DIALECTICAL BEHAVIOUR THERAPY Fi Conington Clinical Lead OASIS
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
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.
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
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).
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
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.
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.
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
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
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.
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
3. Theory of change • Principles of learning and ideas from behaviour therapy. • Analysis of antecedents and consequences • Functional analysis/behaviour chain analysis.
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)
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
Dialectical Dilemmas • Dilemma • Emotional Vulnerability vs. Self-invalidation • Treatment Target • Increasing emotional modulation • Decreasing emotional reactivity • Increasing self-validation
Dialectical Dilemmas • Active Passivity vs. Apparent Competence • Treatment Target • Increasing active problem solving • Decreasing active passivity • Increasing accurate communication • Decreasing mood dependency of behaviour.
Dialectical Dilemmas • Unrelenting Crisis vs. Inhibited Grieving • Treatment Target • Increasing realistic decision making and judgment • Decreasing crisis-generating behaviours • Decreasing inhibited grieving
DIALECTICAL BEHAVIOUR THERAPY THE PRACTICE
Outline of Treatment Programme Functions and Modes • Functions • 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
DBT - Overview • Structure • Behaviour Therapy • Validation • Dialectics • Mindfulness
Structure the Treatment • Outpatient individual Psychotherapy • Outpatients Group Skills Training • Telephone Consultation • Therapist consultation meeting • Uncontrolled Ancillary Treatments • Pharmacotherapy • Acute-inpatient admissions
Structure of sessions • Individual Sessions • Diary cards • Hierarchy of treatment goals • Chain analysis • Solution analysis
Distress Tolerance 6 weeks Mindfulness 2 weeks Mindfulness 2 weeks Interpersonal Effectiveness 6 weeks Emotion Regulation 6 weeks Mindfulness 2 weeks • Programme Outline – Stage 1 • One year period to include: • Weekly Group consisting of the following 6 month modules (run twice): 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
Structure of Group • Mindfulness exercise • Diary cards/ homework feedback • Skills training • Setting homework
Structure of DBT service • Group training • Each patient has an individual therapist • Group skills taught by 2 therapists • DBT consultation group • Case management strategies
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.
Case Management Strategies • Consultation-to-the patient strategy • Environment intervention strategy
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
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.
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.
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
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.
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
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.
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
DIALECTICAL BEHAVIOUR THERAPY THE SKILLS
Mindfulness • WHAT skills • Observe • Describe • Participate • HOW skills • Without judgment • In the moment (one mindfully) • Effectively
Distress Tolerence • Wise mind ACCEPTS • Self-soothing • IMPROVE the moment • Pros and Cons
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’
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