DIALECTICAL BEHAVIOURAL THERAPY

1. DIALECTICAL BEHAVIOURAL THERAPY THE STORY SO FAR . . . 7 Years of DBT Presenter: Gay Boaden BSS, BC DBT Coordinator

2. Dialectical Behavioural Therapy Program“Moving Forward” in the Manning • Institutional Context for DBT • In 2004, 30 clinicians from Taree Community Health were trained in Dialectical Behavioural Therapy, by Rachel Rossiter and Jennifer Koorey from The Centre for Psychotherapy, James Fletcher Psychiatric Hospital, Newcastle. • Gay Boaden was appointed DBT Coordinator and commenced work on a business plan and implementation of the program in the Manning and Great Lakes area. • Based on empirical evidence from the Centre for Psychotherapy and the Hunter Valley Mental Health Service, DBT was found to be a cost effective approach for managing multiple, acute presentations of individuals with Borderline Personality Disorder. • Our program is a community, outpatient program within a rural setting, in the Mid North Coast of NSW.

3. Organisational Diagram

4. Rationale for DBT • The Dialectical Behaviour Therapy Program for treating Borderline Personality Disorder, was developed by Marsha Linehan during the early 90's and has been shown to reduce costs to services by an average of 50% (Behavioral Technology Transfer Group 2002). • This costing advantage is being replicated in Australian DBT program outcomes within the Hunter Valley Mental Health Service (HVMHS). • Based upon these results, we anticipate similar outcomes for our services. (2004 Business Plan:Boaden,G & Macauslane,S)

5. Business Case for Implementing BPD Treatment Program • One of the main aims of introducing a specific treatment program for BPD was to reduce the frequency of interactions and the associated costs to each of the service providers across the range below: • Ambulance / Police / GP • Admissions to both MBH A&E & Taree Psychiatric Inpatient Unit • Crisis Interventions – Sexual Assault, Community Mental Health & Acute Inpatient Unit, Alcohol & Other Drugs Teams • Ongoing Counselling sessions through each of the teams listed above, without any structured clinically tested framework.

6. Background to Dialectical Behaviour Therapy • Dialectical Behaviour Therapy (DBT) can be described as a cognitive-behavioural therapy for BPD. It combines problem solving, informed by behaviour principles and techniques, with an attitude of acceptance characterised by validation of, and empathy for the individual with BPD (Linehan 1993). • The treatment model for DBT typically involves a combination of individual therapy, skills training, between session telephone support and an ongoing therapist consultation & support group. The treatment can extend for 12 - 18 months and involves a pre-treatment stage, and four main stages of therapy

7. 4 Stages of DBT 1 During the pre-treatment phase a comprehensive mental health assessment is conducted, with particular emphasis on the individual's potential ability to commit to such a demanding program. 2 The next stage of therapy concentrates on reducing suicidal ideation & behaviours that interfere with the therapy process and to their quality of life. 3 The third stage addresses problems associated with post traumatic stress, as many BPD clients have experienced physical, emotional & sexual abuse. 4 The fourth stage of the therapy deals with self esteem and individual treatment goals. The final stage is concerned with building the individual's capacity to experience joy. (Kiehn & Swales 2001).

8. 5 Program Components & Their Interrelationships Our Program “Moving Forward” includes all Five components of DBT: 1 DBT Individual Therapy. 2 DBT Skills Group Training. 3 After hours DBT Phone Coaching. 4 Consultation to all DBT therapists. Clinical Supervision is provided within our team as well as accessed externally by videoconference through the Centre for Psychotherapy 5 Supportive Ancillary treatments such as; Pharmacotherapy and Acute Inpatient Liaison are provided.

9. Patient Characteristics of BPD • More generally, Linehan (1993) suggests that clients with BPD tend to demonstrate:- • Emotional Dysregulation • Interpersonal Dysregulation • Behavioural Dysregulation • Cognitive Dysregulation • Dysregulation of the self

10. Characteristics Of BPD This translates into what she describes as 6 typical patterns of behaviour. 1. Emotional Vulnerability - Inability to label & understand ones feelings 2. Self Invalidation - having unrealistic goals & expectations 3. Unrelenting Crisis - each crisis following another without being resolved 4. Inhibited Grieving - unable to face negative feelings of loss and grief 5. Active passivity - active in finding others to solve their problems 6. Apparent competence - have learned to give the impression of being competent in response to an invalidating environment

11. Diagnostic Criteria For BPDDSM IV TR A pervasive pattern of instability of interpersonal relationships, self image, and affects as well as marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:- • frantic efforts to avoid real or imagined abandonment • a pattern of unstable and intense personal relationships characterised by alternating between extremes of idealisation and devaluation • identity disturbance: markedly and persistently unstable self image or sense of self • impulsivity in at least two areas that are potentially self damaging (eg. Spending, sex, substance abuse, reckless driving, binge eating Note: Suicidal or self harming behaviour in criterion 5 • recurrent suicidal behaviour, gestures or threats or self mutilating behaviour • affective instability due to marked reactivity in mood (eg. Intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days) • chronic feelings of emptiness • inappropriate intense anger or difficulty controlling anger (eg frequent displays of temper, constant anger, recurrent physical fights) • transient, stress related paranoid ideation or severe dissociative symptoms

12. Personality DisordersDSM IV TR CLUSTER A – Odd & Eccentric • Paranoid – distrust & suspiciousness such that others motives are considered malevolent • Schizoid – detachment from social relationships & restricted range of emotional expression • Schizo typal * – acute discomfort in close relationships, cognitive or perceptual distortions, eccentricities of behaviour CLUSTER B – Dramatic, Emotional & Erratic • Antisocial* – disregard for, & violation of the rights of others • Borderline * – instability in interpersonal relationships, self image & affects, marked impulsivity • Histrionic – excessive emotionality & attention seeking • Narcissistic – grandiosity, need for admiration, lack of empathy CLUSTER C - Anxious & Fearful • Avoidant*– social inhibition, feelings of inadequacy, & hypersensitivity to negative evaluation • Dependent – submissive & clinging behaviour related to an excessive need to be taken care of • Obsessive Compulsive*– preoccupation with orderliness, perfectionism & control Personality Disorder Not Otherwise Specified – traits of several PD’s, or one not classified eg Passive Aggressive PD * Proposed DSM V Personality Disorders plus PD Trait Specified

13. Definition of Program Components • Individual therapy (1 Hour each week) is provided by one of our eight therapists. This process addresses clients’ personal needs, developing a strong therapeutic relationship, which will hold them throughout times of heightened distress in their lives. This relationship is often reported as the first long term, stable relationship that has not “blown up”. • DBT Skills Group (2½ hours each week) provides a teaching environment, where skills acquisition, development and generalisation occurs. Home work is given and reviewed combined with mindfulness exercises. The function of the group is to inform, clarify DBT teaching, as well as to engender a culture of respect, validation and advanced vicarious learning. The group is lead by two skills group leaders who use the power of the group to inform, cheerlead and validate participants.

14. DBT Phone Coaching • DBT Phone Coaching is provided by individual therapists and skills group leaders, who are all members of the Consult Group. • The function of the after hours phone coaching is to decrease suicide crisis behaviours and to increase generalisation of skills, in times of high emotional distress. • The phone coaching line provides an opportunity to cheerlead and validate our clients in their environment as well as providing acute care for self-harming and or suicidal clients.

15. DBT Consult Group • DBT Consult Group is the engine that drives the program or the oil that keeps the machine running smoothly. • One function of the Consult Group is to enhance therapist capabilities and motivation to treat patients effectively. • As in the Client Skills Group our Consult Group provides ongoing teaching, generalization of skills acquisition, cheerleading and validation for its members. Clinical Supervision is an integral component of our consult group

16. Nature and Numbers of Personnel Offering DBT • Our Consult Group consists of a team of nine Mental Health Professionals. • We have five registered Mental Health Nurses one Clinical Nurse Specialist, one Intern Psychologist, one Social Welfare Counsellor and one Clinical Psychotherapist.

17. Therapist's Agreements • We adhere to standard DBT agreements. We attend and participate in weekly Consult Meetings (90 minutes) • We agree to make every reasonable effort to conduct competent and effective therapy. • We agree to obey standard ethical and professional guidelines • We agree to be available to our client for weekly therapy sessions and provide therapy backup if unavailable. • We agree to respect the integrity and rights of the client. • We agree to maintain confidentiality. • We agree to obtain consultation when needed.

18. Clients' Agreements • Clients' Agreements in standard DBT are an integral part of the pre-treatment phase. Clients as do Therapists sign off on their respective agreements early in treatment. Clients agree to: • Stay in therapy for a minimum of twelve months. • Agree to work towards reducing self-harming behaviours. • Work on problems that interfere with therapy. • Attend weekly individual sessions. • Participate in weekly skills groups. • Complete Diary Cards and homework assignments.

19. ENTRY CRITERIA • Patients in “Moving Forward” DBT Program. • Entry criteria depends on a diagnosis of Borderline Personality Disorder, with at least one serious suicide attempt in the past twelve months, with intent to die. • To maintain consistency in diagnoses we engage our own DBT treating Psychiatrists. • Our patients come to us from many referral sources and locations. We receive referrals from Hospitals, Probation and Parole Justice Departments, Psychiatrists, General Practitioners, Social Workers, Psychologists within our area, as well as out of area. • We have had contact with more than one hundred and fifty clients since our program commenced during the past seven years. It is anticipated that this number will continue to grow as our service gains greater exposure and the number of successful outcomes are more widely known.

20. Modifications of Standard DBT • We also provide a 10 week Skills Group Program “Life Matters'" for the general population who do not meet the criteria for the comprehensive program. This is a stand alone program. • The rationale for this program is to meet the needs of people who are experiencing problems with interpersonal relationships, difficulty in regulating emotions and tolerating distressful situations, but without serious self-harming behaviour • This group is run by two experienced DBT therapists / Skills Group Leaders. This is a useful introduction and training ground for new members of our team, to gain knowledge and practise their acquisition and development of DBT Skills. Students on placement enjoy being part of this group.

21. DBT Coordination • Patients in our comprehensive program, “Moving Forward”, are aware that they are in a well coordinated DBT Program. Many have expressed sincere thanks for the opportunity given to them, to be included in this valuable, life changing program. • Some participants have researched DBT on the net and have discovered that our program delivers a comprehensive program, one that includes all the necessary components of DBT. Some have looked into private services and have found that not all the components are offered and without private health insurance it is unavailable to them.

22. DBT Coordination • Our process in providing a coordinated, comprehensive service, was guided by Marsha Linehan’s research clearly showing that life changing outcomes, can occur for clients who participate in the full program. • My determination to implement a model as close to Marsha's model, came with this knowledge and the belief that our patients deserve the greatest opportunity to access this successful program, even in a rural setting, with limited resources. • I have been encouraged by our local team of mental health professionals, who have willingly changed the way that they work, embracing this Dialectical Behavioural Therapy model.

23. Outcomes so far . . .

24. Pre and Post Testing

25. Self Report K10

26. Our demographic data • In six years we have had 30 participants successfully graduating after 12 months program • 87% female, 13% male • 100% unemployed (entry), 27% employed (exit) • 100% BPD, 13% BPD only diagnosis • 87% BPD plus at least one other co-morbidity • Age range 18 – 52 years, Average age 36 • 50% graduated from the full program • 27% discontinued group prior to graduation

27. Our successes • We have celebrated with clients who have: • graduated after completing DBT program • completed Stage 2 therapy • returned to complete DBT after dropping out • returned for a ‘refresher’ short course • achieved all of their DBT goals • gone on to marry their life partner • moved into or back into the workforce • started their own business • teaching DBT behaviours to others

28. Professional Reflections “ …. one of the glaring impacts of the DBT Programme, as it is delivered across the Manning Mental Health Cluster, would be the impact on the admission rate/frequency of those clients that attract a diagnosis of Borderline Personality Disorder, that is to say it is extremely rare for anyone from this diagnostic group to be admitted to the Inpatient Unit as opposed to the previous high levels of frequent and very short admissions that still occur in other mental Health Services. The benefits to the client, and their family, is less disruption to their day to day living and the development of healthy ways to communicate and handle their distresses. At the risk of sounding mercenary this extremely low admission rate equates to significant savings to the Health budget and funding.” Ron Haigh Manager Mental Health

29. Professional Reflections Prior to the introduction of DBT, treatment of clients presenting with a BPD were largely crisis management and time consuming. I remember feeling powerless to help clients, apart from short term strategies, which often were hit and miss or sabotaged if the client felt it wasn’t what they wanted. Post DBT, there is now the scope to offer a tangible hope to sufferers, from a clinicians perspective, we can now focus more on offering hope for the future than simple managing the immediate crisis. From a consumers perspective the knowledge that things don’t have to stay the same, that there is an alternative, often allows them to gain control in the immediate sense and hold hope in their situation in the long term. Stuart Perks Clinical Nurse Consultant in Consultation Liaison Psychiatry

30. Professional Reflections “In the Emergency Department, we used to have people presenting very regularly, highly distressed, overdosing, cutting and other self-harming behaviours, such as overuse of alcohol and drugs, high speed driving and dangerous sexual activities to name a few……..after DBT was introduced, I noticed an amazing reduction in the number of presentations of these people.” Robyn Rooney Emergency Department Nurse

31. Professional Reflections “DBT is an invaluable program for people wanting to work on long-standing dysfunctional patterns of behaviour (e.g. emotional dysregulation, suicidal/self-harm ideation) who otherwise will find it quite difficult to get help.” Dr. Rahul Gupta Acting Clinical Director, Manning Mental Health Service

32. Reference List APA (2000) Diagnostic Skills Manual IV TR Behavioral Tech (2010) DBT Intensive Training Notes Seattle: Behavior Tech Boaden,G & Macauslane,S (2004) Dialectical Behaviour Therapy- Project Overview: A Treatment Program for Clients with Borderline Personality Disorder Centre for Psychotherapy (2005) The Dialectical Behaviour Therapy Approach to Borderline Personality Disorder. Newcastle: Hunter New England Mental Health. Dimeff, L., Koerner, K. & Linehan, M.M. (2002) Summary of Research on DBT. Seattle: Behavioural Tech, LLC. Dimeff, L. & Linehan, M.M. (2001) Dialectical behaviour therapy in a nutshell. The California Psychologist, 34, 10-13. Germer, C.K., Siegel, R.D., & Fulton, P.R., (Eds.) (2005) Mindfulness and Psychotherapy. New York: The Guilford Press. Kabat-Zinn,J. (1994) Wherever you go, there you are; Mindfulness meditation in everyday life. New York: Hyperion. Linehan, M.M. (1993a) Cognitive – Behavioural Treatment of Borderline Personality Disorder. New York: The Guilford Press. Linehan (1993b)Skills Training Manual for Treating Borderline Personality Disorder Macauslane,S. (2010) DBT Intensive Poster Presentation 32