Dialectical Behavioural Therapy and Dual Diagnosis

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Rudolph McKenzie
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1 Dialectical Behavioural Therapy and Dual Diagnosis Presenters: Sara Luck, BSc, CYW Dual Diagnosis Coordinator Lisa St. Pierre, BA (Hons), MSW Program Manager

Coordinator sluck@cmhaottawa.ca Lisa St.

2 Learning Objectives 1. Provide an overview of Dialectical Behavioural Therapy 2. Understand how CMHA-Ottawa branch has adapted DBT to increase support to clients 3. Understand how CMHA is adapting DBT for clients with dual diagnosis

3 Exercise

4 What is Dialectical Behavioural Therapy? Dialectical Behavioural Therapy (DBT) was developed by the Psychologist Marsha Linehan initially for individuals with Borderline Personality Disorder. It is a cognitive behavioural approach that is useful to people with impulsive and sometimes life threatening behaviours, with difficulty tolerating distress, who have difficulties in relationships and with regulating their emotions. DBT is essentially a skills based therapy offering more practical and effective coping techniques. It includes a strong emphasis on acceptance of the person as they are, combined with the expectation that current behaviour need to change. Dialectics refers to finding the middle ground between two opposites (radical acceptace vs. need for change) DBT requires a strong commitment to therapy from both the client and the therapist

and with regulating their emotions. DBT is essentially a skills based therapy offering more practical and effective coping techniques.

5 Who Benefits From DBT DBT was particularly designed for adults with a diagnosis of Borderline Personality Disorder but has shown to be beneficial when applied to other diagnoses such as depression, anxiety, eating disorders, substance use, etc. Individuals who benefit tend to have difficulties with: Communication skills Conflict resolution Anxiety management Recognizing and regulating emotions Dealing with stressful situations Interpersonal relationships Sense of identity Problem solving Consider how intellectual disability affects the above.

Individuals who benefit tend to have difficulties with: Communication skills Conflict resolution Anxiety management Recognizing and

6 DBT Components Primary components 1. Skills training (group) 2. Weekly individual sessions 3. Phone coaching 4. Weekly consultation meetings

7 DBT Modules Mindfulness Distress tolerance Emotion regulation Interpersonal effectiveness

8 Our Clients CMHA Ottawa works with individuals aged 16 and over with severe and persistent mental illness and complex needs (problematic substance use, homelessness, legal issues, isolation, health problems )

illness and complex needs (problematic substance

9 CMHA at a glance Concurrent Disorders Smoking cessation Volunteer Program/Peer support Clinical support DBT Case Management (Community Support Services) Outreach (Housing, Hospital, Court) Vocational support Dual Diagnosis Service Housing Capacity building and education Recreation Extended Hours

Support Services) Outreach (Housing, Hospital, Court) Vocational support

10 DBT Team Senior Manager (Supervisor) 2 Psychiatrists (hospital and private practice) Nurse (CMHA staff) DBT Worker (CMHA, 1FTE) 2 Case Managers/DBT Workers (equivalent 2 FTE) 1 Community Mental Health and Addiction Worker/DBT Worker

Worker (CMHA, 1FTE) 2 Case Managers/DBT Workers

11 DBT at CMHA-Ottawa DBT Modified model of standard DBT Group with participation of case managers DBT Worker s Group- required learning opportunity and consultation for Case Managers on DBT skills and strategies in working with supporting BPD Clients. DBT-S- modified standard DBT group tailored to individuals with substance use issues

for Case Managers on DBT skills and strategies in working with supporting BPD

12 DBT at CMHA-Ottawa (cont d) DBT Butterfly Group- continual use of DBT skills focusing on meaningful and mindful living; peer facilitation component DBT Focus Group learning opportunity for CMHA staff on DBT skills, strategies and theory DBT for DD Pilot Project-12 week group for clients and workers

component DBT Focus Group learning opportunity for CMHA staff on DBT

13 Challenges doing DBT with people who have intellectual disability/developmental delay (ID/DD) Use of metaphors and abstract ideas Reliance on memory (use of acronyms, etc.) DEAR MAN, IMPROVE the moment, Wise Man ACCEPTS, GIVE, FAST, PLEASE MASTER Reading comprehension and writing skills Attention span Typical yes or no answers and black or white thinking patterns can be counter-dialectical Often have lots of dependency on family or professional supports, which can work against the consultation to the client approach of DBT Ability to generalize classroom skills in the community DBT is a long process, and people with ID/DD require more time than average to absorb material. Resources might be limited in providing DBT for several months

patterns can be counter-dialectical Often have lots of dependency on family or professional supports, which can work against the consultation to the client approach of DBT Ability to

14 Benefits in doing DBT with people who have ID/DD Approximately 1/3 of adults with ID/DD have emotion dysregulation and challenging behaviours yet there is a lack of services specific to this population People are able to learn the skills Skill building (with homework, handouts, etc.) more concrete than therapeutic counseling sessions ( talk therapy ) More empowering than traditional behaviour modification approaches Cost effective (ex. learning skills in the community to keep a person out of hospital)

15 Helpful adaptations Longer treatment time, more repetition Hold some sessions in the community to encourage generalization of skills Customize individual sessions Modify handouts and diary cards (more colour, less words, etc.) Simplify language and concepts

skills Customize individual sessions Modify handouts and diary

16 Helpful adaptations, cont d Involve family/support network Emphasis on having fun Use hands-on activities involving all the senses (film, music, pictures, visual aides, comfort kits, role play, games, etc.). Less lecturing and more group discussion Other typical approaches when working with someone who has a delay (ask for feedback, pay attention to speed of speech and complexity of sentences, etc.)

17 Example of individualized emotion regulation and relationship effectiveness lesson/exercise: The Roommate from Hell A Choose Your Own Ending Story by Sara Luck

18 Thoughts vs. feelings about the neighbours A look back on some texts What am I thinking? What am I feeling? What s another way of thinking about the problem? I slept at moms last night didn t sleep much Sat night guy was nuts lol (Monday, November 26, 2012, 9:51 am) He never goes out much either I am complaining if he keeps me up all night again he has no respect (Monday, November 26, 2012, 10:17 am) Wakie wakie the guy was at it til 1230 am past bilaw I hardly slept this is war with him (Tuesday, November 27, 8:23 am) He has no respect for other people Im mad (Tuesday, November 23, 8:23 am) I only sleep till late last night cause of banging above but it is what it is cant change it (Friday, December 14, 11:39 am)

night again he has no respect (Monday, November 26, 2012, 10:17 am) Wakie wakie the guy was at it til 1230 am past bilaw I hardly slept this is war with him (Tuesday, November 27,

19 Emotion recognition lesson/exercise: explaining the difference between emotions and thoughts How do you think this woman is feeling? What makes you say that? Let s use our imaginations why do you think this woman might be feeling that way?

this woman is feeling? What makes you say that?

20 Relationship effectiveness lesson/exercise: Steps in a Relationship HUSBAND OR WIFE/LIFE PARTNER BOYFRIEND OR GIRLFRIEND/GOING STEADY/EXCLUSIVE DATE FRIENDS WITH BENEFITS/ FRIEND BOOTY CALL HOOK UP/ ONE NIGHT STAND START AS STRANGERS ACQUAINTANCE

GIRLFRIEND/GOING STEADY/EXCLUSIVE DATE FRIENDS WITH BENEFITS/

21 DISTRESS TOLERANCE BINGO DISTRACT WITH AN ACTIVITY CONTRIBUTE (DO SOMETHING NICE FOR SOMEONE) COMPARISON (TO SOMEONE WHO HAS IT WORSE OFF OR TO A TIME IN YOUR LIFE WHEN THINGS WERE WORSE) TRY OUT THE OPPOSITE EMOTION TO WHAT YOU RE FEELING (LIKE WATCHING A COMEDY IF YOU RE ANGRY OR SAD) USE ICE ON YOUR SKIN TO HELP CALM YOURSELF FOCUS ON LOOKING AT SOMETHING THAT MAKES YOU FEEL GOOD LISTEN TO SOMETHING THAT MAKES YOU FEEL GOOD AND FOCUS ON THIS SMELL SOMETHING SOOTHING AND FOCUS ON THIS TOUCH SOMETHING SOOTHING (LIKE YOUR CAT) AND FOCUS ON THIS TASTE SOMETHING YOU LIKE AND FOCUS ON THIS LOOK FOR A POSITIVE MEANING BEHIND WHATEVER S BOTHERING YOU (THINK ABOUT EVERYTHING HAPPENING FOR A REASON) PRAY OR MEDITATE DO SOMETHING RELAXING FOCUS ON ONE THING AT A TIME (LIKE WASHING DISHES OR VACCUUMING) TREAT YOURSELF TO A MINI VACATION /SPOIL YOURSELF THINK OF THE PROS AND CONS BEFORE ACTING ON SOMETHING YOU MIGHT REGRET LATER AVOID NON-PRESCRIPTION DRUGS AND ALCOHOL EAT HEALTHY FOODS EXERCISE GET ENOUGH SLEEP DISTRACT YOURSELF WITH DIFFERENT THOUGHTS (LIKE DOING A WORD SEARCH OR COUNTING ALL THE ROUND OBJECTS IN A ROOM) IMAGINE YOUR HAPPY PLACE GIVE YOURSELF WORDS OF ENCOURAGEMENT (LIKE YOUR OWN PERSONAL WARM FUZZY JAR) TAKE TEN DEEP BREATHS WRITE IN A JOURNAL

22 Some existing programs The Bridge (Dr. Lew, Central Massachusetts) Aurora Mental Health Centre/Intercept Center Aurora Mental Health Centre/Intercept Center (Dr. Charlton, Colorado)

23 The model we re using at CMHA The Skills System (Julie Brown, Rhode Island) Involves a set of 9 skills that participants learn during the program

24 Skills covered:

25 Our pilot project 5 clients and their mental health workers 2 co-facilitators (dual diagnosis worker and psychiatrist) 12 week program, each session 1.5 hours long 12 week program, each session 1.5 hours long with a 15 minute break

26 Format of DBT for DD group: Mindfulness exercise Review of homework and diary cards (how they practiced their skills during the week) Teach new material Break Activity based on new material Assign new homework Debrief ( what worked for people this week )

27 Questions?

Who We Serve Adults with severe and persistent mental illnesses such as schizophrenia, bipolar disorder and major depression.

Who We Serve Adults with severe and persistent mental illnesses such as schizophrenia, bipolar disorder and major depression. We Serve Adults with severe and persistent mental illnesses such as schizophrenia, bipolar disorder and major depression. We Do Provide a comprehensive individually tailored group treatment program in