Dialectical Behaviour Therapy (DBT)

Dr Amanda WildgooseConsultant Clinical Psychologist/DBT Lead (MAP CAG)

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.

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

Bio-Social Theory

DBT views BPD as resulting from a pervasive dysfunction of the emotion regulation

system

BIOSOCIAL THEORY

BIOLOGICAL DYSFUNCTION in the EMOTION REGULATION SYSTEM

INVALIDATING ENVIRONMENT

PERVASIVE EMOTION DYSREGULATION

Biological component

Social component

Emotion Dysregulation

Emotional Vulnerability

Inability to Modulate Emotions

Emotion dysregulation

Emotional Stimuli High sensitivity to

ES

Intense

IntenseResponse to ES

Slow return to

baseline

Emotional Response

Cannot up-regulate physiological arousal when

neededCannot turn away from ES

Information processing distorted/

dysregulated

Cannot work towards non

mood dependent

activity

Cannot control impulsive behaviour related to

strong negative affects

SHUTS DOWN

What is DBT?

5 Functions of Comprehensive Treatment:

1. Enhance capabilities2. Improve motivational factors3. Assure generalisation to natural

environment4. Enhance therapist capabilities and

motivation to treat effectively5. Structure the environment

Enhancing capabilitiesFunction:• 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)

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.

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)

Enhancing Therapist Capabilities and MotivationFunction:• 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

Structuring the EnvironmentFunction:• 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)

Structuring the Treatment

Pre-Treatment Goals and Targets

1. Agreement on goals:- Commitment to change- Initial targets of treatment2. Agreement to recommended treatment:- Client agreements- Therapist agreements3. Agreement to therapist-client relationship

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)

Therapy Target HierarchySevere Behavioural Dyscontrol Behavioural Control

Decrease:- Life-threatening behaviours- Therapy-interfering behaviours- Quality-of-life interfering behavioursIncrease behavioural skills:- Core mindfulness- Interpersonal effectiveness- Emotion regulation- Distress tolerance- Self-management

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

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

Vulnerability

CHAIN ANALYSIS OF PROBLEM BEHAVIOR

Name: __________________________ Date: _________________ Date of Problem Behaviour:___________ LINKS

Prompting Event

Problem Behavior

Consequences

Links: Thoughts Feelings Actions

What is the major PROBLEM BEHAVIOR that I am analysing?

What PROMPTING EVENT in the environment started me on the chain to my problem behavior? Date of Prompting Event:________________

What things in my environment and myself made me VULNERABLE?

What is the function of my behavior?

CHAIN ANALYSIS OF PROBLEM BEHAVIOUR

WHAT WAS THE CHAIN THAT LED YOU TO THE PROBLEM BEHAVIOUR…FROM ONE LINK TO THE NEXT…LINKS CAN BE THOUGHTS, FEELINGS, ACTIONS, EVENTS, BODY SENSATIONS…..

What actually happened What skills I could have used

What were the CONSEQUENCES in the environment?

Immediate: Delayed:

What were the CONSEQUENCES in myself? Immediate: Delayed:

Ways to reduce my VULNERABILITY in the future:

Ways to prevent Prompting Event from happening again:

Plans to REPAIR, CORRECT, and OVERCORRECT harm that problem behaviour caused:

My Deepest Thoughts and Feelings about this that I want to share:

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

Goals of Skills Training

Behaviours to Increase: Behaviours to Decrease:

Mindfulness skills Identity confusionEmptinessCognitive dysregulation

Interpersonal skills Interpersonal chaosFears of abandonment

Emotion Regulation skills Labile affectDifficulties with anger

Distress Tolerance Impulsive behavioursSuicide threatsParasuicide

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!!!

Any questions?