Developing an ACT-based group intervention for DBT graduates with

personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’

Sue Clarke, University of Bournemouth; Dorset HealthCare University NHS Foundation Trust

Helen Bolderston, University of Southampton Bob Remington, University of Southampton

ACBS World Conference IX, Parma, ItalyJuly 2011

Acknowledgments

• Kelly Wilson• Kirsty James

DBT: Development and aims

• Developed for BPD women with self-harming behaviour Linehan, et al., 1991, 1992, 1993, 1994

• BPD is a pervasive disorder of the emotional regulation system– BPD behaviours function to regulate emotions or

are a natural consequence of emotion dysregulation

• DBT aims to reduce out-of-control behaviours in the service of a ‘life worth living’

DBT: Theoretical

ValidationProblem

Solving

Dialectics

Radical behaviourismMindfulnessZen

DBT: Structure

• Multi-modal1. Individual - 2. Skills training groups3. Out of hours skills coaching4. DBT consultation group5. DBT team leader

• Highly structured / focussed• Treatment hierarchy

1. life threatening behaviour2. therapy interfering behaviour3. quality of life interfering behaviour

DBT: Style

• Psycho-educational– Explicit– Didactic– Prescriptive– Often busy

Empirical support for DBT

• Randomized Controlled Trial: DBT vs TAU with chronically suicidal BPD women Linehan, et al., 1991, 1992, 1993, 1994

• DBT reduces self-harm, suicide attempts, hospitalisation and reduces some Axis-I symptomatology in BPD Lynch et al. 2007

Empirical support for DBT

• Overview of results– When used with high-risk clients BPD

• produces significant reductions in suicide attempts, self-harm, hospitalization and outperforms TAU

• but has less impact on Axis 1 disorders, and does not outperform TAU on Axis 1 variables

– When used with less risky clients• greater impact on Axis 1 disorders, and outperforms

TAU

DBT: Clinical experience

• DBT graduates– report ‘quite desperation’ Linehan 1991

• living restricted lives– over-use distress tolerance skills – e.g., distraction, self

soothing

– continue to have a sense of self defined by self-harm and suicidality despite no longer engaging in those behaviours

• ACT for stage-two DBT graduates Pistorello and Clarke 2006

Exercise: Why ACT?

• In pairs:• Why might ACT be a good candidate for DBT

graduates?– Theoretical– Empirical– Clinical

Why ACT?

Philosophical / theoretical continuity

– Functional contextualism– Operant– Classical – Private events important– Third-wave

Why ACT? Contin.

Correlational data

• EA predicts depression in BPD during and after DBT– Berking et al. 2009

• EA mediates the relationship between both negative affect intensity and childhood trauma and risk-taking behaviours Kingston, Clarke & Remington, 2010; Kingston, Clarke, Ritchie & Remington, 2011

Why ACT? contin.

Outcome data

• ACT DBT hybrid with self-harming, BPD clients (N=24) Gratz & Gunderson 2006

•

– RCT 14 weeks TAU or TAU + ACT– reduction in self-harming behaviour and increases

in global indices of psychological well-being

Why ACT? contin.

• ACT group for treatment resistant (TR) 50% PD

– Open trial ACT with TR (N=10) Clarke, Kingston, Remington et al (in press)

• clinically significant gains (E.S. moderate to large)

• Gain maintained 12 month f/up• Changes in follow-up scores were associated with

changes in Acceptance

– RCT ACT vs TAU with TR (N=61) Clarke, Kingston, Remington et al (in prep)

• Similar outcome and process data 12 month f/up

Why ACT? contin.

Clinical

• Importance of values vs. goals

• Over-reliance on distress tolerance and mindfulness as avoidance strategies

• Specific diagnosis (BPD) vs trans-diagnostic – not all people who self harm = BPD

Our aims• Participants

– Maintain behavioural stability– Improve quality of life

• Treatment Developers– Refine the treatment protocol– Trial measures– Evaluate effectiveness

ACT TR Protocol• Group-based• 2 ½ hours per week for 16-weeks• “Get out of Your Mind and Into Your Life” Hayes and Smith, 2006

• Format– mindfulness exercise– homework review

– week topic: teaching and experiential– mindful review of session– homework

• Style– Kelly Wilson, 2010

• process orientated• slowing down• self-involving self-disclosure

Exercise: ACT for DBT- graduates

• In pairs:• What might be in/exclusion criteria?• What ACT processes might be particularly

challenging for – participants?– therapists?

• What tensions/issues between DBT and ACT might we expect?– How might these be resolved?

The HexaflexContact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Adaptations 1st cohort DBT-graduates• Strengthen support

– 16 - 20 weekly sessions– offer 2 individual sessions

• Maintain behaviour stability– DBT diary review

• Facilitate transition from DBT to DBT+ACT– Encourage flexible use of both ACT and DBT strategies

(including short-term avoidance strategies) rather than just ‘control is the problem’

– Two review sessions– Similarities / differences between two approaches

Adaptations 1st cohort DBT-graduates• Strengthen values, committed action

– Begin lightly and end with values – Shaping valued action

• commitment off the table initially• Stylistic adaptation

– Permission seeking– Fewer emotionally evocative interventions

• e.g. ‘eyes on’ lightly• less slowing down, moving in

– Avoidance/adaptation of highly evocative content• e.g. attending your own funeral as a values exercise

Cohort 1: Outcomes

• Post intervention– Using reliable and clinically significant change indicators

Jacobson & Truax, 1991

– 4 participants• improved or recovered category on at least one of BDI-II, SCL-90,

SIPP118• otherwise, no reliable change range

– 1 participant dropped out• no reliable change

– 1 participant• deteriorated category on the BDI-II and SCL-90• no change on any of the SIPP118 domains

Unstructured Interviews 1st Cohort • Helpful

– Permission seeking– Normalising thought

processes– Specific exercises

• Mindfulness• Mind train, leaves on a

stream • Passengers on the bus

– Individual sessions

• Unhelpful – Too much material too

little time– Creative hopelessness

• “fear and despair,” “angry”

– DBT ACT link elaborated too late

– Emotionally evocative– Opening up issues– 6 mnth f/up too long

4/6 recommendation

Participants 1st Cohort: PD and Depression

Total PD Diagnoses PD diagnoses BDI-II

1 5BPD, Paranoid, Pass-Agg, Depressive, Dependent, 28 (Moderate)

2 3 BPD, Paranoid, Pass-Agg 22 (Moderate)

3 4 BPD, Paranoid, Pass-Agg, Depressive 24 (Moderate)

4 5BPD, Paranoid, Pass-Agg, Depressive, Schizotypal 11 (Minimal)

5 6BPD, Paranoid, Pass-Agg, Avoidant Depressive, Dependent, 38 (Severe)

6 3 Avoidant, Depressive, Dependent, 38 (Severe)

     

Mean: 4.3  26.8 (Moderate)

Categorical to Dimensional Approach to PD and personality styles

• Emerging Consensus– Two super-ordinate personality dimensions:

• under-controlled and over-controlled e.g., Clark, 2005; Livesley et al., 1998; Markon et al., 2005; DSM-V PD Task Force

DSM-IV Commonalities core characteristics of PPD, AVPD, OCD

• Strong desire to control one’s environment• Restrained emotional expression• Limited social interactions/ problems with close

relationships due to mistrust, aloofness, distancing, fear of rejection/criticism

• Cognitive and behavioural rigidity• Associated with TR depression

UnderUnder--Controlled Controlled vs.vs. OverOver--ControlledControlled

DramaticDramatic--ErraticErratic ConstrictedConstricted--ControlledControlled

High and Variable High and Variable ExpressivityExpressivity

Inhibited ExpressionInhibited Expression

Impulsive and RiskyImpulsive and Risky Risk AvoidantRisk Avoidant

Chaotic and IntenseChaotic and Intense

RelationshipsRelationships

Distant & Aloof Distant & Aloof RelationshipsRelationships

Emotionally Emotionally

LabileLabile

Emotionally Emotionally

StaticStatic•Lynch & Cheavens(2008). Dialectical behaviour therapy for co-morbid personality disorders. Journal of Clinical Psychology, 64, 1- 14.

Biosocial theory emotionally over-controlled disorders

• Sensitive to threat in keeping with over-controlled• Insensitive to reward

– performing, achieving value

• Mask emotions• Suspicious of

– self-disclosure– ‘intimacy bids’

• Lynch & Cheavens(2008). Dialectical behavior therapy for co-morbid personality disorders. Journal of Clinical Psychology, 64, 1- 14.

Cohort 1: Lessons learned

• Participants may lean towards over- rather than under- controlled– may explain DBT outcomes

• Participants reported feeling scared, desperate and angry during early sessions: creative hopelessness

• Limited ability to tolerate individual process work– discomfort, dissociation

• Extreme construing– DBT = bad, ACT = good– diving in head first rather than dipping toe in the water

• Values work prompted shame, regret, hopelessness• Didn’t appear to get RFT or self as context

Participants 2nd Cohort:

PD and Depression

Total PD Diagnoses PD diagnoses BDI-II

7 2 BPD, OCD PD 15 (Mild)

8 4 BPD, Avoidant, Dependent, Depressive 40 (Severe)

9 5 BPD, Paranoid, OCD PD, Pass-Agg, Depressive 36 (Severe)

10 1 BPD 40 (Severe)

11 5 BPD, Avoidant, Dependent, Schizptypal, Antisocial 21 (Moderate)

     

Mean: 3.4  30.4 (Severe)

Adaptations 2nd cohort DBT graduates contin.

• Strengthen support further– 20 – 24 group sessions– 3+ individual sessions– telephone coaching– 1 month, 3 month and 6 month f/up

• Lighter touch for creative hopelessness– specifically linked to DBT skills– acceptance and change– noticing

• bias• short- long-term effectiveness

Adaptations 2nd cohort DBT graduates contin.

• Mindfulness– external / internal shaped– linked to teaching content

• mindful of – level of distress – grounding required

• Defusion as 1st ACT skill– 3 sessions

Adaptations 2nd cohort DBT graduates contin.

• Facilitate transition from DBT to ACT = DBT– Weekly monitoring of ACT skills on dairy

card• diffusion skills• valued action• observing self

Adaptations 2nd cohort DBT graduates contin

• Building capacity to mindfully choose• Crisis survival skills for discrete, short-term

crisis– to ground and steady

• Willingness / engagement – for chronic difficulties – in service of values

Adaptations 2nd cohort DBT graduates contin.

• Further shaping tolerance of difficult experience– eyes closed, paired, then group feedback

• RFT light– Impact of language– Impact of evolution

Adaptations 2nd cohort DBT graduates contin.

• Multiple exemplars of self-as-context exercises

• gestalt old/young woman picture• use of actual chess board• mountain meditation

copyright Thomas R. Lynch

Adaptations 2nd cohort DBT graduates contin.

• Invitation to focus on less challenging life domain when addressing values

• Shaping up commitment to valued action– commitment off the table initially– tiny steps when planning valued action– normalizing process of commitment and re-

commitment

Adaptations 2nd cohort DBT graduates contin.

Style• More limited 1-to-1 interventions

– stepping back from stirring material earlier – less intimate/personal therapist style

• Monitoring impact of– emotionally evocative content– self-disclosure

• invalidating or threatening– therapeutic style

• Adjusting presence

Unstructured Interviews 2nd Cohort• Helpful

– Didactic• Handouts• Mindfulness CDs• DBT refresher / integration

– ACT skills• diary card

– Encouragement to take small steps

– Permission seeking– Being part of a group

• full participation• closed

– Pace and length

• Unhelpful – Homework

• challenging

5/5 recommendation

Lessons to be learned

• Attachment to DBT as a life saver– Love’s Executioner Yalom– non-traumatic, gentle disillusionment

• Respect of DBT dialectic– acceptance and change– wise mind choices

• emotion and life

Lessons to be learned contin.

• Build on DBT framework– group, individual, telephone coaching– monitor ACT skills

Lessons to be learned contin.

• Start from where your participants are• intensity, intimacy and pacing

• DBT graduates not necessarily BPD– under and over-controlled– BPDs not necessarily under-controlled

• Offer good questions concerning effectiveness rather than solutions

– encourage ownership– use group process

• individual, pairs, group

Lessons to be learned contin.

• Adjust– content emotionally evocative interventions– therapist’s presence

• slowing down, focussing• self involving self disclosure• intimacy

Lessons to be learned contin.

• Monitor individual outcomes– post and follow-up– monitor what works for whom

• Be flexible and be willing!

Thank You!

susan.clarke@dhuft.nhs.uk

ParticipantsInclude• PD diagnosis (SCID-II)• Minimum 12 months DBT• No parasuicidal behaviour for minimum 6 months• Significant, ongoing mental health problems Exclude• current psychosis• eating disorders BMI < 17.5• DSM-IV diagnostic criteria for substance dependence

2 x groups of 6 - 10 participants