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

2. 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.

3. 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

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

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

6. Emotion Dysregulation
Emotional
Vulnerability
Inability to
Modulate Emotions

7. 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

8. What is DBT?

9. 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

10. 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)

11. 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.

12. 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)

13. 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

14. 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)

15. Structuring the Treatment

16. 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

17. 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)

18. 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

19. 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

20. 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

24. 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

25. 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

26. 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!!!

27. Any questions?