Dialectical Behaviour Therapy (DBT) for Borderline Personality Disorder

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1 Dialectical Behaviour Therapy (DBT) for Borderline Personality Disorder Dr. Kathy Fitch, Psychiatrist Janice Wingrave,, RPN, Clinical Supervisor Janice Wingrave,, RPN Clinical supervisor to comprehensive DBT outpatient program with 9 therapists, 2 psychiatrists, and allied supports (OT, ILS), CCMHC Maintaining our program s s participation in ongoing formal training and research with BTech Organizing educational opportunities for clinicians outside the clinic DBT Intensive Training (BTech( BTech), Parts 1 & 2, and ongoing BTech supervision Dr. Kathy Fitch Psychiatrist in DBT program (25% of time), CCMHC Psychiatrist on general adult psychiatry inpatient unit, Foothills Medical Centre (75% of time) Involved in training and supervision of medical students and residents DBT Fellowship, DBT Foundational Training (BTech), Beck Institute CBT External Fellowship 1

2 Standard DBT Program DBT individual therapy (weekly) DBT skills group (weekly when in group) DBT consult group (therapists only) Telephone coaching (ideally 24/7) 12 month commitment +/- DBT generalization group (approaching graduation) +/- DBT family education series DBT Skills Group 4 Skills Training Modules: Mindfulness skills Emotion Regulation skills Distress Tolerance skills Interpersonal Effectiveness skills What is Borderline Personality Disorder? (DSM-IV IV-TR definition) A pervasive pattern of instability of interpersonal relationships, self- image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: 2

3 What is BPD? 1. Frantic efforts to avoid real or imagined abandonment. *Not (5) 2. Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. What is BPD? 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). *Not (5) 5. Recurrent suicidal behaviour,, gestures, or threats, or self-mutilating behaviour. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,, irritability, or anxiety usually lasting a few hours and only hours and only rarely more than a few days). What is BPD? 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related related paranoid ideation or severe dissociative symptoms. 3

4 Objectives 1. Gain an understanding of the Biosocial Theory of Borderline Personality Disorder 2. Gain an understanding of the key components of a DBT approach: Core Strategies and Dialectical Assumptions 3. Leave the session with one clear strategy that can be used with a client and/or loved one Objectives 1. Gain an understanding of the Biosocial Theory of Borderline Personality Disorder 4

5 Bio-Social Theory EMOTION DYSREGULATION Emotionally Vulnerable individual Invalidating Environment Linehan 1993 Communication can be verbal or nonverbal, and often it is both. What is an invalidating environment? Core features: Indiscriminately rejects communication of private experiences and self-initiated behaviours Intermittently reinforces escalation of emotional responses and display Oversimplifies ease of problem solving and meeting goals 5

6 What is an invalidating environment? The private experience of an individual is negated by the environment E.g. You don t t really think that. E.g. You re doing that on purpose. I didn t t even mean it that way. E.g. That s s not how you really feel. Eg.. You re being stupid/ridiculous/silly. E.g. You re not really hurt. What is an invalidating environment? The private experience of an individual isn t t accurately recognized or reflected by the environment E.g. emotionally sensitive child with a busy/preoccupied parent Internalized invalidating environment Stop trusting your own emotions. Stop trusting your own perspective. Tendency to judge yourself and others. Lack of skills in managing your thoughts/feelings/behaviours behaviours. 6

7 Objectives 1. Gain an understanding of the Biosocial Theory of Borderline Personality Disorder 2. Gain an understanding of the key components of a DBT approach: Core Strategies and Dialectical Assumptions DBT Core Strategies Acceptance/validation Change 7

8 Successful Validation: Reduces arousal Validation has succeeded when arousal associated with invalidation is reduced Highly aroused Ready to learn Too relaxed What to validate Validation does not automatically imply liking, approval or preference MM Linehan 1997 What to validate Recognizing the kernel of truth in the person s s experience. Remember: emotions are one of the easiest things to validate E.g. You seem really hurt/mad/affected by that. 8

9 Remember! Match the verbal and nonverbal message NB: If the tone of voice is mismatched, then words intended to validate the person s s feelings may be experienced as invalidating E.g. (irritable instead of concerned) You seem really angry about that. E.g. (cheerful instead of concerned) You seem really sad. Challenges of validating the sensitive individual Quicker reaction to events than expected Higher than expected intensity of reactions Slower settling of emotions 9

10 Mindfulness The repetitive act of directing your attention to only one thing in this one moment means training your mind to pay attention to what you choose to pay attention to instead of letting your mind hijack you. Whatever your attention is on, that s s what life is for you at any given moment. Considered the core skill required to develop other DBT skills. Metaphors: Untrained puppy TV channel surfing Clouds in the sky Mindfulness 10

11 Change strategies Based on thought/emotion/behaviour change techniques used throughout cognitive-behaviour therapy (CBT) Strong emphasis on validation to balance the strain of change Mindfulness skills allow for clear observation, and contemplation of alternatives for change 11

12 DBT Assumptions about Patients Patients are doing the best they can Patients want to improve The lives of suicidal BPD patients are unbearable as they are being currently lived Patients must learn new behaviours in all relevant contexts Patients cannot fail in DBT Patients did not cause all their own problems, but they are responsible for solving them Patients need to do better, try harder and/or be more motivated to change Dialectics A dialectic is finding synthesis in opposing experiences and points of view Dialectics involves several assumptions about the nature of reality: 1) everything is connected to everything else; 2) change is constant and inevitable; and 3) opposites can be integrated to form a closer approximation to the truth (which is always evolving). Nothing is just black and white. Dialectic: an example 2 people standing on opposite ends of an elephant will offer very different descriptions of what an elephant looks like The synthesis of these descriptions incorporates both points of view 12

13 Objectives 1. Gain an understanding of the Biosocial Theory of Borderline Personality Disorder 2. Gain an understanding of the key components of a DBT approach: Core Strategies and Dialectical Assumptions 3. Leave the session with one clear strategy that can be used with a client and/or loved one What strategy will you take away from today s session? 13

14 Summary 1. Gain an understanding of the Biosocial Theory of Borderline Personality Disorder 2. Gain an understanding of the key components of a DBT approach: Core Strategies and Dialectical Assumptions 3. Leave the session with one clear strategy that can be used with a client and/or loved one Contact Information Referrals: Access Mental Health ( ), private clinic Inner Solutions Website information: behavioraltech.org, borderlinepersonalitytoday.com, bpdcentral.com Staff recruitment: CHR website For more information: DBT Clinic phone number: CHR People First Awards: Dialectical Behaviour Therapy Treatment Team 14

15 Community Education Service To register for notification or an upcoming education session go to: For general CES enquiries Call: Funding generously provided by Encana Corporation and the Alberta Children s Hospital Foundation 15

Aggression and Borderline Personality Disorder. Michele Galietta, Ph.D. January 15, 2012 NEA.BPD Call-In Series

Aggression and Borderline Personality Disorder Michele Galietta, Ph.D. January 15, 2012 NEA.BPD Call-In Series Goals for this Presentation Define Aggression Distinguish Anger from Aggression Discuss Evidence-Based