Does your mental health service need Dialectical Behaviour Therapy?

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Does your mental health service need Dialectical
Behaviour Therapy?

• S.Fox
• L.Gauld
• C.Lamza
• E. Malcomson

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How it all begins....

• From the service users point of view

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Getting the patient ready

• Consider
• Do you use a formal assessment for the patient
  who describes impulsive, chaotic, self-damaging
  behaviours
• Do you discuss and diagnose your patient with
  Borderline Personality Disorder (BPD)
• What treatment options are available for patients
  with BPD

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The Treatment Options?

• Discharged/GP only follow up
• Medication
• In-patient care/Respite admission
• AE
• Counselling
• Standard out-patient follow up
• Psychotherapy........

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Psychological Therapy choices

• Acceptance and Commitment Therapy
• Cognitive Analytic Therapy
• Cognitive Behaviour Therapy
• Dialectical Behaviour Therapy
• Interpersonal Psychotherapy
• Psychodynamic Psychotherapy/Mentalisation
• Solution Focused Therapy
• STEPPS, REBT, FAP, PCT, EMDR........

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Referring a patient for DBT

• Ideally,
• Ensure that the diagnosis of BPD is confirmed and
  that the patient has a clear understanding of the
  therapy
• Provide a detailed referral, completed jointly
  with the patient. Highlight problematic
  behaviours.
• Include background information

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The Assessment

• Welcome and orientate the patient to the
  treatment
• Explore patients views on diagnosis
• Confirm and update referral information
• Assess commitment
• Complete a diagnostic examination using validated
  instruments
• Offer a prompt and solution focused outcome

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Assessment Instruments

• Structured Clinical Interview for DSM IV Axis II
  Personality Disorder (SCID II) (First et al,
  1995)
• - Assesses personality disorders either
  categorically or dimensionally using DSM IV
• It is a semi-structured clinical interview.
• Diagnostic Interview for Borderlines
  DIB-R(Revised Version) (Zanarini et al, 1989)

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Pre-treatment

• Preparing your patient for therapy
• The structure and the theory of the DBT
• The targets DBTs and the patients
• The contract and consenting to treatment
• The rules telephone, individual and group
• Chain analysis
• The diary card

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Full DBT

• The manualised therapy consists of
• Weekly individual therapy session (with DBT
  therapist) for 1 year
• Weekly Skills Group training (with DBT trained
  facilitators) a 6 month programme, repeated.
• Arranged telephone consultation
• Consultation group supervision (for therapists
  all DBT)

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The Individual therapy session

• Always based on the diary card
• Attends to the treatment targets in a
  hierarchical way
• Is the combination of the core strategies of
  validation and problem solving plus Dialectical,
  Irreverent, Reciprocal communication and Case
  management strategies
• Maintains a balance between acceptance and change

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Date of Session Urge to Quit Therapy Misery Suicidal Ideation Urge to Self-Harm Action on Self-Harm Urges Did I have a structured routine Misuse of medication (and how many tablets) Probs with sleep (how many hours) Anx Starving/ Bingeing Use of Laxatives (if yes, how many)
2011 0 - 5 0 - 5 0 - 5 0 - 5 YES/ NO 0 - 5 YES/NO YES/NO 0 - 5 YES/NO YES/NO
Mon
Tues
Wed
Thur
Fri
Sat
Sun
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The Skills Group

• Mindfulness - teaches the individual how to
  balance the mind (2 sessions, repeated after each
  module)
• Emotion Regulation Skills - helps to regulate or
  balance painful emotions (8 sessions)
• Interpersonal Effectiveness Skills - helps the
  individual to ask effectively for what they need
  and to cope with interpersonal conflict (8
  sessions)
• Distress Tolerance - promote acceptance in a
  non-judgemental way of the individual and the
  situation (4 sessions)
• 26 weeks, then repeated again.

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Telephone Consultation

• All calls must be before a patient engages in
  self-harming/suicidal behaviours
• The patient does not require to be suicidal to
  initiate telephone consultation patient has to
  be in crisis/unable to cope with problems in
  living
• Telephone consultation is designed to teach the
  patient how to apply DBT skills
• Should be brief, skills based and in line with
  the telephone strategy checklist

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Consultation Group Supervision

• All therapists must attend regularly
• Requires a structured agenda
• Mindfulness exercise to begin
• Feedback on both individual and skills group is
  essential
• Provides an opportunity for Cheerleading
• Ensures dialectical balance
• Helps identify further DBT training needs

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The DBT patient experience

• From the service users point of view.....