Dialectical Behavior Therapy – Adaptation for Family Physicians

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Dialectical Behavior Therapy Adaptation for
Family Physicians
Shelley McMain, PhD, C. Psych Head, BPD
Clinic Centre for Addiction and Mental Health and
Department of Psychiatry University of Toronto
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Objectives

• Be familiar with DBTs biosocial theory of BPD
• Identify two core DBT strategies used to
  effectively engage individuals with BPD
• Be familiar with strategies to reduce burnout and
  enhance self care

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BPD Diagnosis

• Personality Disorder
• enduring pattern of inflexible and maladaptive
  traits which causes impairment or distress
• arbitrary cutoff between BPD and traits 5/9
• utility of diagnosis
• diagnosis not made by your own reaction to the
  patient

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Dialectical Behavior Therapy

• Standard DBT is a comprehensive, multimodal
  treatment originally developed for people with
  BPD
• DBT has been adapted for various patient
  populations and across a variety of settings
• Any professional can implement selected
  strategies

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Vignette 1

• 42 year old single woman with chronic suicidal
  and self harm behavior
• Tx history includes numerous psychotropic
  medications, lengthy hospital stays and repeated
  ER visits, lengthy history of psychosocial
  treatments
• Patient frequently presents in a state of
  emotional often angrily demanding more time and
  additional appointments

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Clinical Consideration

• How do you understand this patients problems?
• If you believe that this patient meets criteria
  for BPD, should you discuss the diagnosis?
• How should you engage this patient?

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Etiology of BPDDBTs Bisosocial Theory
Emotion Modulation Deficits
High Emotion Vulnerability
Problematic Behaviours (e.g. suicide, substance
use)
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DBTs Biosocial Theory
Fruzzetti et al, 2005
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Educate Patients about BPD diagnosis

• Helps to de-stigmatize diagnosis
• Helps to increase hopefulness about possibility
  for change
• Encourages active participation in treatment
  planning
• Education about the diagnosis has been shown to
  reduce symptoms (Zanarini,2008)

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Adopt a Clear Treatment Structure

• Establish a treatment contract clarify your
  roles, responsibilities, treatment goals
• Clarify structure of appointments frequency of
  appointments, expectations about attendance
• Be clear about your limits and availability
• Anticipate and plan for crises
• APA, 2001

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Guidelines on Concomitant Treatments

• Treatment by more than one clinician is viable
  however good collaboration is essential (APA,
  2001).
• Someone should be identified as the primary
  clinician
• (APA, 2001 Oldhman et la., 2001 Gabbard, 2000
• Gunderson, 2001 Linehan, 2003 Kernberg, ).

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Clinical Vignette 2

• Ill kill myself if you dont get me admitted to
  the hospital for the weekend
• Patients parting words to therapist who
  indicated that she didnt think that
  hospitalization would be helpful

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Clinical Considerations

• Is this client being manipulative?
• How should you respond?
• If you attend to the suicide threat will you
  reinforce this behavior?
• Should she be hospitalized?

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Functions of Self-injurious Behaviour
Gunderson, 2001 adapted from Shearer, 1994b
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Opt For the Least Restrictive Safe Treatment
Setting

• Hospitalization may be iatrogenic
• Hospitalization should be viewed as a vehicle for
  maintaining safety
• Hospitalization should be considered if the risk
  of suicide outweighs the risk of inappropriate
  hospitalization
• Focus on helping patients cope in their natural
  environment

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Validate and Emphasize Patient Control

• Move flexibly from validating kernal of truth and
  helping patient take responsibility (APA, 2001)
• Dont rush in and take care of patient
• Dont reinforce dysfunctional behavior with extra
  attention (i.e., avoid scheduling extra
  appointments in response to self-harm)
• Validate patients capability of behaving
  reasonably

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Validation

• Why Validate?
• an essential need of people with BPD
• the only way to build alliance
• reduces distress
• reduces polarization
• a prerequisite for cooperation

• How to Validate?
• listen, reflect
• make educated guesses at what shes not saying
  (read her thoughts and emotions)
• normalise
• remember where shes coming from
• find what is valid, right or understandable

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Encourage Effective Coping

• Always start by validating AND then
  paradoxically
• Cheerlead - validate her strength and ability to
  cope/survive
• 2. Reinforce progress towards goal - reinforce
  the small steps
• 3. Negotiate - offer the options you are willing
  to offer and have clear limits
• 4. Suggest alternatives to the behaviour if
  possible

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Vignette 3

• Thinking of your patient or seeing your patient
  evokes the following response
• hope that shell get admitted to hospital
• relief when she cancels
• daydreaming about transferring her care
• Wish that youd chosen another career
• feeling angry or irritated with her (comments to
  office staff)

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Reducing Burnout

• Validate yourself since stress is understandable
• Validate your patient remind yourself of why
  she is doing the best she can
• Seek support from colleagues
• Assume responsibility for observing your personal
  limits

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Observing Your Personal Limits

• Monitor your limits with your patients
• Be honest with yourself and clear with your
  patients about your limits
• Observing limits is different than setting
  boundaries
• When your client exceeds your limits, validate
  and problem-solve
• negotiate a better arrangement for yourself (more
  resources for the patient?)

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Summary

• DBTs biosocial theoretical model can increase
  understanding of symptoms.
• Educate patients about the diagnosis
• Treatment should be well structured
• Emphasis on validation in addition to helping the
  client control behavior
• Observe your limits and get support