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.
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
Dialectical Behavioral Therapy 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. Originally created for treatment of symptoms of Borderline Personality Disorder, Primarily suicide and self-harm Has been modified for a variety of treatment settings A bio/psycho/social model that builds on traditional behavioral approaches Uses group work (skills training), individual therapy and self- monitoring to change target behaviors. Provides support for clinicians to be able to work with a difficult population.
DBT as Evidence Based Practice DBT vs TAU comparison group DBT had higher global functioning scales DBT had fewer parasuicidal (self-injurious) behaviors DBT had fewer psychiatric inpatient days Multiple Randomized Control Trials and Meta-Analyses Conducted Two separate meta-analysis reviewed effect sizes Evidence strongest for Suicidal Behaviors/Attempts, Self-Injury, Dropout Conflicting evidence for Axis I conditions – depression, anxiety, bi-polar Counterindicated for schizophrenia/psychosis, developmental delays, manic episodes Replicated across treatment conditions and different treatment manuals Substance Abuse (DBT-S) Eating Disorders Inpatient Settings, Forensics & Older Adults - not supported by RCT Evidence for clinicians Reduces clinician drop-out and clinician burnout
DBT requires fidelity DBT is a Manualized Treatment Program requiring treatment fidelity Use of Linehan DBT treatment manual (others have not been tested) Intensive training for providers Must use all four components Individual Therapy Skills Training Group 24 Hour access to skills coaching Consultation Team for providers Can only claim to be doing DBT with all of these components Skills training alone does not constitute DBT as an EBP “DBT Light” No consultation or fidelity checks required to implement program
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)
Stages of Treatment Stage I Treatment Stage IV Life Threatening Behavior Incompleteness Therapy Interferring Behavior Life Interferring Behaviors Stage III Quiet DesperationProblems in Living Inhibited Grieving Re-Learning to Experience Stage II EmotionsQuiet Desperation 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
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 Radical Acceptance One mindfully Willingness vs. Effectively Willfulness Non-Judgementally Turning the Mind
DBT Group SkillsInterpersonalEffectiveness Emotional Regulation DEAR MAN Model for Describing To make requests Emotions GIVE Check the Facts To maintain relationship ABC Please FAST To maintain self-respect Mindfulness of Emotions Intensity and Options for Opposite Action Asking Brainstorming and Provides Middle Ground for when, how and if to ask Problem solving
To complete the full program For DBT fidelity, clients must: Be able to develop “behavioral” goals Participate in weekly individual therapy Attend group sessions for minimum of 6 months It is recommended that clients repeat and do two rounds for a year of time Complete diary cards on a daily basis Commit to creating a “life worth living”
DBT for children Appropriate for children? DBT requires insight, impulse control and ability to notice and control one’s thought patterns Children under 10-12 years old have not yet developed necessary skills No treatment manual with differing literacy levels Modified treatment manuals (those using images rather than text) have limited evidence as to their use Perepletchikova, F. Axelrod, S.R., Kaufman, J., Rounsaville, B.J., Douglas, H., & Miller, A.L. (2011). Adapting dialectical behaviour therapy for children: Toward a new research agenda for pediatric suicidal and non-suicidal self-injurious behaviours. Child & Adolescent Mental Health, 16,(2) 116-121. Beginning stages of creating treatment manual Very small sample Found that it may be more effective as parent training strategy than for the children themselves
DBT for adolescents Miller, A.L., Rathus, J.H., Linehan, M.M., & Swenson, C.R. (2007). Dialectical Behavioral Therapy with suicidal adolescents. New York: Guilford Press. Book about possibility of implementing DBT with adolescents Not a treatment manual Suggests different components to treatment Suggests different dialectics
Differences from standard DBTTreatment Manual Adolescent Dialectics Shorter modules Excessive Less time in treatment Leniency Force Normalize How groups are conducted Pathological Autonomy Behavior Implementation of a “Graduate Group” Pathologize Normal Foster Dependency Behaviors Involvement of the parents Authoritarian Control
Issues using DBT with adolescents No specific treatment manual Miller book primarily theory based, not like specific steps to treatment like Linehan model Cannot diagnose adolescents with BPD Personality does not stabilize until after adolescence Most “typical” adolescent behavior could be considered BPD Recent concerns with using group treatment methods with adolescents Can reinforce deviant/negative behaviors Many providers moving to Multi-Family Group, where parents are involved Not evidence based No RCT’s
Recent publications in DBT-A Klein, D.A. & Miller, A.L. (2011). Dialectical behavior therapy for suicidal adolescents. Child & Adolescent Psychiatry Clinics of North America, 20(5), 205-216. “Although research to date on dialectical behavior therapy (DBT) for adolescents has its limitations, growing evidence suggests that DBT is a promising treatment for adolescents with a range of problematic behaviors.” Backer, H.S., Miller, A.L., & van den Bosch, L.M. (2009). Dialectical beahviour therapy for adolescents; a literature review. Dutch Journal of Psychiatry, 51(1) 31-41. “There were no rcts involving dbt in adolescents, but we did find one quasi-experimental design and several other studies with a pre-post treatment design. However, the studies were difficult to compare. In some cases it was doubtful whether the treatment could still be called dbt.”
Recent publications in DBT-A Fleischhaker, et. al (2011). Dialectical Behavioral Therapy for Adolescents (DBT-A): a clinical Trial for patients with suicidal and self-injurious behavior and borderline symptoms with a one-year Follow-up. Child and Adolescent Mental Health, 28(1) 3-10. Pre-post with improvements directly related to suicide attempts One year follow up with still no attempts Only 12 participants in study, no comparison group
So what does this all mean? DBT is effective in reducing suicide and self-injurious behaviors in adults Must have fidelity to model to say using DBT DBT is not appropriate for children at this time Unlikely that it will be any time soon – work is too far out and not appropriate developmentally It is unknown if DBT is effective with adolescent population A “promising practice” Further evidence should be available in next few years, but to date, no large scale studies done