaving Care), CAMHS, Forensic CAMHS and Youth Offending Teams. The capacity of the DBT team was 8 clients as recommended for the group skills training (Linehan 1993b).

67 Participants. To be included in the study subjects had to have a history of more than six months of persistent SH, defined after Hawton et al. (2002) as: an act with a non-fatal outcome in which an individual deliberately did one or more of the following: self cutting; jumping from a height which they intended to cause harm; ingesting a substance in excess of the prescribed or generally recognised therapeutic dose; ingesting a recreational or illicit drug that was an act that the person recognised as self harm; ingesting a non-ingestible substance or object. Exclusion criteria included a diagnosis of schizophrenia, bipolar disorder, autism, autistic spectrum disorder and those with moderate and severe mental impairment.

68 Participants Twenty young people agreed to engage in DBT, four young men and 16 young women. The mean age at treatment onset was 15.3 years (sd = 1.4), the youngest being 13, the oldest 17 years of age. Of those 20, 14 engaged in full DBT, with 6 disengaging after the pre-treatment motivation stage. Nine completed two full cycles of the group (2 male, 7 female), and 5 dropped out of full DBT within the first skills module of group. Of those that began DBT 7 were in full-time education, 2 were in partial supported education and 5 were unemployed. When they started DBT 2 young people were in a secure unit, 3 were living in local authority children’s homes, 3 were living with foster carers, 3 were living independently, 2 were living with family members and 1 was living in homeless sheltered housing. Five young people were prescribed medication- all serotonin re-uptake inhibitors (SSRIs) antidepressants - fluoxetine (2), sertraline (1) citalopram (1).

69 Procedures The Structured Clinical Interview for DSM-IV 11 (SCID-II) was used to assess and quantify borderline personality traits.,. Independent audit outcome measures were carried at the start of full treatment and end of treatment. These were Beck Depression Inventory (BDI), (Beck, 1979), Beck Hopelessness Scale (BHS), (Beck et al., 1974), Attachment Style (Attachment Style Questionnaire (ASQ), (Feeney et al, 1993), Negative Automatic Thoughts (Childrens Automatic Thoughts Scale (CATS), (Schniering & Rapee, 2002),) and a Global Assessment of Functioning (GAF), (DSM-IV-TR, APA 2000). The number of episodes of DSH per week was determined by clinical interview.

70 Results. For those who completed treatment (n = 9) there was a significant reduction in depression scores (t = 2.83, d.f. = 8, p = 0.025,); hopelessness scores (t = 2.49, d.f. = 8, p = 0.038,) and a significant reduction in frequency of self harm (t = 4.051, d.f. = 8 p = 0.004,). There was also a significant increase in global functioning scores (t = 6.11, d.f. = 8 p < 0.001).

71 Results. Of note at the end of treatment 7 had totally stopped DSH, one still cut superficially approximately once a month, compared to daily cutting and ligature tying, and one enrolled in drug rehabilitation to treat heroin addiction, but showed no other kinds of DSH. At the end of treatment there were no significant changes in negative automatic thoughts (CATS), or quality of life scores (Adolescent Comprehensive Quality of Life Scale) scores. All participants were rated according to the Attachment Style (ASQ) as being insecurely attached.

72 Results. Of the nine who completed treatment, four where already in education and remained in school or moved to further education, Three were supported back into education, one was supported to get a job and one went into a drug rehabilitation centre. By the end of treatment two young people were moved from secure units, one returned back to their family and the other moved to supported lodgings. Two young people moved from foster care, one into independence and the other back to their family.

73 Results. Fity-five percent (11/20) of young people who agreed to start the programme dropped out after pre-treatment or within the first module of group. Those who dropped out had significantly higher scores of depression on the BDI (t = 2.26, d.f. = 12, p = 0.045) and hopelessness on the BHS (t = 2.71, d.f, = 12, p = 0.025), but achieved higher positive ratings on the Global Assessment of Functioning (t = 2.545, d.f. = 12, p = 0.026). There was no significant difference in scores on any other measure.

74 Discussion. Problems – High drop out rate. Other treatments available. Treatment of depression Time for a multi-centre randomised controlled trial (RCT) (Fleischhaker et al, 2006).

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