FI CONINGTON CLINICAL LEAD OASIS DIALECTICAL BEHAVIOUR THERAPY.
-
Upload
nigel-huband -
Category
Documents
-
view
242 -
download
22
Transcript of FI CONINGTON CLINICAL LEAD OASIS DIALECTICAL BEHAVIOUR THERAPY.
FI CONINGTONCLINICAL LEAD OASIS
DIALECTICAL BEHAVIOUR THERAPY
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.
DSM 5 ICD-10Cluster AThe odd & eccentric
ParanoidDistrust and suspiciousness
ParanoidDistrust and sensitivity
Schizoid Socially and emotionally detached
Schizoid Emotionally cold and detached
Schizotypal :difficulty in establishing and maintaining close relationships
with others.
No equivalent
Cluster BThe
dramatic & erratic
AntisocialViolation of the rights of others
DissocialCallous disregard of others, irresponsibility and
irritability
BorderlineInstability of relationship, self-image and
mood
Emotionally UnstableA) Borderline type: unclear self-image and intense
unstable relationshipsB) Impulsive type: inability to control anger,
quarrelsome and unpredictable
HistrionicExcessive emotionality and
attention-seeking
HistrionicDramatic, egocentric and manipulative
NarcissisticGrandiose, lack of empathy, need for
admiration
No equivalent
Cluster CThe anxious
& fearful
AvoidantSocially inhibited, feelings of inadequacy,
hypersensitivity
AvoidantTense, self-conscious and hypersensitive
DependentClinging and submissive
DependentSubordinates, personal need, seeking constant
reassurance
Obsessive compulsivePerfectionist and inflexible
AnankasticIndecisive, pedantic and rigid
DBT’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 7
•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).
Presentation within care settings
Historical Context
Marsha 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 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
1. Stage Theory of Treatment2. Bio-social theory of the etiology and
maintenance of BPD3. Learning principles and ideas from
behaviour therapy4. BPD behavioural patterns and Dialectical
Dilemmas5. Dialectical Orientation to change
1. Stages of Treatment: Behaviours to target in DBT
1. Suicidal/homicidal or other imminently life-threatening behaviour
2. Therapy interfering behaviour – client and therapist
3. Quality of life interfering behaviour4. Deficits in behavioural capabilities needed
to make life changes
2. Bio-social Theory
Emotional vulnerability
Genetic/biological/neurological developmentEmotional Dysregulation
High sensitivity, Strong reactions, slow return to baseline.Invalidating environment
Fails to confirm, corroborate or verify individual.
Examples 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
3. Theory of change
Principles of learning and ideas from behaviour therapy.
Analysis of antecedents and consequencesFunctional analysis/behaviour chain analysis.
4. 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)
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
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
THE PRACTICE
DIALECTICAL BEHAVIOUR THERAPY
Outline of Treatment Programme Functions and Modes
NorthDevonDBTProgramme2011
Functions1. Enhanced Capabilities2. Improve Motivational
factors3. Assure generalisation
to natural environment
4. Structure the environment
5. Enhance therapist’s capabilities & motivation to treat effectively
Modes1. Skills Training
Group2. Individual therapy
3. Telephone, Milieu coaching
4. Organisational interactions (consult-to-client)
5. Team consultation to hold therapists inside the treatment
DBT - Overview
StructureBehaviour TherapyValidationDialecticsMindfulness
Structure the Treatment
Outpatient individual PsychotherapyOutpatients Group Skills TrainingTelephone ConsultationTherapist 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
Interpersonal Effectiveness 6 weeks
Mindfulness 2 weeks
Mindfulness 2 weeks
Emotion Regulation 6 weeks
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
Programme Outline – Stage 1One year period to include:
Weekly Group consisting of the following 6 month modules (run twice):
Structure of Group
Mindfulness exerciseDiary cards/ homework feedbackSkills trainingSetting homework
Structure of DBT service
Group trainingEach patient has an individual therapistGroup skills taught by 2 therapistsDBT consultation groupCase management strategies
Structure - Rules
Clients who drop out of therapy are out of therapyEach 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.
Case Management Strategies
Consultation-to-the patient strategyEnvironment 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
ContractsRules 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.
Chain analysis
Case illustration
Role play – behavioural analysisOn 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 observingLevel 2 – ReflectionLevel 3 – Mind ReadingLevel 4 – Validation in terms of the pastLevel 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-disclosureBy Validating the patient’s experience.
Including negative feelings about therapy Explicitly identifying such feelings
• Anticipating therapy-interfering behaviours
• Being available by phone between sessions
Dialectics
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 assessmentIntroduction to the modelEngagement and CommitmentPro’s and con’s of engaging in therapyIdentifying Target behaviours to decreaseIdentifying aims for therapyIntroduction to toolsContracting
Mindfulness
THE SKILLS
DIALECTICAL BEHAVIOUR THERAPY
Mindfulness
WHAT skills Observe Describe Participate
HOW skillsWithout judgmentIn the moment (one mindfully)Effectively
Distress Tolerence
Wise mind ACCEPTSSelf-soothingIMPROVE the momentPros 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 RelationshipsBalancing Priorities and DemandsBalancing the wants-to-shouldsBuilding mastery and self-respect
Objectiveness effectiveness Relationship effectiveness Self-respect effectivness
Radical Openess
Turning the mindRadical AcceptancePractice WillingnessNotice Willfulness
DBT - Adaptions
Different Client GroupsIndividual DBT DBT light
Pros and Cons of Adapting the model
National Research Evidence
Based on various research findings, the Department of Health
(NICE Guidelines 2009 - CG78 to be updated in 2012) hasrecommended the following for people with BorderlinePersonality Disorder:treatment that lasts at least 12-18 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
Research Findings
Linehan et al., 1991, 1993, 1994. 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.
Research Findings
Bohus et al., 2004. 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.
Research Findings
Comtois et al., 2007. 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.
Research local – evaluation procedures
• Outcomes of TreatmentOutcome measuresBehavioural 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
Discussion
Diagnosis of BPDDBT in the context of the wider Psychiatric
systemStrengths, limitations of DBT