Is It DBT Implementing Comprehensive Dialectical Behavior Therapy in the Community

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Is It DBT? Implementing Comprehensive
Dialectical Behavior Therapy in the Community 
Ronda Oswalt Reitz, Ph.D. Spring Training
Institute Tan-Tar-A Resort and Conference
Center May 14, 2008
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Dialectical Behavior Therapy Making it Work
in Our Communities 
Ronda Oswalt Reitz, Ph.D. Joplin, St. Louis,
Kansas City, and Cape Girardeau
Missouri Winter-Spring 2008
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• Helping people find lives worth living through
  relentless compassion and effective behavior
  change strategies.

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Research Support

• 1. DBT vs TAU with chronically suicidal
• BPD women (1991, 1992, 1993, 1994
• RCT)
• 2. DBT vs TAU for BPD Substance Abusers
• (1991 RCT)
• 3. DBT vs TAU with female Veterans
• diagnosed with BPD (2001 RCT)
• 4. DBT vs TAU with suicide and self- harming
  behaviors (1998
• Matched Control Design)

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Research Support Cont.

• 5. DBT vs TAU for suicidal adolescents
• (1996 Parallel Controlled Trial)
• 6. DBT vs TAU for Forensic Inpatients
• (1996 Parallel Controlled Trial)
• 7. DBT vs Wait List for an inpatient
• BPD population (2002 Waiting
• List Controlled Trial)
• 8. DBT vs Non-behavioral Treatment by
• Experts in the Community (in progress
• RCT)

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Research Support Cont

• 9. DBT vs Comprehensive Validation
• with BPD Heroin Addicts (NIDA 3)
• 10.DBT vs TAU for BPD Inpatients
• (1993 Non-randomized Clinical
• Trial)
• 11. DBT vs TAU for Incarcerated
• Juvenile Offenders (2002 Parallel
• Control Group)

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Applications of DBT

• BPD Outpatients
• Inpatients
• Substance Abusers
• Geriatric Depressed
• Bulimic College Women
• Intensive Outpatient
• Veterans
• Adolescents

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Inclusionary Criteria

• Individuals with significant mood and behavioral
  dysregulation that would benefit from skill
  training in any of the following areas
• 1. Attention/Concentration
• 2. Interpersonal Effectiveness
• 3. Emotion Regulation
• 4. Distress Tolerance

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What is BPD?

• Nine DSM Criteriathe only diagnosis that
  includes self-harm as a criteria.
• Historically considered as an excess of
  aggression disorder.
• Evolved into a disorder about which treaters
  became hopeless, burned out.
• Now viewed as a relative of mood disorders

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BPD is Common

• 11 of psychiatric outpatients meet DSM-IV
  criteria for BPD
• 19 of psychiatric inpatients meet criteria
• 33 of personality-disordered outpatients meet
  criteria
• 63 of personality-disordered inpatients meet
  criteria
• 74 of BPD population is female

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BPD is often Lethal

• 70-75 have a history of at least one
  self-injurious act
• Suicide rates for BPD are 9
• Those with history of self-injurious behavior
  have at least double the risk of completed suicide

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BPD is Expensive

• One Year Health Care Costs Per Patient
• Estimated for Treatment as Usual (TAU)
• Individual Psychotherapy 2,915
• Group Psychotherapy 147
• Day Treatment 876
• Emergency Room Care 56
• Psychiatric Inpatient Days 12,008
• Medical Inpatient Days 1,094
• 17,609

Behavioral Tech, LLC 2003
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DBT Reduces Symptoms

• When compared to TAU, DBT significantly reduced
• Frequency of self-harm behaviors
• The severity of self-harm behaviors
• Treatment drop-out
• Inpatient psychiatric days
• (Linehan, Armstrong, Suarez, Allmon, Heard,
  1991)

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DBT Reduces Costs (A LOT!)

• TAU DBT
• Individual Psychotherapy 2,915 3,885
• Group Psychotherapy 147 1,514
• Day Treatment 876 11
• Psychiatric Inpatient Days 12,008 2,614
• Medical Inpatient Days 1,094 360
• 17,609 8,610

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The Dialectical Behavior TherapyApproach to
Treatment

• Applies research about emotions and their
  management to treatment.
• Based heavily upon principles of behavior
  therapy, cognitive therapy, and Zen practices.
• A stages of treatment model with hierarchies of
  targets at each stage.

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Emotional Vulnerability

• High Emotional Sensitivity
• Immediate reaction
• Low threshold for emotional arousal
• High Emotional Reactivity
• Extreme reaction
• Hard to think clearly
• Slow Return to Baseline
• Long-lasting reactions
• Sensitized before next event

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A Disorder of Dysregulation

• Emotional Dysregulation
• Interpersonal Dysregulation
• Self Dysregulation
• Cognitive Dysregulation
• Behavioral Dysregulation

• Rapidly shifting feelings and moods Problems with
  anger
• Chaotic relationships fear of being left
  alone/abandoned
• Fluctuating or absent sense of self sense of
  emptiness
• Dissociation
• paranoid thinking/over-personalization
• Self-harm behaviors
• impulsive behaviors

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The Biosocial Model
Biological Mood Sensitivity
Invalidating Learning Environment .
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(No Transcript)
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Emotional Dysregulation
Active Passivity
Unrelenting Crisis
Inhibited Grieving
Apparent Competence
Self-Invalidation
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• What Makes DBT Work???

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Five Functions of a Comprehensive Treatment

• Structuring the Environment
• Enhancing client capabilities
• Generalizing skills to the natural environment
• Improving client motivation
• Enhancing the capabilities and improving the
  motivation of staff

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What Makes DBT Work?
Dialectics Helping clients find true balance
in BothAnd emotion, thoughts, and
behavior and/or
choices. Teaching them, as well as
showing them how live in balance.
Validation Acknowledging another
persons reality, YesAnd noting that
their thoughts, feelings, sensations, and
responses are real, and are valid in their
own right.
Practice, Practice, Practice
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The Fundamental Dialectic
Acceptance
Change
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Levels of Validation

• Staying awake
• 2. Accurate reflection
• 3. Stating the unstated
• 4. Validation in terms of history
• or biological dysfunction
• Validation in terms of present
• context or normative functioning
• 6. Radical genuineness

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What About When Its Impossible?

• Client is a surly, venomous, snarling ball of
  hatred and is assaultive.
• Client has seriously injured a staff member or a
  peer.
• Client argues with every point you make.
• Client appears to agree, then re-engages is the
  same behavior, over and over and over.

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Validate

• The clients emotional experience
• The clients cognitive state at the time
• The clients secret longings (Chief Hope)
• To belong to someone without question
• To connect with someone in a real way
• To be seen as worthy by others
• To be respected by peers
• To be a person who might someday walk upon the
  earth without shame

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When in doubt
VALIDATE!
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Four Components of DBT

• Individual DBT-based treatment
• One hour per week
• Group Skills Training
• Two hours per week
• Skills Coaching
• Limited by individual therapist
• Consultation Team
• Two hours per week

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Individual Therapy Protocol

• Hierarchy
• Structure

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Treatment Hierarchy

• Harm to self/others (behaviors, urges, thoughts)
• Therapy interfering behavior
• Severe quality of life interfering behaviors
• Skills training

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Structure of Sessions

• Warm, genuine greeting
• Request for diary card
• If no diarybehavior chain and complete card.
• Review diary card.
• Address hierarchy in order
• Reinforce with free time at end of session

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Generalization/Coaching

• 24/7 availability by individual provider
• Provider observes limits
• Provider manages limits
• Provider has back up 24/7
• Team members support each other
• in managing limits
• Coaching calls are very brief and do not solve
  the problem

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Group Skills Training

• 2.5 Hours per week
• Two providers
• Mindfulness
• Diary Card Review
• Homework Review
• Break
• Teaching
• Wind Down

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Core Mindfulness

• Extending attention and concentration
• Learning to direct focus to internal experience
  and to tolerate it for extended periods of time.
• Honoring naturally arising experience as real,
  logical, and understandable.
• What Skills Observe, Describe, and
  Participate.
• How Skills One Mindfully, Non-Judgmental
  Stance, and Effectively.

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Interpersonal Effectiveness

• Evaluate values relative to interpersonal
  interactionswhat are my goals, beyond this
  moment?
• Develop a skill set for making decisions in
  difficult situations.
• Learning to effectively make requests and refuse
  the requests of others.
• Objectives Effectiveness DEARMAN
• Relationship Effectiveness GIVE
• Self Respect Effectiveness FAST

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Emotion Regulation

• Increase non-mood-dependent decisions to improve
  movement toward long-term goals.
• Understanding ones own emotions and developing a
  language to express them.
• Prevent mood variabilityreduce vulnerability to
  Emotion Mind (Please Mastery)
• Increase positive emotion events
• Decrease emotional suffering

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Distress Tolerance

• When problems can not be solved immediately,
  tolerating the distress without making the
  situation worse.
• Crisis Survival Skills distracting self,
  self-soothe with the five senses, improve the
  moment, and pros and cons.
• Reality Acceptance Skills breathing exercises,
  half-smile, awareness exercises, radical
  acceptance, turning the mind, and willingness.

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DBT assumes

• that effective treatment must pay as much
  attention to the therapists behavior and
  experience in therapy as it does to the clients.

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DBT Consultation Team

• A community of therapists treating a community of
  clients.
• A community of therapists
• treating each other.

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Certification and Accreditation

• MML refused to initiate the process
• DBT adaptations proliferated
• WA State public health and private insurance
  providers threatened to establish their own
  standards
• MML initiated a workgroup via BTECH
• National/International standards underway

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Missouri DBT Initiative

• Concurrent with Transformation Grant efforts to
  make empirically supported treatments standard
  and available in the community.
• DMH collaboration with community providers to
  raise the capacity of communities to effectively
  treat Borderline Personality Disordered and other
  mood/behaviorally dysregulated populations.

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Goals

• Provision of DBT training to community providers
  across settings
• To establish state standards of practice that
  will guide consumers and funding sources in
  selecting providers
• To develop a funding base for sustained
  programming into the future
• Establish high quality services in select areas

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Adopt? Or Adapt?

• 1.Modifications may not work as well as the
  standard model (e.g., is a little DBT better than
  none?)
• 2. Untested modifications complicate informed
  consent.
• 3. Untested modifications may not be funded.
• 4. Adapting DBT can heighten risk and legal
  liability.

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Finding a Dialectical Synthesis

• Accept the reality that the tension between the
  ideal of perfect adherence and living in the
  real world will always be present.
• Rather than abandoning DBT or shoehorning it
  uncomfortably into a setting, insist that any
  solutions include the truth of both positions.

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Guidelines
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• Start where you are, but KNOW where you are
  going.
• DBT Informed the intent is to significantly
  anchor adoption or adaptation in DBTs treatment
  principles, strategies, and modes.
• Technical Eclecticism one selectively adds
  elements of DBT to his or her therapeutic
  toolkit.
• Haphazard Adaptations environmental pressures
  push choices away from adherence in an unplanned
  manner.

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• If you decide NOT to implement comprehensive DBT
• Accurately describe your program to the public.
• Collect data on your outcomes so you can obtain
  informed consent for treatment.
• Provide information about how your program
  differs from comprehensive DBT.

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Implementing Standard DBT

• Begin with a small pilot program
• Spend time studying the standard model and
  planning your program before implementing
  treatment elements.

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Questions to Address

• Who will you treat?
• Who will to exclude from treatment?
• Consider the 5 functions when barriers to modes
  arise, generate creative alternatives.
• How will we manage suicidal clients in the
  community?
• How will we address conflicts in authority over
  care in our system?
• Does our treatment attendance policy conflict
  with DBT?
• How will we manage the staffing demands of 2
  co-leaders in group, the consultation team, and
  after hours on-call duty?
• How will we integrate new members on team?

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Maintain an Open Attitude

• Ask for help!
• Have experts evaluate your program.
• Expect that outcomes will result in continuous
  change.

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Further Resources

• ronda.reitz_at_dmh.mo.gov
• Behavioraltech.org
• See Client and Clinician Materials
• See Products and Links
• See Trainers and Consultants Tab
• Alec Miller Adolescents
• Tom Lynch Elderly
• Randy Wolbert ACT/DBT
• Linda Dimeff Substance Abuse
• Kate Comtois DBT and Work
• Alan Fruzetti DBT and Families

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• Books
• 1. Linehan, Marsha M. (1993). Cognitive
  Behavioral Treatment of Borderline Personality
  Disorder. Guilford Press, New York.
• 2. Linehan, Marsha M. (1993). Skills Training
  Manual for Treating Borderline Personality
  Disorder. Guilford Press, New York.
• 3. Miller, A., Rathus, J. Linehan, Marsha M.
  (2007). Dialectical Behavior Therapy with
  Suicidal Adolescents. Guilford, New York.
• 4. Dimeff, L. Koerner, K. (Eds) (2007).
  Dialectical Behavior Therapy in Clinical
  Practice. Guilford, New York.