Dialectical Behaviour Therapy (DBT) Dr Amanda Wildgoose Consultant Clinical Psychologist/ DBT Lead (MAP CAG)

The Evidence Base DBT currently has 16 RCTs and numerous published quasi experimental and uncontrolled studies. All studies demonstrate that DBT reduces suicidal behaviour, self-harm and hospitalisations and leads to an increase in global functioning. Many studies also demonstrate a reduction in comorbid substance misuse, eating difficulties, anger, hopelessness, impulsivity and depression. NICE Guidelines recommend DBT in the first instance for clients with BPD, for whom reducing self-harm is a priority.

Efficiency & costs of DBT v TAU Studies looking at health economic data have determined that the cost for DBT is approximately 50% of TAU Significantly fewer inpatient days Fewer and less severe episodes of intentional self-injury Fewer A&E attendances Less therapy dropout

Bio-Social Theory DBT views BPD as resulting from a pervasive dysfunction of the emotion regulation system

BIOSOCIAL THEORY Biological component BIOLOGICAL DYSFUNCTION in the EMOTION REGULATION SYSTEM Social component INVALIDATING ENVIRONMENT PERVASIVE EMOTION DYSREGULATION

Emotion Dysregulation Emotional Vulnerability Inability to Modulate Emotions

Emotion dysregulation Intense Response to ES Emotional Stimuli High sensitivity to ES Slow return to baseline Emotional Response Cannot up-regulate physiological arousal when needed Cannot turn away from ES Cannot control impulsive behaviour related to strong negative affects Cannot work towards non mood dependent activity Information processing distorted/ dysregulated SHUTS DOWN

What is DBT?

5 Functions of Comprehensive Treatment: Enhance capabilities Improve motivational factors Assure generalisation to natural environment Enhance therapist capabilities and motivation to treat effectively Structure the environment

Enhancing capabilities Function: Acquisition of new cognitive, emotional/ physiological and overt behavioural response repertoires Integration of response repertoires for effective performance DBT Modes: Skills training Psychoeducation (individual therapy)

Improving Motivation Function: Contingency clarification and strengthening of clinical progress Reduction of inhibiting and/or interfering: emotions/physiological responses, cognitions/cognitive style, overt behaviours and/or environmental events Modes: Individual therapy: Contingency management, extinction, exposure/response prevention, cognitive modification etc.

Ensuring Generalisation to Natural Environment Function: Transfer of skilful response repertoire to natural environment Integration of skilful responses within changing natural environments to achieve effective performance Modes: Telephone consultation In vivo interventions Systemic interventions (e.g. 12-week ‘Family Connections’ group for carers/family)

Enhancing Therapist Capabilities and Motivation Function: Acquisition, integration and generalisation of cognitive, emotional, and behavioural repertoires for effective application of treatment Strengthening of therapeutic responses and reduction of responses that inhibit and/or interfere with effective application of treatment Modes: Weekly therapist consultation meetings Supervision (incl. adherence and competency rating) Continuing professional development/training

Structuring the Environment Function: Contingency management within the treatment program as a whole Contingency management within the community Modes: Care coordination(environmental intervention) System interventions (e.g. couples work, staff training and support in hostels)

Structuring the Treatment

Pre-Treatment Goals and Targets Agreement on goals: Commitment to change Initial targets of treatment Agreement to recommended treatment: Client agreements Therapist agreements 3. Agreement to therapist-client relationship

Pre-treatment 3-6 sessions Identify goals (be specific) Assess past behaviour (target relevant behaviours – parasuicide, substance misuse, therapy interfering behaviour etc) Weave in orienting (biosocial theory, targets, modes, diary card etc) Weave in commitment strategies throughout Develop relationship throughout Orient to treatment (behavioural analysis, solution rehearsal – taster session, personal limits) Commitment strengthening (re treatment and goals)

Therapy Target Hierarchy Severe Behavioural Dyscontrol Behavioural Control Decrease: Life-threatening behaviours Therapy-interfering behaviours Quality-of-life interfering behaviours Increase behavioural skills: Core mindfulness Interpersonal effectiveness Emotion regulation Distress tolerance Self-management

Criteria for PE protocol for comorbid PTSD Not at imminent risk of suicide/life threatening behaviour (no self-harm for 8 weeks) No serious TIB; client and therapist are actively engaged in treatment Ability to experience intense emotion without functional or dysfunctional escaping Ability to come into contact with cues for higher-priority behaviours (e.g. self-harm/suicide attempt) without engaging in those behaviours Knows and uses sufficient skills It is the client’s goal to target PTSD now

Individual Session Structure Review diary card Check in on other aspects of treatment Set agenda according to target hierarchy Identify a specific instance of a target relevant problem behaviour (topography, frequency, intensity and duration) Do a behavioural chain analysis Perform a solution analysis Rehearse some new behaviour, plan generalization and ask for commitment to it, troubleshoot obstacles Notify of session ending, plan for next session, wind down

Skills Group Structure Weekly 2 hour group: Homework review—round robin with skills leader taking feedback Break New skill taught Use of active teaching style Provide rationale for skills Get “buy in” and examples of how new skills might be useful Teach skills Pull out new behaviour Set homework Get a commitment to do homework, troubleshoot any difficulties

Goals of Skills Training Behaviours to Increase: Behaviours to Decrease: Mindfulness skills Identity confusion Emptiness Cognitive dysregulation Interpersonal skills Interpersonal chaos Fears of abandonment Emotion Regulation skills Labile affect Difficulties with anger Distress Tolerance Impulsive behaviours Suicide threats Parasuicide

Function of weekly consultation team Help with formulation and difficulties encountered in applying the treatment adherently Education Empathy and support To keep team motivated and away from burnout For validation As your own treatment community to deal with your own “process issues” arising in the relationship To help you use your own DBT skills To share SUCCESSES!!!

Any questions?