Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from...
-
Upload
clarence-berry -
Category
Documents
-
view
217 -
download
0
Transcript of Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from...
![Page 1: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/1.jpg)
Developing an ACT-based group intervention for DBT graduates with
personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’
Sue Clarke, University of Bournemouth; Dorset HealthCare University NHS Foundation Trust
Helen Bolderston, University of Southampton Bob Remington, University of Southampton
ACBS World Conference IX, Parma, ItalyJuly 2011
![Page 2: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/2.jpg)
Acknowledgments
• Kelly Wilson• Kirsty James
![Page 3: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/3.jpg)
DBT: Development and aims
• Developed for BPD women with self-harming behaviour Linehan, et al., 1991, 1992, 1993, 1994
• BPD is a pervasive disorder of the emotional regulation system– BPD behaviours function to regulate emotions or
are a natural consequence of emotion dysregulation
• DBT aims to reduce out-of-control behaviours in the service of a ‘life worth living’
![Page 4: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/4.jpg)
DBT: Theoretical
ValidationProblem
Solving
Dialectics
Radical behaviourismMindfulnessZen
![Page 5: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/5.jpg)
DBT: Structure
• Multi-modal1. Individual - 2. Skills training groups3. Out of hours skills coaching4. DBT consultation group5. DBT team leader
• Highly structured / focussed• Treatment hierarchy
1. life threatening behaviour2. therapy interfering behaviour3. quality of life interfering behaviour
![Page 6: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/6.jpg)
DBT: Style
• Psycho-educational– Explicit– Didactic– Prescriptive– Often busy
![Page 7: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/7.jpg)
Empirical support for DBT
• Randomized Controlled Trial: DBT vs TAU with chronically suicidal BPD women Linehan, et al., 1991, 1992, 1993, 1994
• DBT reduces self-harm, suicide attempts, hospitalisation and reduces some Axis-I symptomatology in BPD Lynch et al. 2007
![Page 8: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/8.jpg)
Empirical support for DBT
• Overview of results– When used with high-risk clients BPD
• produces significant reductions in suicide attempts, self-harm, hospitalization and outperforms TAU
• but has less impact on Axis 1 disorders, and does not outperform TAU on Axis 1 variables
– When used with less risky clients• greater impact on Axis 1 disorders, and outperforms
TAU
![Page 9: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/9.jpg)
DBT: Clinical experience
• DBT graduates– report ‘quite desperation’ Linehan 1991
• living restricted lives– over-use distress tolerance skills – e.g., distraction, self
soothing
– continue to have a sense of self defined by self-harm and suicidality despite no longer engaging in those behaviours
• ACT for stage-two DBT graduates Pistorello and Clarke 2006
![Page 10: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/10.jpg)
Exercise: Why ACT?
• In pairs:• Why might ACT be a good candidate for DBT
graduates?– Theoretical– Empirical– Clinical
![Page 11: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/11.jpg)
Why ACT?
Philosophical / theoretical continuity
– Functional contextualism– Operant– Classical – Private events important– Third-wave
![Page 12: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/12.jpg)
Why ACT? Contin.
Correlational data
• EA predicts depression in BPD during and after DBT– Berking et al. 2009
• EA mediates the relationship between both negative affect intensity and childhood trauma and risk-taking behaviours Kingston, Clarke & Remington, 2010; Kingston, Clarke, Ritchie & Remington, 2011
![Page 13: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/13.jpg)
Why ACT? contin.
Outcome data
• ACT DBT hybrid with self-harming, BPD clients (N=24) Gratz & Gunderson 2006
•
– RCT 14 weeks TAU or TAU + ACT– reduction in self-harming behaviour and increases
in global indices of psychological well-being
![Page 14: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/14.jpg)
Why ACT? contin.
• ACT group for treatment resistant (TR) 50% PD
– Open trial ACT with TR (N=10) Clarke, Kingston, Remington et al (in press)
• clinically significant gains (E.S. moderate to large)
• Gain maintained 12 month f/up• Changes in follow-up scores were associated with
changes in Acceptance
– RCT ACT vs TAU with TR (N=61) Clarke, Kingston, Remington et al (in prep)
• Similar outcome and process data 12 month f/up
![Page 15: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/15.jpg)
Why ACT? contin.
Clinical
• Importance of values vs. goals
• Over-reliance on distress tolerance and mindfulness as avoidance strategies
• Specific diagnosis (BPD) vs trans-diagnostic – not all people who self harm = BPD
![Page 16: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/16.jpg)
Our aims• Participants
– Maintain behavioural stability– Improve quality of life
• Treatment Developers– Refine the treatment protocol– Trial measures– Evaluate effectiveness
![Page 17: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/17.jpg)
ACT TR Protocol• Group-based• 2 ½ hours per week for 16-weeks• “Get out of Your Mind and Into Your Life” Hayes and Smith, 2006
• Format– mindfulness exercise– homework review
– week topic: teaching and experiential– mindful review of session– homework
• Style– Kelly Wilson, 2010
• process orientated• slowing down• self-involving self-disclosure
![Page 18: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/18.jpg)
Exercise: ACT for DBT- graduates
• In pairs:• What might be in/exclusion criteria?• What ACT processes might be particularly
challenging for – participants?– therapists?
• What tensions/issues between DBT and ACT might we expect?– How might these be resolved?
![Page 19: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/19.jpg)
The HexaflexContact with the Present Moment
Defusion
Acceptance
Committed Action
Values
![Page 20: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/20.jpg)
Adaptations 1st cohort DBT-graduates• Strengthen support
– 16 - 20 weekly sessions– offer 2 individual sessions
• Maintain behaviour stability– DBT diary review
• Facilitate transition from DBT to DBT+ACT– Encourage flexible use of both ACT and DBT strategies
(including short-term avoidance strategies) rather than just ‘control is the problem’
– Two review sessions– Similarities / differences between two approaches
![Page 21: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/21.jpg)
Adaptations 1st cohort DBT-graduates• Strengthen values, committed action
– Begin lightly and end with values – Shaping valued action
• commitment off the table initially• Stylistic adaptation
– Permission seeking– Fewer emotionally evocative interventions
• e.g. ‘eyes on’ lightly• less slowing down, moving in
– Avoidance/adaptation of highly evocative content• e.g. attending your own funeral as a values exercise
![Page 22: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/22.jpg)
Cohort 1: Outcomes
• Post intervention– Using reliable and clinically significant change indicators
Jacobson & Truax, 1991
– 4 participants• improved or recovered category on at least one of BDI-II, SCL-90,
SIPP118• otherwise, no reliable change range
– 1 participant dropped out• no reliable change
– 1 participant• deteriorated category on the BDI-II and SCL-90• no change on any of the SIPP118 domains
![Page 23: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/23.jpg)
Unstructured Interviews 1st Cohort • Helpful
– Permission seeking– Normalising thought
processes– Specific exercises
• Mindfulness• Mind train, leaves on a
stream • Passengers on the bus
– Individual sessions
• Unhelpful – Too much material too
little time– Creative hopelessness
• “fear and despair,” “angry”
– DBT ACT link elaborated too late
– Emotionally evocative– Opening up issues– 6 mnth f/up too long
4/6 recommendation
![Page 24: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/24.jpg)
Participants 1st Cohort: PD and Depression
Total PD Diagnoses PD diagnoses BDI-II
1 5BPD, Paranoid, Pass-Agg, Depressive, Dependent, 28 (Moderate)
2 3 BPD, Paranoid, Pass-Agg 22 (Moderate)
3 4 BPD, Paranoid, Pass-Agg, Depressive 24 (Moderate)
4 5BPD, Paranoid, Pass-Agg, Depressive, Schizotypal 11 (Minimal)
5 6BPD, Paranoid, Pass-Agg, Avoidant Depressive, Dependent, 38 (Severe)
6 3 Avoidant, Depressive, Dependent, 38 (Severe)
Mean: 4.3 26.8 (Moderate)
![Page 25: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/25.jpg)
Categorical to Dimensional Approach to PD and personality styles
• Emerging Consensus– Two super-ordinate personality dimensions:
• under-controlled and over-controlled e.g., Clark, 2005; Livesley et al., 1998; Markon et al., 2005; DSM-V PD Task Force
![Page 26: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/26.jpg)
DSM-IV Commonalities core characteristics of PPD, AVPD, OCD
• Strong desire to control one’s environment• Restrained emotional expression• Limited social interactions/ problems with close
relationships due to mistrust, aloofness, distancing, fear of rejection/criticism
• Cognitive and behavioural rigidity• Associated with TR depression
![Page 27: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/27.jpg)
UnderUnder--Controlled Controlled vs.vs. OverOver--ControlledControlled
DramaticDramatic--ErraticErratic ConstrictedConstricted--ControlledControlled
High and Variable High and Variable ExpressivityExpressivity
Inhibited ExpressionInhibited Expression
Impulsive and RiskyImpulsive and Risky Risk AvoidantRisk Avoidant
Chaotic and IntenseChaotic and Intense
RelationshipsRelationships
Distant & Aloof Distant & Aloof RelationshipsRelationships
Emotionally Emotionally
LabileLabile
Emotionally Emotionally
StaticStatic•Lynch & Cheavens(2008). Dialectical behaviour therapy for co-morbid personality disorders. Journal of Clinical Psychology, 64, 1- 14.
![Page 28: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/28.jpg)
![Page 29: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/29.jpg)
Biosocial theory emotionally over-controlled disorders
• Sensitive to threat in keeping with over-controlled• Insensitive to reward
– performing, achieving value
• Mask emotions• Suspicious of
– self-disclosure– ‘intimacy bids’
• Lynch & Cheavens(2008). Dialectical behavior therapy for co-morbid personality disorders. Journal of Clinical Psychology, 64, 1- 14.
![Page 30: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/30.jpg)
Cohort 1: Lessons learned
• Participants may lean towards over- rather than under- controlled– may explain DBT outcomes
• Participants reported feeling scared, desperate and angry during early sessions: creative hopelessness
• Limited ability to tolerate individual process work– discomfort, dissociation
• Extreme construing– DBT = bad, ACT = good– diving in head first rather than dipping toe in the water
• Values work prompted shame, regret, hopelessness• Didn’t appear to get RFT or self as context
![Page 31: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/31.jpg)
Participants 2nd Cohort:
PD and Depression
Total PD Diagnoses PD diagnoses BDI-II
7 2 BPD, OCD PD 15 (Mild)
8 4 BPD, Avoidant, Dependent, Depressive 40 (Severe)
9 5 BPD, Paranoid, OCD PD, Pass-Agg, Depressive 36 (Severe)
10 1 BPD 40 (Severe)
11 5 BPD, Avoidant, Dependent, Schizptypal, Antisocial 21 (Moderate)
Mean: 3.4 30.4 (Severe)
![Page 32: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/32.jpg)
Adaptations 2nd cohort DBT graduates contin.
• Strengthen support further– 20 – 24 group sessions– 3+ individual sessions– telephone coaching– 1 month, 3 month and 6 month f/up
• Lighter touch for creative hopelessness– specifically linked to DBT skills– acceptance and change– noticing
• bias• short- long-term effectiveness
![Page 33: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/33.jpg)
Adaptations 2nd cohort DBT graduates contin.
• Mindfulness– external / internal shaped– linked to teaching content
• mindful of – level of distress – grounding required
• Defusion as 1st ACT skill– 3 sessions
![Page 34: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/34.jpg)
Adaptations 2nd cohort DBT graduates contin.
• Facilitate transition from DBT to ACT = DBT– Weekly monitoring of ACT skills on dairy
card• diffusion skills• valued action• observing self
![Page 35: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/35.jpg)
Adaptations 2nd cohort DBT graduates contin
• Building capacity to mindfully choose• Crisis survival skills for discrete, short-term
crisis– to ground and steady
• Willingness / engagement – for chronic difficulties – in service of values
![Page 36: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/36.jpg)
Adaptations 2nd cohort DBT graduates contin.
• Further shaping tolerance of difficult experience– eyes closed, paired, then group feedback
• RFT light– Impact of language– Impact of evolution
![Page 37: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/37.jpg)
Adaptations 2nd cohort DBT graduates contin.
• Multiple exemplars of self-as-context exercises
• gestalt old/young woman picture• use of actual chess board• mountain meditation
![Page 38: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/38.jpg)
copyright Thomas R. Lynch
![Page 39: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/39.jpg)
Adaptations 2nd cohort DBT graduates contin.
• Invitation to focus on less challenging life domain when addressing values
• Shaping up commitment to valued action– commitment off the table initially– tiny steps when planning valued action– normalizing process of commitment and re-
commitment
![Page 40: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/40.jpg)
Adaptations 2nd cohort DBT graduates contin.
Style• More limited 1-to-1 interventions
– stepping back from stirring material earlier – less intimate/personal therapist style
• Monitoring impact of– emotionally evocative content– self-disclosure
• invalidating or threatening– therapeutic style
• Adjusting presence
![Page 41: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/41.jpg)
Unstructured Interviews 2nd Cohort• Helpful
– Didactic• Handouts• Mindfulness CDs• DBT refresher / integration
– ACT skills• diary card
– Encouragement to take small steps
– Permission seeking– Being part of a group
• full participation• closed
– Pace and length
• Unhelpful – Homework
• challenging
5/5 recommendation
![Page 42: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/42.jpg)
Lessons to be learned
• Attachment to DBT as a life saver– Love’s Executioner Yalom– non-traumatic, gentle disillusionment
• Respect of DBT dialectic– acceptance and change– wise mind choices
• emotion and life
![Page 43: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/43.jpg)
Lessons to be learned contin.
• Build on DBT framework– group, individual, telephone coaching– monitor ACT skills
![Page 44: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/44.jpg)
Lessons to be learned contin.
• Start from where your participants are• intensity, intimacy and pacing
• DBT graduates not necessarily BPD– under and over-controlled– BPDs not necessarily under-controlled
• Offer good questions concerning effectiveness rather than solutions
– encourage ownership– use group process
• individual, pairs, group
![Page 45: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/45.jpg)
Lessons to be learned contin.
• Adjust– content emotionally evocative interventions– therapist’s presence
• slowing down, focussing• self involving self disclosure• intimacy
![Page 46: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/46.jpg)
Lessons to be learned contin.
• Monitor individual outcomes– post and follow-up– monitor what works for whom
• Be flexible and be willing!
![Page 48: Developing an ACT-based group intervention for DBT graduates with personality disorder: Moving from ‘quiet desperation’ to ‘a life worth living’ Sue Clarke,](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e245503460f94b11c6f/html5/thumbnails/48.jpg)
ParticipantsInclude• PD diagnosis (SCID-II)• Minimum 12 months DBT• No parasuicidal behaviour for minimum 6 months• Significant, ongoing mental health problems Exclude• current psychosis• eating disorders BMI < 17.5• DSM-IV diagnostic criteria for substance dependence
2 x groups of 6 - 10 participants