Kelowna Mental Health and Substance Use Service. DBT Comprehensive Service Demonstration Project and Beyond. June 7, 2013

Transcription

1 1 Kelowna Mental Health and Substance Use Service DBT Comprehensive Service Demonstration Project and Beyond June 7, 2013 Kathryn Kuhn, RPN Christopher Wilson, PhD, RPsych Overview/Presentation Objectives Review of Borderline Personality Disorder (BPD), incidence, prevalence, morbidity Introduction and overview of Dialectical Behavior Therapy (DBT) The KMHSU DBT Demonstration project Current KMHSU DBT Informed Services Discussion 3

2 What is so Important About Personality Disorders? Personality disorders are one of the most important sources of long term impairment in both treated and untreated mental health populations. Nearly one in every 10 adults in the general population and over one-half of those in treated populations suffer from one of the personality disorders. The presence of a Personality Disorder is an important predictor of slow recovery, poor treatment compliance, and long-term psychosocial risk. 4 BPD Quick Facts Affects: 1.8-4% of the general population 8-15% of outpatient population 14-25% of inpatient population Most commonly diagnosed Personality Disorder: Up to: 80% are women 80% have history of parasuicide 67% have co-morbid substance use disorder Highest risk of suicide (females) of all MH disorders Second highest risk of suicide (males) of all MH disorders 8-10% will complete suicide High percent of males with BPD in forensic system High Co-morbidity with: Axis I Mood and Anxiety Disorders, SUDS, Axis II Disorders Causes: Likely genetic, environmental, maturational, and cultural - Early childhood deprivation, neglect, abuse, inconsistency, and invalidation contributory Individuals with BPD require disproportionate mental health resources, up to 40%, and pose particular difficulties to public sector mental health service provision 5 DSM-IV-TR BPD Criteria (5 or more for Dx) Frantic efforts to avoid real/imagined abandonment Intense unstable relationships idealizing/devaluing Identity disturbance, unstable sense of self Impulsivity in two main areas that are self-damaging Recurrent suicidal behavior, gestures, or threats, or self-mutilating/self-harm behaviors Affective instability and marked reactivity of mood Chronic emptiness Inappropriate/intense anger or rage episodes Stress related paranoid ideation or dissociation 6

3 DSM5 and Personality Disorders The criteria for personality disorders in DSM5 (Section II) are essentially unchanged Section III contains alternative approach for further study (revised criterion based on clinical measures of core impairments; empirically set levels of impairment to minimize prevalence changes and disorder overlap; and PD NOS criteria different) 7 What is Dialectical Behavior Therapy (DBT)? Developed by Marsha Linehan, PhD, for chronically suicidal patients, and expanded to individuals with problems regulating mood, thoughts, behaviors, and relationships (e.g. BPD) A principle-driven treatment which includes protocols DBT blends Cognitive Behavior Therapy (how Behaviors are learned, maintained, and changed) with Eastern Philosophies (awareness, mindfulness, and acceptance) Evaluated with behaviorally dysregulated patients One of few BPD treatments with demonstrated efficacy 8 The Basis for DBT A collaborative commitment by client and therapist to treatment process A stage theory of treatment with clearly defined functions and modes of delivery A Biosocial theory of BPD Learning principles and behavior therapy Eastern philosophical approaches and a dialectical orientation to change Addressing behavioral patterns and dilemmas 9

4 Linehan s Re-organization of BPD Emotional Dysregulation Affective lability Problems with anger Interpersonal Dysregulation Chaotic relationships Fears of abandonment Self Dysregulation Identity disturbance/difficulties with sense of self Sense of emptiness Behavioral Dysregulation Intentional self-harm behavior Impulsive behavior Cognitive dysregulation Dissociative responses/paranoid ideation 10 Biosocial Model of BPD Biological Dysfunction in the Emotion Regulation System Invalidating environment Pervasive Emotional Dysregulation 11 5 Functions of Comprehensive DBT 1. Enhance client capabilities 2. Improve client motivational factors 3. Assure generalization to natural environment 4. Enhance therapist capabilities and motivation to treat effectively 5. Structure the environment 12

5 5 Modes of Comprehensive DBT 1. Outpatient Group Skills Training (Enhance capabilities skills acquisition) 2. Outpatient Individual Psychotherapy (Improve motivation) 3. Telephone Coaching by Individual Therapist (Generalize skills) 4. Therapists Consultation Meeting (Enhance therapist capability/motivation) 5. Uncontrolled Ancillary Treatments Pharmacotherapy Acute Inpatient Psychiatric Treatment Other agencies 13 DBT Assumptions About Clients Clients want to improve Clients must learn new behaviors in all relevant contexts Clients are doing the best they can Clients cannot fail in DBT Clients may not have caused all of their own problems, but they have to solve them anyway Clients need to do better, try harder, and/or be more motivated to change The lives of suicidal, borderline individuals are unbearable as they are currently being lived 14 DBT Assumptions About Therapy The most caring thing a therapist can do is help clients change in ways that bring them closer to their own ultimate goals Clarity, precision, and compassion are of the utmost importance in the conduct of DBT The therapeutic relationship is a real relationship between equals Principles of behavior are universal, affecting therapists no less than clients DBT therapists can fail DBT can fail even when therapists do not Therapists treating BPD clients need support 15

6 Stages of DBT Treatment Pre-treatment: Orientation and Commitment Stage 1: Severe Behavioral Dyscontrol Achieve Behavioral Control Stage 2: Quiet Desperation - Enhanced Emotional Experiencing Stage 3: Problems in Living - Achieve Ordinary Happiness/Unhappiness Stage 4: Incompleteness - Capacity for Joy and Freedom 16 Stage 1 Targets: Dialectical Synthesis Pre-Treatment Commitment & Agreement Decrease Life-threatening behaviors Therapy-interfering behaviors Quality of life interfering behaviors Increase behavioral skills Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion Regulation 17 DBT- Balancing ACCEPTANCE and CHANGE ACCEPTANCE (Validation) Mindfulness, attention to the present with a non-judgemental approach, focusing on effective here and now awareness, validation, and support CHANGE (Problem Solving) Analysis of problem Behaviors to increase understanding of cause and effect, learning new skills, finding solutions and implementing new Behaviors through problem-solving

7 DBT Validation A Core Strategy One of the most important tools is VALIDATION. We need to be able to VALIDATE the hurt and feelings of pain in a real and genuine way, even though we may not like the behavior Validation verifies the truth and is non-judgemental Validation indicates an understanding of client beliefs and expectations Validation communicates that the client s emotional reactions, beliefs, and expectations are understandable and make sense in the context of their lives Validation looks for the diamond in the rough find something to validate in even the most dysfunctional reaction 19 Tired Vulnerabilities Hungry Drug use Missed meds DBT Chain Analysis Cue Emotion Behavior Consequences 20 The Four DBT Skills Modules Core Mindfulness Interpersonal Effectiveness Emotion Regulation Distress Tolerance 21

8 DBT Core Mindfulness Skills (Core) Mindfulness involves learning to be in control of what one pays attention to, and for how long Decreases rumination about past, future, current emotional pain (e.g. mistakes) Improves control and soothes overwhelming emotions Helps identify and separate judgmental thoughts that often fuel difficult emotions Increases choice due to increased awareness Develops Wise Mind 22 What is Mindfulness? FULL AWARENESS: Being aware of your present moment (i.e., thoughts, feelings and physical sensations) without being critical and without trying to change it ATTENTIONAL FOCUS: Staying focused on one thing at a time In DBT/BPD, being unmindful can have devastating consequences (e.g. impulsive and mood dependent behaviors) 23 Mindfulness Works! Helpful in reducing a second depressive episode, anxiety, chronic pain, binge eating/bulimia Decreases impulsivity Increases relaxation and ability to tolerate distressing feelings/situations Builds the ability to approach both desirable and unwanted situations with a similar state of mind 24

9 DBT Mindfulness Skills - What and How WHAT Skills Observe, Describe, Participate HOW Skills Nonjudgmental, One-mindful, Effective These are practiced through mindful meditation, such as mindful breathing, mindful activity, mindfulness of emotions, etc. 25 DBT Interpersonal Effectiveness Skills Individuals with BPD struggle with intense, unstable relationships, panic, anxiety, and dread over relationships ending, and make frantic attempts to avoid abandonment. Individuals with BPD typically alternate between avoiding conflict, and engaging in intense confrontation. Both patterns create their own problems. Individuals with BPD tend to end relationships prematurely as a result of an inability to tolerate the stress of relationships, frustration with relationships, and difficulty turning potential conflicts into positive encounters. 26 DBT Interpersonal Effectiveness Skills In DBT Skills, specific aspects of relationships and skills to manage relationships better are covered e.g. effective strategies for asking for what you need, for saying no, and for coping with conflict. Interpersonal Effectiveness Focuses on dealing with conflict, getting wants and needs met, and learning to say No to unwanted requests and demands in a way that keeps selfrespect, and others liking and/or respect. Effectiveness has to do with obtaining requested changes, maintaining relationships, and maintaining self-respect. 27

10 Factors That Can Reduce Interpersonal Effectiveness Lack Of Skill Worry Thoughts Emotions Indecision Environment 28 Interpersonal Effectiveness (O*R*S*) Objectives Effectiveness - Getting your Objectives or goals in a situation Relationship Effectiveness - Getting or keeping a good Relationship Self-respect Effectiveness - Keeping your liking/respect for Self 29 DBT Emotion Regulation Skills People with BPD have trouble controlling their actions because of intense and lightening-quick emotional reactivity and lability Dysfunctional behaviors are often behavioral solutions to intolerable emotional pain Learning emotion regulation skills can go a long way in achieving primary target goals (decreasing suicidality, self-harm) 30

11 DBT Emotion Regulation Skills (cont.) Emotion Regulation best taught in the context of emotional validation and self-validation Searches for and figure out how even the most dysfunctional behavior makes sense given the context and circumstances in which it occurred and given the client s (difficult) life experiences Teach the client to IDENTIFY and DESCRIBE emotions, as well as the context in which they occur 31 Pay-offs of Emotional Behaviors Basic premise is that actions are shaped by consequences It is hard to change behaviors that are being reinforced: Positive reinforcement ( reward ) Negative reinforcement ( relief ) Chain Analysis can help to identify reinforcers 32 DBT Strategies to Regulate Emotions DECREASE VULNERABILITY to NEGATIVE EMOTIONS Health (treat physical illness) Eat Regularly (balanced nutrition) Avoid Mood Altering Substances Rest/sleep Mastery (do one rewarding thing daily that promotes feelings of competence) Exercise INCREASE POSITIVE EMOTIONAL EVENTS In the short term, and in the long term (e.g. Pleasant Events Schedule) OPPOSITE TO EMOTION ACTION Change an emotion when needed and wanted Prevent acting on emotionally generated urges when to do so would be harmful or ineffective 33

12 DBT Distress Tolerance Skills Learning To Bear Pain Skillfully? Pain and distress are an inevitable part of life. Life is just not pain free! When we are in distress, we can act impulsively. If we can t change the situation, at least for now, we need to get through it without making things worse. Distress tolerance (AT LEAST OVER THE SHORT TERM) is integral to change impulsive self-destructive behaviors get in the way of getting better. Tolerating distress includes a mindfulness of breath and mindful awareness of situations and self 34 DBT Distress Tolerance Skills Distress tolerance is about the ability to accept, in a nonjudgmental way, oneself and the current situation Involves the skill to perceive the environment without putting demands on it to be different to experience emotional states without trying to change them to observe thoughts and emotional responses without attempting to stop or control them 35 DBT Crisis Survival Strategies DISTRACT with Wise Mind ACCEPTS SELF-SOOTHE the five senses (VHSTT) IMPROVE the moment PROS AND CONS/Decisional Balance RADICAL ACCEPTANCE WILLINGNESS VS WILLFULNESS 36

13 DBT, BPD and the KMHSU Experience 37 Why DBT? Has support from several randomized clinical trials and demonstrated to be efficacious with the following multidisordered populations (BPD; suicidal and self-injurious behaviors; substance abuse; depressed elderly; bulimia nervosa; binge eating disorder; comorbid anger; gambling substance abuse) Only treatment to date that has sufficient BPD outcomes studies to allow metaanalytic support Validated by several authoritative organizations as meeting the highest standards of evidence with other treatments having lower evidence ratings UK Government NICE Guidelines (2009) SAMHSA report to US Congress (2011) American Psychological Association (2012) Australian Psychological Society (2010) American Psychiatric Association BPD practice guidelines* Cochrane reviews* Is accessible 38 The Challenges Since 1997, primary service to this client population at KMHSU was time limited DBT Informed Skills Training Group treatment. More complex, multi-disordered, and hard to manage clients with BPD that required more intensive services than afforded by DBT Informed interventions were variously managed by mental health service teams/clinicians using a variety of non-specific treatment interventions. These include crisis management, case management, CBT/DBT informed interventions, eclectic, and/or ancillary non-evidence based interventions. Demand typically exceeded the existing treatment structure s capacity to provide ongoing service to clients with BPD leading to a moratorium on DBT services in Clinician burnout. Perception that a small group of clinicians were shouldering the burden. 39

14 BPD/DBT Service Demand (Referrals by year for DBT Skills Training Group 1997 onwards) * *only aggregated referral data available waitlist rises to 170 (then closed) 2010 waitlisted clients offered 8 week DBT skills 2010/2011 Service Resumes with DBT Informed/DBT Comprehensive Pilot 40 DBT Demonstration Project Goal to provide one year of Comprehensive DBT service covering the continuum from time limited DBT Informed interventions (skills training workshops, time limited DBT Skills Groups, etc.) to a Comprehensive DBT service providing all five DBT treatment functions across the four treatment modes* Service staffed from existing centre resources drawn from all KMSHU teams (ACSS; ASTAT;EDP;SMH;SU) and across disciplines (RNs; RPNs; OT; Psychologist; SW; Dieticians) as well as KGH Psychiatry and DDMH with dedicated clinical leadership and administrative support, based on an agency integrated primary treatment model. Guiding principle behind the demonstration project was that DBT service delivery was a centre wide shared and collective responsibility Project implemented with the guidance of Dr. Lorne Korman, Research Scientist, British Columbia Mental Health and Addictions Services (BCMHAS), Provincial Health Services Authority (PHSA), and a Registered Psychologist and experienced DBT consultant and trainer. 41 DBT Comprehensive Service Framework Consultation/Training Provided by Dr. L. Korman, BCMHAS, PHSA Comprehensive DBT Skills Training Group 6 month cycles 2 to 4 clinicans per cycle Phone Based Coaching Provided by all clinicians with after hours support TBA* Weekly DBT Team Consultation Meeting Attended by all clinicians Weekly Individual DBT Therapy Provided by all clinicians 1 to 3 clients per caseload DBT Informed Skills Training Groups (4 to 12 sessions) ongoing during year resourced by all members of DBT service Ongoing Evaluation 1. DBT Comprehensive Service 2. DBT Informed Service 42

15 Key Events/Timeline October 2009 November day Introduction to DBT workshop attended by over 100 KMHSU staff (Dr. L. Korman) 2 Consultation Teams formed and training started (Weekly 90 minute sessions for the consultation group; DBT clinical skills, orienting clients to treatment, treatment stages, case formulation, chain analysis, treatment strategies, change strategies, crisis management, group skills training, coaching, client eligibility. Readings, discussions, Lineman's training videos; Linehan's text Cognitive Behavior Therapy of Borderline Personality Disorder.) March 2010 April - May 2010 June 2010 July 2010 June 2011 To present DBT Informed treatment resumes DBT Comprehensive client selection DBT Comprehensive Treatment program 2 Day Advanced DBT Training Consultation Teams only (Dr. L. Korman) Demonstration Project ends (TAU/service end) DBT informed service continues 43 DBT Therapist Agreements Therapist will make every reasonable effort to conduct therapy as competently as possible Therapist will adhere to all ethical guidelines and professional codes Therapist will attend scheduled sessions (duration, cancellations; backup/phone availability discussed) Therapist will respect integrity and rights of client Therapist agrees to confidentiality and limits of confidentiality Therapist will obtain consultation when needed 44 DBT Client Agreements Client agrees to be in therapy for 1 year Client will attend all individual sessions* Client suicidal or self-harming behaviors are a treatment priority Client will work on therapy interfering behaviors Client agrees to attend skills training group* Client agrees to research and evaluation 45

16 DBT Consultation Team Agreements Weekly consultation meeting keeps team in DBT frame (e.g. acceptance vs. change dialectic), cheerleads, reduces burnout, supports ongoing learning, counteracts therapy interfering behaviors of team members.*** Dialectical Agreement: The team agrees to a dialectical philosophy - no absolute truth - but a synthesis of polarities when extreme viewpoints arise. Consultant to Client Agreement: Team agrees to consult with client on how to interact effectively with the environment, rather than consulting with the environment to interact effectively with the client. Consistency Agreement: Consistency of therapists is not expected. Team members act in a manner called for in a particular situation (based on DBT principles) rather then rigidly adhering to consistency. Team members not only agree to disagree with each other but may not be consistent from client to client or over time with the same client. Clashes are inevitable opportunities for clients and staff to practice DBT Skills. Observing Limits Agreement: Therapists agree to observe their own personal and professional limits without judging others. They also agree not to make inferences about other team members limits. Phenomenological Empathy Agreement: Clinicians agree to strive for non-judgemental, nonpejorative, phenomenologically empathic understanding of clients/behaviors. Fallibility Agreement: The team agrees all members are fallible. DBT assumes therapists will make mistakes opportunity to support/cheerlead, be nonjudgmental, and practice DBT Skills. 46 DBT Comprehensive Demonstration Project Outcomes It is possible! Reduction in ER visits for certain clients Reduced in frequency of hospitalizations for certain clients; decreased length of stay for clients admitted; decreased self-harm, harmful behaviors Increased number of clinicians trained in DBT Increase in DBT services across teams (e.g. Inpatient; EDP; DDMH; SMH Mindfulness) Monthly Education seminar consultation meeting continuing for one year post demonstration project and facilitated by original DBT team members Restructured DBT informed service maintained Waitlist for DBT informed services reduced to weeks Monthly DBT Consultation meetings ongoing 47 KMHSU DBT Informed Service All clients attached to MRC with safety plan in place, some individual contact during treatment, and then attend weekly groups Clients all begin with DBT Core Mindfulness Group Three Components to DBT Skills groups DBT Part l - Core Mindfulness Group - (4 weeks; runs monthly) DBT Part II - (8 weeks; group starts every 2 months) Emotion Regulation, Interpersonal Effectiveness, Distress Tolerance DBT Part lll - Graduate Group - (6 months weekly group sessions upon completion of Part ll) review of all previous skills ***Clients must meet attendance expectations and experience success at each stage in order to move on to the next group*** 48

17 KMHSU DBT Informed Program Referrals ( ) (Average 9.8 referrals/month) (Average 7.7 referrals/month) (Average 10.9 referrals/month)* 2013 (to May 16) 50 (Average 11 referrals/month) Wait times: Referral to MRC - 2 to 6+ weeks MRC to Group - 1 to 4 weeks (depending on referral day/period) (Longer if client requires more preparation with MRC) *(76% attended the 1st Session) 49 Perhaps You Want to Offer DBT? Behavioral Technology Transfer: Participate in an online learning course, attend a two-day workshop, or purchase and view one of the training videos to learn about DBT skills and other components of DBT. Form a study group to read Dr. Marsha Linehan s Cognitive Behavioral Treatment of Borderline Personality Disorder and Skills Training Manual for Treating Borderline Personality Disorder. Attend the annual ISITDBT and Association for Behavioral and Cognitive Therapies conferences for workshops on DBT and related topics. 50 BPD Resources Internet Information and advocacy group for individuals with BPD and family Centre for Addictions and Mental Health (Canada) - excellent BPD guide - Marsha Linehan s Behavioral Technology Transfer Group - Dr. Kernberg s website on BPD - Dr. Friedel s website on BPD - Information about BPD including help for families and friends - Information about DBT written primarily by people who have been through DBT Books The Borderline Personality Disorder Survival Guide. Chapman, A.L., Gratz,K.L., Perry D., Hoffman,P.D., (2007) I Hate You - Don t Leave Me. Kreisman, J. & Strauss, K. (1989) Sometimes I Act Crazy: Living with Borderline Personality Disorder. Kreisman, J. & Straus, K. (2004) Walking on Eggshells: When someone you care about has BPD. Kreger, R, & Mason, P. Skills Training Manual for Treating Borderline Personality Disorder. Linehan, M. M., (1993) A Family Guide to Validation. Valerie Porr (2002) available thru BPD Central New Hope for People with Borderline Personality Disorder. Bockiam, N. (2002) available at TARA Website. Borderline Personality Disorder Demystified: An Essential Guide for Understanding and Living with BPD. Friedel, R. O. (2004) The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation, Fruzetti, A.E. (2006) Borderline Personality Disorder: Meeting the Challenges to Successful Treatment. Hoffman, P. D. & Steiner-Grossman, P. (2008) The Buddha and the Borderline: My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating. Van Gelder, K. (2010) 51

18 Workbooks The Stop Walking on Eggshells Workbook: Practical Strategies for Living with Someone who has BPD. Kreger,R. & Mason,P.(2002) Depressed and Anxious: The Dialectical Behavior Therapy Workbook for overcoming Anxiety and Depression. Marra,T. (2004) Don t Let your Emotions Run your Life: How Dialectical Behavior Therapy Can put you in Control Spradlin,S.E. (2003) The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. McKay, M., Wood, J.C., Brantley, J., & Marra,T 52