Dialectic Behavioral Therapy: Treatment Efficacy in Clinical Settings A Torrance Experience

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Dialectic Behavioral Therapy Treatment
Efficacy in Clinical Settings A Torrance
Experience

• Edna I. McCutcheon, ACSW
• Safdar I. Chaudhary, MD

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Objectives

• A brief overview of Dialectic Behavior Therapy (
  DBT)
• Potential clinical/practical implications for
  Western Pennsylvania counties served by Torrance
  State Hospital.
• Educational Training Collaborative
  Opportunities Between Torrance State Hospital and
  affiliated counties

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Art of Healing
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A brief overview of DBT Initiative
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Making a Difference

• In the lives of people we serve
• Those who administer programming for their
  counties
• Effectiveness and demonstrating outcomes
• Collaborating rather than competing
• The budget we can sustain

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Working together

• Surviving together
• Healing Together
• Growing Together

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Changing clinical paradigm

• Changing nature of our patients with various
  disorders
• Increasingly difficult to treat symptoms
• Complex cases
• Striving for coordination of care
• Increasing need to collaborate than ever before.
• Working together essential rather than an optional

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My Story

• Wellness, Empowerment and Recovery

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A Case study to Illustrate DBT effectiveness at
Torrance

• Effect over time for patient care and effective
  management.

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What is DBT ?

• A form of treatment with practical comprehensive
  approach for difficult to treat psychiatric and
  substance abuse disorders.
• Very strong emphasis on the sanity of clinicians
  treating such disorders.

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Dialectical Behavioral Therapy (DBT)

• Developed by Marsha Linehan, PhD from the
  University of Washington specifically to treat
  this population

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DBT Skills Training

• Mindfulness
• Distress Tolerance
• Interpersonal Effectiveness
• Emotion Regulation

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Five Functions of Comprehensive Treatment

• 1. Enhance capabilities (skills training and
  meds)
• 2. Improve motivational factors (what matters to
  patient)
• 3. Assure generalization to natural environment
  (Role Play, Coaching, Case Management)
• 4. Enhance therapist capabilities and motivation
  to treat effectively (Involve staff in a positive
  way, reduce staff responses that inhibit
  effective skills applications by patient)
• 5. Structure the environment (Institutions tend
  to reinforce institutional behaviors)

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Philosophical Assumptions

• Behavior Science Change Behavior
• Acceptance Zen Practices
• Dialectic Philosophy- Tension disagreements are
  part of lifeseek synthesis
• There is something valid in both extremes,
  validate the opposing point of view

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DBT Assumptions about therapy

• The most caring thing a therapist can do is help
  patients change in ways that bring them close to
  their own ultimate goals
• Clarity, precision, and compassion are of the
  utmost importance in the conduct of DBT
• The therapeutic relationship is a real
  relationship between equals
• Principles of behavior are universal, affecting
  therapists no less than patients.
• DBT therapists can fail
• DBT can fail even when therapist do not
• Therapists treating BPD patients need support.

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The Overarching DBT Goal is...
A LIFE Worth Living
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Medication Enhance Hardware capacity
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Software Skills learning DBT
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The Problem

• Borderline Personality Disorder

• Most common personality disorder in inpatient and
  outpatient settings
• 1 in 4 psychiatric inpts meet BPD criteria
• Occurs in 15-25 of all patients

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Typical Responses

• Neither helps the patient

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Typical Responses to those with BPD

• Over react out of sense of urgency
• Become too judgmental and non-compassionate

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DBT is Effective

• Treatment Retention
• Reducing Anger Ratings
• Reducing Depression Ratings
• Reducing Anxiety Ratings
• Reducing Positive Urine Drug Screens

• Increased Functioning (GAF)

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DBT treatment demonstration

• Mindfulness exercise

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Core Mindfulness skills States of Mind
Emotional Mind
Wise Mind
Reasonable Mind
Wise mind
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Core Mindfulness SkillsWhat Skills

• Observe Just notice the experience
• Describe Put words on experience
• Participate Enter into your experiences let
  yourself get involved in the moment letting go
  of ruminations act intuitively from wise mind
• Practice your skills

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MindfulnessHow Skills

• Non-Judgmentally See but Dont Evaluate, Unglue
  Your Opinions Accept Each Moment Acknowledge
• One-Mindfully Do one thing at a time When you
  are eating, eat When you are walking, walk
  Concentrate your mind
• Effectively Focus on what works Play by the
  rules Let go of vengeance, useless anger

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Interpersonal EffectivenessDEAR MAN

• Describe Describe the situation - Stick to the
  facts
• Express Express your feelings about the
  situation
• Assert Assert yourself by asking clearly
• Reinforce Reinforce or reward the person ahead
  of time by explaining consequences

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DEAR MAN

• Mindful Maintain your focus on your objectives,
  ignore if other person attacks, threatens or
  tires to change subject.
• Appear Confidante Be effective and competent,
  good eye contact, confident voice
• Negotiate Be willing to give to get, offer and
  ask alternative solutions. Turn the table to
  other person. What do you thing we should do ?

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Emotion Regulation

• What good are emotions ?
• Reduce vulnerabilities' to negative emotions (
  sleep, physical illness, mood altering drugs,
  lack of exercise)
• Build positive emotions. Pleasant things

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Emotion Regulation

• Letting go of emotional suffering
• Observe your emotion
• Experience your emotions as a wave coming and
  going
• Remember you are not your emotion DO not
  necessarily ACT on emotion.
• Opposite action

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Distress Tolerance

• Distract Wise Mind ACCEPTS
• Self-Soothing the five senses
• Vision
• Hearing
• Taste
• Touch
• Smell

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Distress Tolerance

• Observe your breath
• Deep breathing
• Following your breath while listing to music
• Half smiling exercises

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Why is smiles the longest word? Because there
is a mile between the first and last letters.
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Randomized Controlled Trial

• DBT vs. Treatment-As-Usual
• With Chronically Suicidal
• BPD Women
• (University of Washington)
• Linehan, et al., 1991, 1992, 1993,1994

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Initial DBT Outcome TrialOne-Year
Follow-Up(Linehan, Heard Armstrong, 1993)

• Statistically Significant Findings
• DBT Ss had higher GAS scores throughout follow-up
• DBT Ss had less parasuicidal behaviors, less
  anger, and better social adjustment during
  initial 6 months of follow-up
• DBT Ss had fewer psychiatric inpatient days and
  better interviewer-rated social adjustment during
  final six months

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One Year Health Care Costs Per Patient

• DBT TAU
• Individual Psychotherapy 3,885 2,915
• Group Psychotherapy 1,514 147
• Day Treatment 10 876
• Emergency Room Visits 226 569
• Psychiatric Inpatient Day 2,612
  12,079
• Medical Inpatient Days 360 1,096
• Total 8,607 17,682

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DBTgtTAU ns

• Pre-treatment gt 12-Month
• Depression
• Hopelessness
• Suicide Ideation

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DBTltTreatment As Usual (TAU)

• with parasuicidal
• Parasuicidal
• Medical risk of parasuicidal
• Treatment drop-outs
• Psychiatric inpatient days
• Anger
• DBTgtTAU
• Social adjustment
• Global adjustment

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Balance Core Strategies
PROBLEM SOLVING
VALIDATION
Dialectics
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DIALECTICAL
Communication
Change
Acceptance
Reciprocal
Irreverent
Problem Solving
Validation
Core
Consultation- to-the-Patient
Environmental Intervention
Team Consultation
Case Management
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Dialect

• Many meanings
• Accept patient where they are while also
  accepting the need for change
• Help patients move from rigid to more flexible
  thinking

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Emotional Dysregulation
Emotional Vulnerability

• Inability to
• Modulate Emotions

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Biosocial Theory of BPD
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Randomized Controlled Trial

• DBT vs. Treatment-as-Usual
• With BPD Substance Abusers
• University of Washington
• Linehan, Schmidt, Kanter, Craft,
• Dimeff, Comtois, McDavid, 1999

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Design RCT

• Conditions Dialectical Behavior Therapy
• (DBT)
• Treatment-As-Usual
• (TAU)
• Time Frame 1 year treatment
• 4 month follow-up
• Assessments Pre-Treatment
• 4 month
• 8 month
• 12 month (post-treatment)
• 16 month

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Outcomes
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Outcomes

• Need to be reviewed for internal and external
  purposes
• Publish and print data

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Proportion of Urinalyses (Positive) by Condition
Mean Proportion Dirty
plt.10 plt.05 plt.01
Time
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Interviewer-Assessed Proportion of DAYS USING
Drugs and Alcohol by Condition
Proportion of Days Using
plt.10 plt.05 plt.02
Time
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Percent Treatment Drop-Outs
plt.05
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Mean Number of Treatment Sessions During the Year
by Condition
Individual Psychotherapy Sessions
plt.05
Psychotherapy Sessions Counseling with a Case
Manager
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Pre-post comparison and group vs. time
differences Depression
BDI
HAMD
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Pre-post comparison and group vs. time
differences Anxiety
STAI
HAMA
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Pre-post comparison and group vs. time
differences Anger
STAXI
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Pre-post comparison and group vs. time
differences Social Integration
GAF
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GAF
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Common Psychiatric Disorders

• Mood Disorders
• Psychotic Disorders
• Anxiety Disorders
• Personality Disorders
• Addictive Disorders
• Intellectual Impairment disorders
• Dementia related disorders

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Patients with Schizophrenia and their living
arrangements
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Paradigm shift for treatment

• Setting model programs

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From Pills to Skills
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A potential collaboration Implementation of DBT

• Torrance State Hospital has successfully launched
  this modality of treatment
• DBT ( Dialectic Behavior Therapy)
• Staff being trained and successful patient
  outcomes have been demonstrated.
• Reduced recidivism
• Improved community placements
• Improved quality of life for patients and
  families

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Currently

• Limited DBT programs in many settings
• Although these patients may receive inpatient
  DBT, the continuity is lost and recidivism occurs

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Solutions

• Collaborative Effort to develop DBT Outpatient
  Program

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Solutions

• DBT telephone skills coaching
• Crisis management direction

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Solutions

• Educational Mission

• Internships
• Fellowships
• Practicum experiences
• Workshops

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Educational Training Opportunities Between
Torrance State Hospital and affiliated Counties
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Educational Initiatives

• With practical outcomes
• Sustainable treatments
• Learning state of the art scientific knowledge
• Implementing science into our clinical settings.
• Helping clinicians in trenches

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DBT information

• DBT brochure for patients
• DBT brochure for families/community/providers
• Orientation for new staff
• Material for current staff
• Survey for attitudes and feedback for treatment
  based on DBT

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Training Opportunities

• Potential for offering internships at Torrance
  State Hospital
• Aftercare need determinations
• Educational workshops for difficult to treat
  patients
• Implementing state-of-the-art best practices/care
  in affiliated counties.
• Demonstrating best practices in trenches

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Offering Workshops and hands on Trainings

• Experienced staff
• Share costs of such trainings
• Annual best practice conference hosted by all
  counties and sharing costs

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Torrance in partnerships with our educational
leadership

• Share the costs and educational needs
• Together we can make our region a state of the
  art patient care setting
• Taking charge of our destiny rather than fearing
  for tomorrow

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Lets Join Together and Serve
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Resources

• These slides, those of the other presenters
  today and other regional resources will soon be
  available at the following web site
• www.seclairer.com
• Contact information
• Edna I. McCutcheon, ACSW - 724-459-4511
  emccutcheo_at_state.pa.us
• Safdar I. Chaudhary, MD - 724-468-3999
  telephone safdar3_at_gmail.com
• - 724-468-0039 fax