A New Era: Traditional Dialectical Behaviour Therapy (DBT) and Current Applications Deborah Dimmick Smith, Ph.D., Eilish Parkinson, B.A.A.
St. Lawrence College
A New Era — An Overview
Dialectical Behaviour Therapy is one of the third wave evidence-based behavioural therapies introduced in the 1990’s that turned the tide by bringing together a variety of techniques—some traditional behavioural and cognitive strategies (skzills training and cognitive restructuring) with other techniques such as mindfulness and crisis management.
Originally designed as an intervention for suicidal clients/often with diagnosis of borderline personality—previously thought to be “untreatable”.
After several decades of implementation, other populations and other clinical problems have been found to be responsive to this evidence-based treatment (depression, substance abuse , eating disorders, other personality disorders).
All of this brings up new questions: Does DBT need to be implemented as a package? Or, can components of DBT be adopted or adapted to fit new client populations and/or other clinical settings?
In this Presentation
Overview of traditional DBT and its theoretical underpinnings
Review of implementing DBT program in rural mental health agency in Ontario—evaluation of client outcomes and treatment integrity
Discussion of difficulties of implementation of full DBT program, adaptations made by this agency, difficulties in rural settings
Adopting or adapting DBT
Current applications to other disorders—Studies of treatment of eating disorders and avoidant personality disorder reviewed
Dialectical Behaviour Therapy— The Traditional Approach
Originally designed and developed by Dr. Marsha Linehan for those with Borderline Personality diagnosis and with suicidal or self-harm (parasuicidal) behaviours.
Many of these difficult to treat clients also have co-morbid anxiety, and/or depression, and/or substance use disorders.
Positive research outcomes in 2 initial clinical trials (Linehan et al., 1991 and Linehan, Heard, and Armstrong, 1993)—Reviewed in Linehan (1993a). Nine clinical trials to date showing that DBT is effective with individuals with BPD. http://www.youtube.com/watch?v=SDaHFnpsWzE&feature=relmfu
Dialectical Behaviour Therapy Theoretical Underpinnings (Linehan, 1993a) How Does it Differ from standard Behaviour Therapy (BT) and Cognitive Behaviour Therapy (CBT)? •BT is change directed •DBT emphasizes 4 areas which have not received much attention in CBT Acceptance and validation ● Treatment interfering behaviour ● Therapeutic relationship ● Dialectic processes ●
•Principle of Polarity •
—reality is comprised of opposing forces
•Principle of Continuous Change otension between thesis and antithesis produces change (synthesis) obased on the interrelatedness of individual and environment, but always in continuous change
Dialectical Behaviour Therapy Theoretical Underpinnings (Linehan, 1993a) Biosocial Theory—The vicious cycle
Emotion Dysregulation—arises from combination of vulnerable biology and invalidating social environments – An inability to change or regulate emotional cues, experiences, verbal and nonverbal responses, action
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Leads to maladaptive behaviour--suicidal behaviour, purging, abusing substances
Invalidating Environments – Family environments that consistently and persistently fail to respond as needed to primary emotion and expression of these emotions; Normal needs for soothing are neglected or shamed. –
Individual learns to avoid, interrupt, control primary emotional responses to avoid pain and invalidation.
http://www.youtube.com/watch?v=7KiihIE0d0c
Marcia Linehan—Pre-Conference DBT Skills Workshop 11/2010
Dialectical Behaviour Therapy The Group Treatment (McMain et al., 2009 and Linehan, 1993b)
Skills Training Groups •
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To enhance skills/build capabilities/remediate behavioural skills deficits. Consists of 25 week cycle of 2 hour/week group repeated once for full program. Core Mindfulness Skill training (2 weeks) is repeated between the other 3 skill modules of Emotional Regulation, Distress Tolerance and Interpersonal Effectiveness. Weekly Homework assignments--with behavioural analysis chain are included for homework not completed.
Dialectical Behaviour Therapy Stage 1 (McMain et al., 2009) Therapeutic Stage 1 Achieve behavioural control over life-threatening behaviours and trauma stabilization.
Stage 1 Targets include: 1. Life Threatening Behaviours 2. Therapy-Interfering Behaviours 3. Quality of Life-Interfering Behaviours
Dialectical Behaviour Therapy --- The Skills (McMain et al., 2009) Core
Mindfulness
• Increasing attentional control • Maintaining focus on long term goals despite impulsive urges Emotional
Regulation
• Understanding emotional experiences • Reducing vulnerability to painful emotion • Tolerating or changing painful emotion Interpersonal
Effectiveness
• Making requests or saying no in a clear, direct manner
Distress Tolerance • Surviving crises without making it worse • Accepting reality the way it is
Dialectical Behaviour Therapy Outpatient Individual Sessions (McMain et al.,2009) • • •
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• •
Weekly sessions of 1 hr for 50 weeks with individual therapist. To improve motivation to change/reduce PTSD stress/set individual goals. Diary Cards reviewed each session tracking problem behaviours, urges, feelings, and skills practice. Agenda-setting using target hierarchy (Structural Strategies)
Behavioural chain analysis of target behaviours. Solution analysis Contingency Management (changing consequences): Increase behav. – Positive/negative Reinforcement; Shaping Decrease behav. – Extinction; Reinforcement/Withdrawal
Dialectical Behaviour Therapy Outpatient Individual Sessions (McMain et al.,2009)
Exposure Other Behavioural Strategies • • • • •
•
Operationalize problem behaviour Assist client to describe thoughts, feelings, patterns of behaviour Clarify goals Assist client in generating solution Troubleshoot implementation of solution
Skills Training Cognitive Strategies Commitment Strategies Pros & Cons; Devil’s Advocate; Foot in the Door/Door in the Face; Present/Prior Commitment; Freedom to Choose
Dialectical Behaviour Therapy Outpatient Individual Sessions (McMain et al.,2009)
Validation
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Appear interested; Accurately reflect; Mind reading (articulate unverbalized thoughts/feelings); Past learning/Bio factors; Present moment (context); Radical genuineness/Cheerleading (believing in their capability)
Irreverent Comments
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Matter of fact manner; directly confronts dysfunctional behaviour; unorthodox irreverence/unexpected response, humour
Dialectical strategies
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Balance acceptance-oriented strategies with change-oriented strategies Lemonade out of lemons Use of metaphor; Activating wise mind, Allowing natural change
• •
Dialectical Behaviour Therapy Additional Interventions (McMain et al., 2009) Telephone • • •
Provides as needed skills practice in real-time (available 24/7) Includes crisis management Promotes skill generalization
Therapist •
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Coaching
Consult Meeting
Weekly group for therapists provides mutual validation, support, encouragement and problem solving Insures adherence to DBT framework
ABCT SIG Poster Session11/2010
DBT Client Outcome Evaluation and Treatment Integrity for Rural Mental Health Program (Parkinson & Dimmick Smith, 2010)
Purpose of Study •
To assess the efficacy of the DBT program which has been delivered for 5 years at a rural mental health agency utilizing-• client outcome evaluation • treatment integrity review
Hypothesis •
Participants who completed the DBT group skill training modules and who participated in individual DBT therapy would demonstrate over the course of the study-• An increase in the skills of emotional regulation, distress tolerance, interpersonal effectiveness and/or mindfulness as measured by selected skills measures questionnaires and Diary Card records • A decrease in targeted problem behaviours recorded in Diary Cards
Thesis Method Setting •
Rural mental health agency in a small town of 10,000 people
•
County catchment area covering 2,979.13 sq.km (1,150.25 sq. miles) with a population of 63,785 people (2006 census)
Participants •
Six Caucasian females and one male participated to varying degrees; Age range--22 to 51 years (with an average age of 39 years)
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All with diagnoses of Axis II BPD/BP Traits
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Average of two Axis I Diagnoses (44% anxiety disorders; 77.7% depressive disorders; 44.4 % substance abuse/dependence)
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Prescribed an average of 2 psychotropic medications each
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55.5 % with previous suicide attempts and 11% self harm behaviour
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Income: 80% Ontario Disability Support Program (ODSP) and social assistance from Ontario Works (OW) due to persistent Axis I mental disorder
Method Research Design •
Single subject design across subjects (Dimeff & Koerner, 2007).
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Client Outcome Evaluation Measures
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Kentucky Inventory of Mindfulness Skills (KIMS); Baer, Smith, & Allen, 2004. Distress Tolerance Scale (DTS); Simons & Gaher, 2005. Difficulties in Emotional Regulation Scale (DERS); Gratz & Roemer, 2004. Rathus Assertiveness Scale (RAS); Rathus, 1973. Diary Cards (Linehan, 1999) (weekly recording). Dissociative Experiences Scale (DES); Bernstein & Putnam, 1986. Attendance Records
• • • • • •
Implementation • •
Measures delivered in orientation/baseline and every 8 weeks thereafter. Attendance and Diary card information obtained weekly from individual therapist.
Client Outcome Evaluation Results Diary Card Target Behaviour • • • •
44% Decrease in target behaviours 77% Diary Card completion for target behaviour 44% with both baseline and treatment phases 41% of treatment weeks Diary Card completed
Skills Measures • • • • •
75% of clients reported increased Distress Tolerance 60% of clients reported increased Mindfulness 0.4 -1.2 skills per week weekly increase of skill use 13 skills practiced per week on average 22% completion Diary Card skill use records
Therapy-inty621erfering Behaviour • •
20% average for group and individual session Non-attendance 11% Client drop-out rate
Discussion of Results
No coincidence that the 44% clients who had identified their target behaviour and tracked it in Orientation to obtain baseline data and also tracked it during treatment were the 44% who had a reduction in target behaviours (44%)
Only an average 41% of treatment weeks had diary cards completed – directly impacting the structure of the individual session( compared to 87% in Lindenboim, Comtois & Linehan, 2007)
Lack of attention to Therapy –Interfering behaviour – nonattendance 0-56% Average 20% for both group and individual sessions
75% of clients noticed an increase in their ability to tolerate distress
Weekly skill use was 100%higher than in Lindenboim , Comtois, Linehan (2007) or Stepp, Epler, Jahng & Trull (2008).
Client #8 Weekly Average Grams of Cannabis Smoked
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3.5
3 Trend Line 2.5
2
s m G g ra v A ly k e W
Orientation baseline Group Skill Training 1.5
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0.5
0 Week 4
Week 5
Week 6
Week 7
Weeks of DBT Therapy
Week 8
Week 9
Week 10
Client #2 Diary Card Weekly Frequency of Suicidal Thoughts 20 18 16 Form 1Psych Unit 4 days No Suicide Attempt
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Trend Line
12 Frequency 10 8 6 4 2 0 16
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Weeks of DBT Therapy
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Figure 4 Client #2 Diary Card Weekly Frequency of Skill Use 16
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Trend Line Emotional Regulation
Trend Line Interpersonal Effectiveness
10 Frequency of Use 8
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2 Trend Line Mindfulness 0 Week 13
Week 14
Week 15
Week 16
Week 17
Week 18
Week 19
Week 20
Week 21
Week 22
Week 23
Week 24
Weeks of Group Skill Training Mindfulness
Linear (Mindfulness)
Emotional Regulation
Linear (Emotional Regulation)
Interpersonal Efffectiveness
Linear (Interpersonal Efffectiveness)
Distress Tolerance
Week 25
TREATMENT INTEGRITY REVIEW (Parkinson & Dimmick Smith, 2011)
Group Skill Training
100% Integrity Skills Modules content 90% Frequency of Group sessions/51 weeks
Individual Sessions
85% Frequency of Individual sessions in overall client treatment weeks: 89% Use of Individual session Progress Note (by 2/3 therapists) 5 DBT strategies reviewed per Individual session (average)
DBT Peer Consult
Held weekly Teleconference Case Consultation with CAMH Consultant once/6 weeks
Challenges for Rural Mental Health Agencies
Staff Training and Support/Supervision
Client Transportation
Telephone Support
Adapting vs. Adopting DBT (Dimeff & Koerner, 2007; Marra, 2005)
Considerations before adapting standard DBT ◦ A modification may not work as well as standard DBT. ◦ Offering untested DBT—not evidence-based as is standard DBT—can pose a problem with ethical informed consent if unsure if treatment is beneficial. ◦ Adapting DBT can heighten risk and legal liability, especially with high-risk suicidal populations. ◦ Using DBT with new populations—recommendation is to retain life-threatening behaviour and therapy interfering behaviour as treatment priorities—with disorder specific targets part of quality of life goals when treating new populations (Dimeff & Koerner, 2007). ◦ See Marra’s (2005) chapter, “Not Just for Borderlines Any More” for ideas of adaptations for other clients with diagnosis of PD.
DBT for Binge Eating Disorder Telch, C. F., Agras, W., & Linehan, M. M. (2001).
Sample o Female
, mean age 50 yrs, 70% college education, mean body mass 36.6 (SD6.6) obese o Reported onset 20.9 yrs (SD 11.7) o Mean duration of binge eating 29 yrs (SD 11.7) o Lifetime psychopathology major depression (38%), anxiety disorder (35%), substance abuse/dependence (27%), bulemia nervosa (6%) o Current psychopathology: major depression (9%), anxiety disorders (18%) , PD(27%) Assessments o Eating
Disorder Examination (EDE; Fairbum & Cooper, 1993) o Binge Eating Scale (Gorrnally, Black, Daston, & Rardin, 1982), o Emotional Eating Scale (EES; Amow, Kenardy, & Agras, 1995) o Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988) Negative Mood Regulation Scale (Catanzaro & Meams, 1990)
DBT for Binge Eating Disorder Telch, C. F., Agras, W., & Linehan, M. M. (2001). 1st RCT ď ˝
Intervention Compared to Waitlist
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20 week 2 hr group skills training for emotional regulation, distress tolerance and mindfulness ( to match other BED interventions for research comparison) treatment was based on the hypothesis that binge eating serves to regulate affect. new skills taught were aimed at enhancing adaptive affect regulation, thus reducing the need to binge eat.
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Outcome
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89% (16 of 18) had stopped binge eating for at least 4 weeks prior to the end of treatment, compared with just 12.5% (2 of 16) of controls. Abstinence rates were reduced to 56% at the 6-month follow-up. Findings suggest that treatment may work by reducing the urge or impulse to eat when experiencing negative emotions rather than by working directly on the affect.
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DBT for Binge Eating Disorder Safer , Robinson & Jo (2010) RCT
Intervention Compared to Active Comparison Group therapy (ACGT)
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Sample included men and women meeting research criteria for BED 20 week 2 hr group skills group
Outcome
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Posttreatment binge abstinence and reductions in binge frequency were achieved more quickly for DBTBED than for ACGT (posttreatment abstinence rate=64% for DBT-BED vs. 36% for ACGT) Differences did not persist over the 3-, 6-, and 12-month follow-up assessments (e.g., 12-month follow-up abstinence rate=64% for DBT-BED vs. 56% for ACGT). Specific effects of DBT-BED did not show long term impact beyond nonspecific therapeutic factors in common with ACGT. Rapid Response (RR) > 65% reduction in the frequency of days of binge eating by week 4 of the 20 week intervention. 64% of DBT-BED had significantly higher binge eating abstinence compared to non-rapid responders – 70.7% vs. 33.3% EOT and 70.7% vs. 40% at 1 year follow-up
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Using Adapted DBT with Comordid Personality Disorders (PD) (Lynch & Cheavens, 2008)
This study investigated an adaption of DBT that targeted emotionally constricted, overcontrolled, perfectionistic, and highly risk-aversive individuals (with comorbid PD).
These disorders represent the opposite of BPD and related disorders—emotionally dysregulated, impulsive, and dramatic.
Presents case illustration of Mr. K, 58-year-old male client diagnosed (Axis II) with paranoid PD and obsessive-compulsive PD to illustrate application of this adaptation.
Using Adapted DBT with Comordid Personality Disorders (PD) (Lynch &Cheavens, 2008)
His primary presenting problem was strained interpersonal relationships, particularly intimate relationships. Mr. K was distrustful and suspicious of others and had a preoccupation with details, perfectionism, and rigidity. He also had an Axis I diagnosis of Major Depression disorder (MDD) with early life onset) and was prescribed several medications for his depressive symptoms.
Mr. K described feelings of loneliness, depression, suicidal thoughts, and tended to see himself as unlovable. He presented as extremely sensitive to criticism, no matter how slight, and self-loathing. He had a “unique or special” view of himself, maintaining a superior type attitude which required perfectionism and a life or death attitude around making mistakes; yet being “unique” also meant that his life would be lonely and bleak, as he feared intimacy.
It was speculated that his sensitivity to emotion and threat transacted with his social environment over time that his basic anxiety and sensitivity resulted in always being on guard for a possible attack and having to defend himself.
He also often formed quick judgments about others, preferring to be rejecting and err on the side of missed opportunities than to risk adversive consequences.
Roleplay—This is a transcript from an actual session with Mr. K. At the start of this segment he has just changed the topic from relationships to discussing his medications—and the therapist wonders whether he might be avoiding...
Using Adapted DBT with Comordid Personality Disorders (PD) (Lynch &Cheavens, 2008)
This interaction represents a variety of aspects of DBT in action—particularly informal behavioural exposure to difficult topics (talking about relationships) and/or therapist feedback/criticism, accepting praise from the therapist, disclosure of therapist feelings to the client, and reviewing/positively reinforcing the practice of new thinking and behaviour outside of therapy sessions (therapist praising his singing in church), etc.
Instead of Distress Tolerance Skills, a new skills component was added called Radical Openness Module—which included loving-kindness/forgiveness training and mindfulness training to help Mr. K find balance in the rigidity to openness continuum.
Target goals become maximizing openness and flexibility to new experience, reduces rigidity in thinking, and rigidity in behaviour.
Individual sessions typically were conducted for 50 minute session/28 weeks.
Group skills training was provided in 2 hour sessions/28 weeks to review all of the standard DBT Skills (except Distress Tolerance as suicidal ideation and emotional dysreglation are less likely in more emotionally constricted individuals).
Using Adapted DBT with Comordid Personality Disorders (PD) (Lynch &Cheavens, 2008) Outcome— Following
9 mo. of DBT individual therapy and 6 mo. of DBT group skills training, Mr. K reported reductions in: Judgmental thinking towards others Interpersonal sensitivity Interpersonal aggression and bitterness Rumination/brooding ●
Hamilton Rating Scale for Depression showed improved scores from a baseline score of 17 to 21 (at 17-mo. follow-up) At the completion of the study, Mr. K no longer met full criteria for PPD or OCPD, and he discontinued his psychotropic medication. Mr. K continued to use a number of skills he had learned—mindfulness, flexible thinking and doing, going opposite to the actions associated with aversive/hostile mood states, and “loving kindness and forgiveness”. He noted that other had noticed that he seemed more positive in his social interactions with them.
References Dimeff, L. A., & Koemer, K. (Eds.). (2007). Dialectical behavior therapy in clincial practice: Applicaitons across disorders and settings. New York: Guilford Press Lindenboim, N., Comtios, K. A., & Linehan, M. M. (2007). Skills practice in dialectical behaviour therapy for suicidal women meeting criteria for Borderline Personality Disorder. Cognitive and Behavioral Practice, 14, 147-156. Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064. Linehan, M. M., Heard, H. E., & Armstrong, H.E.(1993) Standard dialectical behavior therapy compared to psychotherapy in the community for chronically parasuicidal borderline patients. Unpublished manuscript. University of Washington, Seattle, WA. Linehan, M. M. (1993a). Cognitive-behavioural treatment of borderline personality disorder. New York: Guilford Press.
References Linehan, M. M. (1993b) Skills training manual for treating borderline personality disorder. New York: Guilford Press McMain, S., Cardish, R., Green, S., Davies, L., & Weston, J.(2009). Dialectical Behaviour Therapy: The basics. Unpublished manuscript. Centre for Addictions and Mental Health, Dept of Psychiatry, University of Toronto. Marra, T. (2005) Dialectical behavior therapy in private practice: A practical and comprehensive guide. Oakland, CA: New Harbinger Publications. McKay, M., Wood, J. C., & Brantley, J. (2007) The dialectical behavior therapy skills workbook. Oakland, CA: New Harbinger Publications Parkinson, E., & Dimmick Smith, D. (2011) An Evaluation of a DBT Program in a Rural Mental Health Agency. Poster presented at 45th Annual Convention of the Association for Behavior and Cognitive Therapy, Toronto, ON. .
References Stepp, S. D., Epler, A. J., Jahng, S., & Trull, T. J. (2008). The effect of dialectical behavior therapy skills on borderline personality features. Journal of Personality Disorders, 22(6), 549-563. Safer, D. L., Robinson, A., & Booil, J. (2010). Outcome From a Randomized Controlled Trial of Group Therapy for Binge Eating Disorder: Comparing Dialectical Behavior Therapy Adapted for Binge Eating to an Active Comparison Group Therapy. Behavior Therapy, 41(1), 106-120. Telch, C. F., Agras, W., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal Of Consulting And Clinical Psychology, 69(6), 1061-1065