Why is it important to treat borderline personality disorder? BPD patients tend to disrupt systems, frustrate providers and cost money. A treatment was needed not only to help patients reduce problem behaviors, also helps to keep therapists working with this populationCluster B or Axis II
Looking at DBT from the five areas of dysregulation allows providers to use the skills to target each of these areas. Each of these categories relates to skills training.
BPD is a Bio/psycho/social issue. Studies using biofeedback with BPD indicate unusual patterns of emotional arousal that are different from non BPD population. This biological/chemical/genetic response to emotions in combination with family who can’t appropriately respond create confusion and chaos – collectively called Emotional Dysregulation.
Understanding of Dialectics. Because people with Borderline PD tend to see things in black and white, the concept of dialectics is one of the grounding theories of this treatment. While standard CBT incorporates thoughts and behaviors, DBT also accounts for the emotions. Validation that emotions are tied to thoughts and behaviors is one of the first concepts presented. With an understanding of the theory behind BPD, contradiction and validation are what make this treatment different.
Referrals to DBT are often broken into patient reasons and provider reasons. Patients may request it to manage strong emotions, but providers may also suggest it when patients are not benefitting from traditional therapy techniques.
DBT treatment first requires patients and therapists to define target behaviors in Stage I of treatment. Within life in hell are three areas that must be addressed in this order. By following this path, therapists are better able to control the sessions and focus on target behaviors without getting thrown off track. Stage I is currently the only stage that is well developed. Research is beginning to address treatment strategies for Stages II & III.
Refer Back to DSM Criteria
Skills can be found in DBT workbook; can use individual skills with any client – do not need full treatment to do specific skills
Amy Lopez, LCSW
What is DBT? DBT is Dialectical Behavioral Therapy. A model of therapy that uses skills training and the therapeutic relationship to manage strong emotions and behavioral dyscontrol. Although originally created for treatment of Borderline Personality Disorder, is now used in a variety of treatment settings A bio/psycho/social model that modifies traditional behavioral approaches Uses group work (skills training), individual therapy and self-monitoring to change target behaviors.
DBT as Evidence Based Practice DBT vs TAU comparison group DBT had higher global functioning scales DBT had fewer parasuicidal behaviors DBT had fewer psychiatric inpatient days At writing, at least 13 separate Randomized Control Trials Two separate meta-analysis reviewed effect sizes Current studies including RCT of DBT vs. Treatment with “Community Expert” and aftercare models Replicated across treatment conditions Substance Abuse Forensics (Correctional Facilities) Eating Disorders Adolescents Older Adults Manualized Treatment Program requiring treatment fidelity Intensive training for practioners Use Individual and Skills Group model Consultation Team
History of DBT Created to specifically “address the needs of problem behaviors within a diagnostic group.” The problem of Borderline Personality Disorders: Among completed suicides, 66% have BPD diagnosis 75% have attempted suicide and 80% self-mutilate. Multiple hospital admissions and ER visits Multiple medication trials Multiple treatment providers “The most difficult patients to treat…” BPD theory is “re-organized” into a workable and treatable framework.
Borderline Personality Disorder DSM IV Criteria: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts A pattern of intense and unstable interpersonal relationships 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 behaviors Affective Instability Chronic Feelings of Emptiness Inappropriate or uncontrollable anger Transient stress-related paranoid ideation or severe dissociative symptoms
BPD reorganized Behavioral Dysregulation Impulsive behaviors Suicidal behaviors Interpersonal Dysregulation Chaotic relationships Fears of Abandonment Cognitive Dysregulation Non-pyschotic paranoid ideation Emotional Dysregulation Affective Lability Problems with Anger Self Dysregulation Identity Disturbance “I don’t know who I am or what I can expect from myself”
Borderline Personality Disorder –Biosocial theory Emotional Chronic Invalidating Sensitivity Emotion Environment DysregulationEmotional Sensitivity: High Sensitivity and Immediate Reaction High arousal and intense body response Slow return to BaselineInvalidating Environment: Lack of appropriate response from parentsEmotion Dysregulation: Person never learns to accurately experience and express emotions, creating confusion both internally and externally
Behavior Modification Theory All behaviors have meaning If a behavior does not serve a purpose, it will no longer exist All behaviors are motivated by rewards and consequences Change to behavior is directly linked to rewards/consequences Theory is focused on outcomes, less on motivation Behavior changes first, attitudes change second Act “AS If” Can’t wait to feel better, behavior is what simulates mood change
What is Dialectics: The idea that two opposite or contradictory ideas can exist simultaneously. Emotions Behaviors Thoughts Similar to CBT and behavior modification with addition of recognition of emotion on thoughts and behaviors (and VALIDATION of emotion)
Who is appropriate for DBT? Strong Emotions Previous Treatment Difficulty with “Failures” (note – relationships patients cannot “fail” Behavioral problems DBT). High users of system Difficulty managing own thoughts resources Inpatient stays ER visits A desire to have a life worth living
Commitment Strategies DBT is MOST effective when Prior to engaging client in used as the full model treatment, client must be: Individual treatment Ready and willing to make Skills training changes Crisis intervention Agree to year long Therapist consultation commitment Willing to engage in a partnership with therapist Full model requires a big Willing to do things differently commitment: than they have always done. 6-12 months of Able to define problems Weekly individual sessions behaviorally Weekly skills training DBT stages of treatment as a Homework house Daily diary card use Pre-treatment – still standing outside
Stages of Treatment Stage I Treatment Life Threatening Behavior Stage IV Therapy Interferring Incompleteness Behavior Stage III Life Interferring Behaviors Problems in Living Quiet Desperation Inhibited Grieving Stage II Re-Learning to Experience Quiet Desperation Emotions Problems in Living Stage I “Ordinary Unhappiness” Life In Hell Incompleteness Capacity for Joy (Existential)
Individual Treatment Strategies Every session follows the stages of treatment: “Let’s start with your diary card.” “Any life threatening behaviors this week?” Diary cards Ways to record impulses and behaviors Rewards for using skills Transitional Object – continues relationship outside office Behavior Chains Maps out rewards/consequences of certain behaviors Focused way for therapist and client to think about behaviors Can serve as negative reinforcement… Skills Review and in-session practice for life situations Role play skills for life situations Problem solving Therapist as participant Observes and addresses violations of personal boundaries Offers opinion, disappointment, uses relationship as both reward and consequence Allows patient to express all emotions, re-teach appropriate emotional response through relationship Middle ground solutions to dialectical dilemmas
Defining Problems Behaviorally When developing target goals, define problem behavior that is to be changed: A Behavioral Excess? Too much of a behavior Drinking, cutting, stealing, acts of violence A Behavioral Deficit? Too little of a behavior Social isolation, exercise Faulty Stimulus control? Appropriate behavior, but wrong context Anger outbursts Describe the Behavior Specifically How often In what context Intensity Duration Will be used to develop diary cards
Dialectical DilemmasBorderline Personality Adolescents Excessive Emotional Leniency Vulnerabilities Force Normalize Unrelenting Active Crises Passivity Autonomy Pathological Midd Behavior le Grou nd Pathologize Apparent Inhibited Foster Competence Grieving Normal Dependency Behaviors Self- Authoritarian Invalidation Control
Group Skills Training Skills Training – NOT Group therapy In CONJUNCTION with individual therapy – the two compliment each other. Serves purpose of: Skill Acquisition Skills Strengthening Skills Generalization Builds relationship with skills groups leaders through therapist modeling and reinforcement of skills.
DBT Group SkillsMindfulness Skills Distress Tolerance Skills Wise Mind Wise Mind ACCEPTS The intersection of Emotion Improve the Moment and Rational Mind Self-Soothe The What and How Skills Pros/Cons Observe Breathing Exercises Describe Half-Smile Participate One mindfully Radical Acceptance Effectively Willingness vs. Willfulness Non-Judgementally Turning the Mind
DBT Group SkillsInterpersonal Effectiveness Emotional Regulation DEAR MAN Model for Describing To make requests Emotions GIVE Check the Facts To maintain relationship ABC Please FAST Mindfulness of Emotions To maintain self-respect Opposite Action Intensity and Options for Brainstorming and Problem Asking solving Provides Middle Ground for when, how and if to ask