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
DBT 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 1V
Would question – abandonment – rejection instead

3. DSM 5
The 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.

4. DSM 5 ICD-10 Cluster A The odd & eccentric Cluster B
Paranoid
Distrust and suspiciousness
Distrust and sensitivity
Schizoid
Socially and emotionally detached
Emotionally cold and detached
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
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
Histrionic
Excessive emotionality and
attention-seeking
Dramatic, egocentric and manipulative
Narcissistic
Grandiose, lack of empathy, need for admiration
Cluster C
The anxious & fearful
Avoidant
Socially inhibited, feelings of inadequacy, hypersensitivity
Tense, self-conscious and hypersensitive
Dependent
Clinging and submissive
Subordinates, personal need, seeking constant reassurance
Obsessive compulsive
Perfectionist and inflexible
Anankastic
Indecisive, pedantic and rigid
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.
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 Disorders
OCD-10: International Classification of Diseases
Cluster A: The Odd, Eccentric Cluster
Cluster B: The Dramatic, Emotional, Erratic Cluster
Cluster C: The Anxious, Fearful Cluster
Cluster A personality disorders
A 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 disorders
A 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 disorders
A 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

5. DBT’s 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
As a means of understanding problems from a behavioural perspective. Prioritising difficulties into a hierachy

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).
Discussion – Experience of dealing with this client group – what are the issues
Manipulation – Marsha Linehan

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
CBT – Invalidating -Asking people to change too quickly-Brought in validation and mindfulness
Linehan 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.[2] She has said that she feels that she actually had borderline personality disorder.[
Bhudist practitioner

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.
Individuals not having the skills to deal with emotional trauma. Fire fighting each session or decompensating – admission to hospital

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 Stage Theory of Treatment
Bio-social theory of the etiology and maintenance of BPD
Learning principles and ideas from behaviour therapy
BPD behavioural patterns and Dialectical Dilemmas
Dialectical Orientation to change

11. Stage 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.

12. 1. Stages of Treatment: Behaviours to target in DBT
Suicidal/homicidal or other imminently life-threatening behaviour
Therapy interfering behaviour – client and therapist
Quality of life interfering behaviour
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.
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 skills
Invalidating environment

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.
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.

16. Chain 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

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)
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 forces
Diachotomous and extreme thinking behaviour and emotions are seen as dialectical failures

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
Learn 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 difference
However also – more complex – eg dieting – acceptance can lead to change
Dialectical tension and resolution (synthesis) between accepting things the way they are(thesis) and working for change (antithesis)

19. Dialectical Dilemmas

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

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.
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

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

23. DIALECTICAL BEHAVIOUR THERAPY
THE PRACTICE

24. Outline of Treatment Programme Functions and Modes
Enhanced Capabilities
Improve Motivational factors
Assure generalisation to natural environment
Structure the environment
Enhance therapist’s 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
NorthDevonDBTProgramme2011

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
Hierarachy – life threatening, therapy interfering, quality of life interfering

28. Programme Outline – Stage 1 One year period to include:
Weekly Group consisting of the following 6 month modules (run twice):
Distress Tolerance
6 weeks
Mindfulness
2 weeks
Interpersonal Effectiveness
Emotion Regulation
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
Procedures 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.

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.
What about prescribed medication?
Rules around telephone consultation.

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

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
Chain analysis begins with a clear definition of problem behaviour. Then vulnerability factors – then prompting event.
Case illustration – role play.

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
Listening and observing what the patient is thinking, feeling and doing in and attentive, non-biased and open manner
Reflection 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 moment
The therapist acknowledges the inherent difficulty of the patient’s current life and therapuetic tasks

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 patient’s experience.
Including negative feelings about therapy
Explicitly identifying such feelings
Anticipating therapy-interfering behaviours
Being available by phone between sessions
Freudian therapists would never do this

40. Dialectics
The teeter totter

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
Pro’s and con’s 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. DBT is NOT a suicide prevention strategy – it is about finding a live worth living

46. Mindfulness HOW skills Without judgment In the moment (one mindfully)
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’
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.

49. Breaking 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 do
Concentration 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)

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
Discussion

53. National Research Evidence
Based on various research findings, the Department of Health
(NICE Guidelines CG78 to be updated in 2012) has
recommended the following for people with Borderline
Personality Disorder:
treatment that lasts at least 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, 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., 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.

56. Research Findings
Comtois 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.

57. Research local – evaluation procedures
Outcomes of Treatment
Outcome measures
Behavioural measures:
Number of visits to A&E
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