Examining 3 Evidence Based Interventions: Dialectic Behaviour Therapy (DBT), Mindfulness and Relational Therapy

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1 Examining 3 Evidence Based Interventions: Dialectic Behaviour Therapy (DBT), Mindfulness and Relational Therapy Jim Cullen, Ph.D., RSW University of Toronto

2 Who are the approaches designed to help?

3 DBT originally designed to help people living with Borderline Personality Disorder, but now being used to treat people who struggle with interpersonal relationships, (primarily romantic, family and friend) and mood, anxiety and substance use disorders. Relational Psychotherapy designed to help people recognize and create healthy relationships. Mindfulness Psychotherapy designed to assist client s who struggle with depression, anxiety, substance abuse and emotional dysregulation

4 Summary of Approaches

5 Dialectic Behaviour Therapy (DBT) is a specific form of cognitive-behavioral therapy. DBT seeks to build upon the foundation of CBT, to help enhance its effectiveness and address specific concerns that the founder of DBT, psychologist Marsha Linehan, saw as deficits in CBT. DBT theory suggests that some people s arousal levels in certain situations can increase far more quickly than the average person s. This leads a person to attain a much higher level of emotional stimulation than normal, and it may take a significant amount of time to return to normal emotional arousal levels.

6 Manualized approach with systematic monitoring to prevent therapy drift Focus on development of 4 sets of skills; Mindfulness Skills teach you to live your life more in the present moment, rather than experiencing painful emotions that come from constantly thinking about the past or the future. Distress Tolerance Skills focus on helping you to learn to cope with crisis situations in healthier, less self-destructive ways. Emotion Regulation Skills help you to manage your emotions more effectively, and to tolerate your emotions when you can't change them or reduce their intensity. Interpersonal Effectiveness Skills help you to maintain relationships through acting assertively, and through taking good care of yourself.

7 DBT differs in practice in one important way. In addition to individual, weekly psychotherapy sessions, most DBT treatment also features a weekly group therapy component during which skills are reviewed and homework provided.

8 Relational Psychotherapy Unlike the traditional view that states that organized drivers and characteristics are the foundation of our psychic structure, Relational Psychotherapy focuses on connectedness to others. Much of the theory has arisen out of the seminal work of psychiatrist, Jean Baker Miller, M.D. She and the "Founding Scholars", Judy Jordan, Janet Surrey and the late Irene Stiver developed the approach in the 1980 s

9 Relationalists argue that personality emerges out of the matrix of early formative relationships with parents and other figures. Philosophically, relational psychoanalysis is closely allied with social constuctionism

10 Core Principles; In order for a person to be emotionally healthy, he or she must maintain fulfilling and satisfying relationships with those around them. Stress and emotional upheaval are often the result of past relational experiences and inhibit the present self from full expression. The therapist administering Relational Psychotherapy provides an atmosphere of empathy and attentiveness in order to elicit a full disclosure of the client s experiences, events, and the affects they have had both relationally and socially. Both the client and therapist work together to forge a strong, uplifting and secure relationship that serves as a model for future relationships the client will strive to develop. This exercise provides a reference for which the client can compare other relationships and can measure them against the supportive one to determine if they are constructive or destructive.

11 Relational Psychotherapy combines the behavioral patterns of a client s experiences with the examination of interpersonal relationships. By facilitating a safe and positive relationship in the security of the therapeutic environment, the client is armed with a stronger sense of self and confidence. The primary goal of this technique is to empower the client with the skills necessary to recognize and create productive and healthy relationships.

12 Every area of social and cultural relevance is considered when working in this type of environment, including race, gender, class, and sexual orientation. The therapist strives to address any and all past and present relationship traumas or impressions that have served to create discord in the present life circumstances of the client.

13 Mindfulness Psychotherapy Mindfulness is a modern reworking of ancient meditation traditions, principally Buddhist. It is designed to help you deal with day to day difficulties by putting you in control of your own mind. Appears to be many definitions but can be traced back to 1979 with the work of Dr. Jon Kabat-Zinn who founded the Mindfulness-Based Stress Reduction Program at the University of Massachusetts

14 Generally it appears that the aim of mindfulness therapy is to help you learn to be aware of your thoughts and bodily sensations and in so doing be able to better cope with day to day emotions and problems.

15 Overall goals offer; Stability of mind maintaining your mind in an alert clear space rather than at the two extremes of a dull or agitated mind. Flexibility of mind the ability to shift your mind to whatever object you choose, rather than having it bounce haphazardly between a number of issues Self awareness being aware of the contents of your mind and understanding the typical patterns of your mind. Acting rather than reacting Becoming less reactive, e.g. when you are angry and choosing how you will act.

16 Appears to be more a collection of approaches that other evidence based therapies already have or are currently incorporating the interventions.

17 Listen to some enjoyable, peaceful music. Each time you become distracted by a thought, write a brief note about the content of that thought. After five minutes, read the notes. What types of thoughts pulled your attention away from the music? Why did those particular thoughts attract you? Were they derived from charged elements in an archetypal field? Watch a movie or television program while maintaining mindfulness. (Our habit -- and the producers' goal -- is to lose ourselves in an emotional involvement.) Try different types of programs: sitcoms, news reports, dramas, soap operas, etc. Write down the details of an activity after you have performed it mindfully. (This activity can be a short walk or a household chore.) Then repeat the activity, and notice the many details which you did not recall the first time. Do a familiar activity as if this is your first time. Say to yourself, "I have never done this before." In Zen, this viewpoint is called "the beginner's mind." Be fascinated and surprised by each step of the process; you don't know what to expect next, so the activity is fresh and exciting and even ecstatic. One of my favorite variations of mindfulness meditation is to use the phrase, "This is just..." (e.g., "this is just walking" or "this is just driving"). That phrase releases me from the burden of analyzing an activity in terms of my personal benefit and thus it frees me to experience the activity in its own manner, with a resulting exhilaration and an experiential intimacy.

18 Various Mindfulness Therapies; Morita Therapy, Gestalt Therapy, Mindfulness-based stress reduction, Mindfulness based cognitive therapy, Acceptance and commitment therapy, Dialectical Behavior therapy, Hakomi Therapy and Internal Family Systems Therapy

19 Once Case: 3 approaches

20 Peter 33 yo male who is completing a MBA while working part-time. Presenting Issues: complains about always choosing the wrong partners. He describes past partners as damaged, and as someone that needs to be taken care of. These failed relationships have left him feeling depressed and anxious regarding his future. He describes his own behaviour in these relationships as extremely jealous, untrusting and needs. But also resentful and emotionally avoidant.

21 What might DBT focus on? What might Relational Psychotherapy Focus on? What might Mindfulness Psychotherapy focus on?

22 The Evidence

23 Levels of Evidence Generally when we are speaking of evidence based practice we mean randomized clinical trials (as the gold standard). Systematic Reviews, Meta-Analysis But do we discount other forms of evidence that should be taken into account? Who conducted the studies?

24 DBT The most consistent observation from research published to date is that the application of standard out-patient dialectical behaviour therapy (stage 1) reduces the rate of suicidal behaviour compared with treatment as usual. Further positive findings have been reported in respect of decreased rates of psychiatric hospitalization and increased patient retention in therapy. The approach has also demonstrated efficacy for patients with borderline personality disorder regardless of the presence of substance use disorders

25 A comprehensive critique of dialectical behaviour therapy has been made by Scheel (2000). The promising findings are acknowledged but significant methodological difficulties in the available studies are outlined. In particular, all studies have had small numbers of participants, who have largely been severely dysfunctional parasuicidal women with borderline personality disorder, and selection criteria have placed restrictions on multiple diagnoses.

26 Borderline personality disorder is a heterogeneous condition with significant differences in individual symptom patterns, and commonly overlaps with other Axis I and Axis II disorders. An important issue for further research is whether this therapy is effective for the entire range of clients with borderline personality disorder or whether it is primarily a treatment for parasuicide. The lack of evidence that it is efficacious for other core features of borderline personality disorder, such as interpersonal instability, chronic feelings of emptiness and boredom and identity disturbance, has led to the suggestion that dialectical behaviour therapy might be the treatment of choice for people with severe, life-threatening life-threatening impulse control disorders rather than for borderline personality disorder

27 Dialectical behaviour therapy is a multifaceted treatment requiring significant theoretical knowledge and clinical skills for its application. Many of the individual therapists in the studies to date were doctoral-level professionals who had been personally trained by Linehan. The finding therefore that this therapy can be effectively learned by mental health professionals outside academic research centres and from a broad range of training backgrounds (Hawkins & Sinha, 1998; Verheul et al, 2003) is important in regard to the clinical usefulness of the treatment. None the less, the difficulties of translating such a model to community mental health settings, where there is often a shortage of suitably trained staff, are obvious

28 Concern also arises as to how long the gains of standard 1-year out-patient dialectical behaviour therapy programmes may last, given that the outcomes in patients given dialectical behaviour therapy and a control group were similar a year after the discontinuation of treatment (Linehan et al, 1993). Research on the later stages of this therapy is awaited. In addition, it has not yet been established that standard out-patient dialectical behaviour therapy is more effective across the range of outcome variables than any other comparatively consistent form of treatment (Scheel, 2000).

29 It is not clear at present how the individual elements of the therapy contribute to treatment outcome. The addition of a dialectical behaviour therapy skills training group to non-dialectical individual therapy has not been shown to be of benefit.

30 It is of interest to note that dialectical behaviour therapy and Bateman & Fonagy s partial hospitalization model have many characteristics in common: an intensive, relationship-focused treatment approach; a highly structured theoretically coherent model; ease of access to therapists; a multimodal approach, with several therapists for each person; regular therapist peer group supervision.

31 Relational Psychotherapy Appears to have the least evidence of the three. Some studies on PTSD and emotional regulation, Substance Abusing Mother s, Family Therapy, Relational functioning and the long term influence of therapy. Research and writing is heavy theoretical but little randomized trials. Despite this the approach is one of the most widely used psychotherapies

32 Scathing critique written by Jon Mills who presents that Relational psychoanalysis is an American phenomenon, with a politically powerful and advantageous group of members advocating for conceptual and technical reform' from a psychologist basis: 'most identified relational analysts are psychologists, as are the founding professionals associated with initiating the relational movement

33 Moreover, in its emphasis on the developmental importance of other people, 'relational theory is merely stating the obvious' - picking up on 'a point that Freud made explicit throughout his theoretical corpus, which becomes further emphasized more significantly by early object relations therapists through to contemporary self psychologists

34 Mindfulness Psychotherapy In spite of significant methodological flaws, the current literature suggests that mindfulness-based interventions may help to alleviate a variety of mental health problems and improve psychological functioning. These studies also suggest that many patients who enroll in mindfulnessbased programs will complete them, in spite of high demands for homework practice, and that a substantial subset will continue to practice mindfulness skills long after the treatment program has ended. Mindfulness-based interventions appear to be conceptually consistent with many other empirically supported treatment approaches and may provide a technology of acceptance to complement the technology of change exemplified by most cognitive-behavioral procedures

35 In general, findings for chronic pain patients show statistically significant improvements in ratings of pain, other medical symptoms, and general psychological symptoms. Many of these changes were maintained at follow-up evaluations. Most of these comparisons used pre-post designs with no control group. Studies also showed benefits for anxiety and depression and fibomyalgia

36 Common Factors across the Literature Therapeutic alliance still the #1 predictor of success It appears that intensity and length of engagement are again correlated factors Is individual better than group? No difference. However individual and group result in higher outcomes

37 Resources (DBT) (Toronto Institute for Relational Psychotherapy)