writing professional treatment plan for psychological disorders
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dbt_.pdf
Psychology 371 Intervention: Process & Outcome
Shannon Zaitsoff, PhD
Simon Fraser University
Borderline Personality Disorder
} A disorder of instability and problems with emotions.
} Unstable across:
} Emotions (up and down; hard to control; easily upset; react quickly; lasts longer)
} Thinking (biased thinking under stress; suspiciousness or paranoia, spaced out when stressed; identity – changing, no idea “who I am”)
} Behaviour (act quickly, without thinking; do things later regret or that make things worse; impulsive behaviour)
} Relationships (fear abandonment; idealization/devaluation)
Serious Mental Health Problem
Inpa%ents)
BPD$ Other$
Suicides(
BPD$ Other$
• 8-10% ultimately die by suicide • 75% have attempted suicide
• 69-80% self-harm
Stigma and Common Misconceptions } Stigma
} WHY does stigma exist? } Misinformation } Media portrayals are often highly stigmatized } Causes of BPD misunderstood (abuse, parenting) } Symptoms can be frightening, confusing } Society values being calm, in control, “rational” } Hard to work with therapeutically } Stigma exists even among treatment providers!
Myths about BPD
} Common Myths } People with BPD are manipulative and attention-seeking
} People with BPD are violent and a high risk for harming others
} People with BPD are crazy and irrational
} BPD is a life sentence
} BPD is caused by bad parenting
} BPD is untreatable
Is BPD a Life Sentence?
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Zanarini et al. 2004
BPD Over Time
} Most likely to improve: } Impulsive, risky, and self-damaging behaviours } Severe paranoid thinking } Unstable, stormy relationships
} Least likely to improve: } Emotional symptoms (depression, anger, etc.) } Dissociative symptoms and negative beliefs } Fears of abandonment and being alone
Available Treatment Approaches
} Psychological Treatments } Dialectical Behaviour Therapy (DBT; Linehan, 1993) } Mentalization-Based Treatment (MBT; Bateman & Fonagy, 1999) } Schema-Focused Therapy (SFT; Young, 1994; Giessen-Bloo et al. 2006) } Transference-Focused Therapy (TFP; Clarkin et al. 2007).
Dialectical Behaviour Therapy
Dialectics
Acceptance Change
• A world view: Reality consists of opposites
• Needs to be synthesized
• Continual change
Why Dialectical?
} Clients found unrelenting focus on change invalidating } Clients found attempts to accept problems invalidating } Frequent drop-out } Also clients can (unintentionally) punish effective
therapist behavior and reinforce ineffective behavior } Difficult to use standard CBT format b/c there are often
SO many problems presenting in each session
Dialectical Assumptions
Acceptance Change
• Patients are doing the best they can <-> Patients need to do better, try harder and/or be more motivated to change
• The lives of suicidal, BPD individuals are unbearable as they are currently being lived
• Patients want to improve
• Patients must learn new behavior in all relevant contexts
• Patients haven’t caused all their own problems, must solve them anyway
• Patients cannot fail in DBT
Solution } Integrate CHANGE and ACCEPTANCE } Develop HIERARCHY of treatment targets } Add modes of therapy to target SKILLS DEFICITS } Increase contact with therapist to promote
GENERALIZATION of skills/change
Therapy Components
} Individual therapy (weekly, 60 minutes) } Group skills training (weekly, 2 hours) } Telephone consultation (as needed) } Consultation team for therapists } Ancillary modes: pharmacotherapy, hospitalization
Linehan’s Biosocial Theory of BPD
2 Components: 1. Emotion Dysregulation 2. Invalidating Environments
EMOTION DYSREGULATION
Emotion Vulnerability
Deficits in Emotion
Modulation
Emotional Vulnerability
} Emotional SENSITIVITY
} Emotional REACTIVITY
} Slow return-to-baseline
Deficits in Emotion Modulation } Impulsive reactions (behavioral and emotionally) } Difficulties controlling or not escalating emotions
DBT: Biosocial Theory
} Second component is an Invalidating Environment:
} Rejects communication of emotions and thoughts
} Oversimplifies the ease of problem solving
} Intermittently reinforces emotional escalation
Transaction of Emotional Vulnerability with Invalidation over time
A1 B1 A2 B2 Ai
BPD
© Marsha M. Linehan
} 1) Decrease Life-Threatening Behaviours } 2) Decrease Therapy Interfering Behaviours } 3) Decrease Quality of Life Interfering Behaviours } 4) Decrease Skill Deficits, Increase Skillful behavior
} Mindfulness } Interpersonal Effectiveness } Emotion Regulation } Distress Tolerance
DBT: Treatment Targets
Targeting in DBT } Review diary card } Collaboratively set the agenda } Devote session time according to hierarchy } Use chain analysis and problem solving } Get commitment to implement solution } Trouble shoot the commitment
Strategies in DBT
} CHANGE strategies
} Irreverence } Problem-solving } Consultation-to-the-
patient
} ACCEPTANCE Strategies
} Reciprocity } Validation } Environmental
Intervention
Strategies in DBT } Irreverence } Devil’s advocate } Extending } And vs. But } Making lemonade out of lemons } Metaphors
Strategies in DBT } Chain Analysis
} What happened before (that day), right before (that hour/ minute), during, and after the behavior
} Ask about emotions, thoughts, events } Non-judgmental, explore
} Problem Solving } Solve the problem } Change emotional reaction to the problem } Tolerate/accept the problem } Stay miserable
Strategies in DBT } Validation } V1: Stay awake, pay attention, remain unbiased } V2: Accurate reflection } V3: Articulating unverbalized emotions, thoughts, patterns } V4: Validate in terms of past learning or biological
dysfunction } V5: Validate in terms of present context and normative
functioning } V6: Radical genuineness } V7: Cheerleading
Let’s see how this works…… http://www.youtube.com/watch? v=nFwAiO22g4Y
DBT Skills Cycle
Mindfulness (2 weeks)
Distress Tolerance (6
weeks)
Mindfulness (2 weeks)
Emotion Regulation (6
weeks)
Mindfulness (2 weeks)
Interpersonal Effectiveness (6
weeks)
Evidence for DBT
DBT: Efficacy (Linehan et al. 1991)
Ø Original Study: Linehan et al. 1991 (N = 44) } DBT > Treatment As Usual (TAU):
} Parasuicidal behaviour } Medical severity of parasuicide } Drop out rates } Inpatient psychiatric days } Anger
} DBT = TAU } Global social functioning } Functioning in follow-up period
DBT: Specificity (Linehan et al. 2006)
Ø Largest Study: Linehan et al. 2006 (N = 101) } DBT > Community therapy by experts:
} Suicide attempts } Hospitalization rates } Angry behaviour } Drop outs } ER visits
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
DBT: Efficiency (Linehan et al. 1991)
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
DBT: Efficiency (Linehan et al. 1991)
Efficacy (other studies)
} Opiate/Drug Dependent women with BPD (Linehan et al. 1999; 2000)
} Women veterans with BPD (Koons et al., 2001) } Women and men with BPD (Turner, 2000)
} Women with Bulimia or Binge Eating Disorder (Safer et al. 2001; Telch et al. 2001)
} Depressed older adults (Lynch et al. 2003)
} Current: Dismantling study…
DBT: Specificity (Harned, Chapman et al. 2008)
} DBT vs. CTBE for Axis I Diagnoses in BPD
Right now….
• Looking at components of DBT
• Individual therapy ONLY
• Skills training ONLY
• Both
Other Treatments for BPD
Mentalization-Based Treatment
} Psychodynamic Approach } Mentalization = ability to imagine/understand other people’s
mental states } 6 hours/week for 18 months: Partial hospitalization program,
incl. individual therapy, group therapy, expressive therapy, community meeting
Mentalization-Based Treatment
} MBCT vs. Treatment As Usual (N = 44) } Suicide attempts, self-harm, depression, anxiety } Social functioning } 8-year follow-up: suicidality (23 vs. 74%), diagnosis (13 vs. 87%),
medication use, good functioning (45 vs 10%), vocational status (Bateman & Fonagy, 2008)
Schema-Focused Therapy (SFT)
} Cognitive/CBT Approach } Cognitive strategies. } “Limited re-parenting” } Two 50-min individual therapy sessions each week
for 3 years. } SFT vs. Transference-Focused Psychotherapy:
} BPD severity, general psychopathology, drop out rates, quality of life (Giessen-Bloo et al. 2006)
Transference-Focused Psychotherapy (TFP)
} Psychodynamic Approach } Insight-oriented approach that involves the therapist helping the
patient to understand and observe the origins and effects of his or her transference reactions.
} 1 year TFP vs. supportive treatment vs DBT (N = 90) (Clarkin et al., 2007).
} Patients in all groups showed significant improvements on depression, global functioning, anger, suicidality, and depression.
Medication
Medication for BPD
} Best Conclusions (Paris, 2006; Frankenburg, 2006) } Best evidence so far for SSRIs (e.g. Prozac): depression, anxiety, and
mood shifts. Fewest serious side effects. } Mood stabilizing medications or “anti-psychotic medications” may be
helpful. Serious side effects (80-100% drop out in some studies). } No Anti-BPD drug exists. } Medication alone is not advisable
Suicide
} In 2000, approximately 1 million people died by suicide } Every 40 seconds } Every 17 minutes in the US alone
} 11th leading cause of death across age groups } 3rd cause of death in teens } Suicide rates rising in most industrialized countries
Suicide Risk } About 90% of people who commit suicide meet criteria
for a psychiatric diagnosis. } 9% BPD } 7% Depression, Bipolar, Substance Abuse } 5% Eating disorders, schizophrenia, antisocial personality
disorder
Assessing Suicidality } “The most straightforward way to determine the
probability of suicide is to ask the patient directly.” } Motto, 1989
What to assess?
} Current and past: } Suicidal ideation (thoughts) } Suicide plan } Means and intent } Attempts } Non-suicidal self-injury (NSSI) } Risk factors } Protective factors
Assessing Suicide Risk
} “Sometimes when people are struggling with difficulties like your own, they will have thoughts about death or that they might kill themselves. Have you had any such thoughts?”
} “Have you ever thought about how you would kill yourself?” } How often? How persistent?
} “Have you made plans to kill yourself in the past?” } Current plan? Means available? Initial actions? Ease of following
through in the next ______? } “Have you ever tried to commit suicide in the past?”
} What did you do? } What happened as a result?
Suicide Risk factors
} Males more likely to complete, females more likely to attempt
} Completion: Males: Females 4.5 to 2.5 : 1
} Attempts: Females: Males 2:1
} First Nations people at 2.5 times greater risk
} Physical/chronic pain
} Impulsivity
} Hopelessness (more than depression or substance use)
} Adverse life events
Suicide Risk factors
} Acquired capability: Need to get practice at withstanding pain and fear
} Military experience
} Self-injury
} Extreme sports
} Desire for suicide: Wanting to end your life, believing it would make things better
} Burdensomeness
} Thwarted Belongingness
Interpersonal Psychological Model of Suicide
Acquired Capability
Desire for
Suicide Suicide
Protective Factors } Social connectedness, belonging
} Responsibility to pets, children, others
} Hopefulness } Reasons for living } Attachment to treatment
Wingate’s Assessment System
} Plans predict suicide, desire does not. } Two most important things to assess:
} History of multiple attempts } Resolved plans and preparedness vs. suicidal desire
} Levels of risk: } Non-existent } Mild } Moderate } Severe } Extreme
Interventions for Suicidality
} Intolerable Problem and……. } Solutions won’t work } Can’t do solution because don’t have resources } … therefore best option seems like suicide
} So we need to come up with as many other solutions to the problem as possible and build hope the person CAN do them and they CAN work.
Interventions for Suicidality
Suicidal Behavior
Instruct not to do it
Solve the problem
Develop crisis plan
Get commitment
Trouble shoot crisis plan
Generate reasons for
living
Clarify negative consequences
Remove lethal means
Arrange follow- up care
What Can You Do?
} Ask the question directly } Always assume they’re serious! } Get the person help as quickly as possible
} Crisis line } Counsellor/psychiatrist } Family doctor } Family
} Stay in touch
