Background/Context. OPA Annual Conference 2018 November 17, Drs. Pires & Pigon 1. Ontario Context

Transcription

1 Dialectically Speaking on DBT for Adolescents Dr. Paulo Pires, Ph.D., C.Psych. Dr. Danielle Pigon, Ph.D., C.Psych. McMaster Children s Hospital Hamilton Health Sciences Background/Context Ontario Context 2017 OSDUHS Mental Health and Well-Being Report 19% rated their mental health as fair or poor 17% of students report a serious level of psychological distress in the past month 14% of students report serious thoughts of suicide in the past year 4% of students report a suicide attempt in the past year Drs. Pires & Pigon 1

2 Suicidal Behaviours in Youth For every death by suicide there are an estimated 8 to 25 suicide attempts.. and more youths engage in NSSI. NSSI is a predictor of subsequent suicide attempts among depressed youth (Asarnow et al., 2011; Wilkinson et al., 2011) 60 to 77% of adolescents with elevated suicide risk demonstrate nonadherence to recommended care (Burns et al., 1995) Drs. Pires & Pigon 2

3 Non-Suicidal Self-Injury Commons reasons for NSSI include (Klonsky, 2007) Affect regulation/avoidance To reduce dissociation Interpersonal communication Self-punishment DBT Theory DBT Linehan, 1993; 2015 Cognitive-behavioral treatment approach for treating chronically suicidal patients, often with Borderline Personality Disorder. Overarching DBT Goal: Building A Life Worth Living Targets treatment engagement, reduction of self-harm and suicide attempts, and focuses on teaching skills Drs. Pires & Pigon 3

4 Biosocial Theory Emotion vulnerability = Emotionally sensitive Emotions are intense Slow return to baseline low emotion vulnerability high emotion vulnerability Agitated, moody, touchy 10 Invalidation. Has been associated with increased levels of affect and physiological arousal (Shenk & Fruzzetti, 2011) Never learned how to label and regulate emotions, how to tolerate distress, or when to trust own emotional responses Invalidate own emotional experiences, look to others for accurate reflections of reality, and oversimplify the ease of problemsolving. Summary of DBT Theory Individuals who are biologically predisposed to experiencing very strong emotions AND experienced invalidation of their emotions by caregivers Experience very strong negative emotions but know few skills to manage them. Suicidal/self-injurious behavior is used as a maladaptive means of coping with negative emotions. DBT teaches positive coping skills. Drs. Pires & Pigon 4

5 Jekyll and Hyde The individual with BPD learns to alternate between one behavioral pattern that underregulates emotion and another that overregulates emotion. The fluctuations between polarities are hypothesized to occur because the tension or discomfort of each extreme triggers its opposite or complementary pattern (Rathus & Miller, 2000). Common Dialectical Dilemmas Emotional Vulnerability Self- Invalidation Active Passivity Apparent Competence Unrelenting Crisis Inhibited Grieving DBT = Acceptance + Change Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion Regulation Acceptance Change Theory Zen practice Behaviourism Tools Validation The Grease Skills, reinforcement, punishment, exposure, cognitive restructuring The Wheels 15 Drs. Pires & Pigon 5

6 Understanding the Structure of DBT DBT Functions & Modes Function= Objective or aim of DBT Mode= Therapy component that supports each objective Behaviouraltech.org Stages of DBT Drs. Pires & Pigon 6

7 Treatment Targets 19 Individual Therapy Focus is determined by treatment target hierarchy and client s behavior since the last session Actively teach/reinforce specific skills Use diary cards to self-monitor Maladaptive behaviors (e.g., self-cutting, drug use) Adaptive behaviors (use of specific skills) Analyze the Chain of Events Moment-to-Moment Over Time Vulnerability Factors Problem Behavior Prompting Event Links Consequences Drs. Pires & Pigon 7

8 The Need for Skills What does the Research Say? Research on DBT in Adults DBT with adults has multiple RCTs supporting its efficacy in decreasing suicide attempts in adults (see behaviourtech.org for list) Psychological therapies for people with borderline personality disorder (Cochrane Review, 2017) DBT is helpful for people with BPD. Effects included a decrease in inappropriate anger, a reduction in self-harm and an improvement in general functioning. Too few studies to allow firm conclusions to be drawn about the value of all the other kinds of psychotherapeutic interventions evaluated. Drs. Pires & Pigon 8

9 DBT is a promising treatment for suicidal youth DBT was adapted for adolescents (Miller, Rathus, & Linehan, 2007). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: A randomized trial. (Mehlum et al., 2014; 2016) DBT-A was superior to enhanced usual care in reducing self-harm, suicidal ideation, and depressive symptoms. Recently Published RCT Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk of Suicide: A Randomized Clinical Trial (McCauley et al., 2018) 4 academic medical centres (N=173, 12 to 18 year olds DBT compared with Individual and Group Supportive Therapy (IGST) With now 2 independent trials supporting efficacy, results support DBT as the first well-established, empirically supported treatment for decreasing repeated suicide attempts and self-harm in youth. Advantage for DBT at 12 months indexed by absence of self-harm Youth in DBT more likely to complete treatment (stronger treatment retention) Importance of Validation Skills Middle Path skills ranked highly among the DBT skills perceived as most helpful, with validation rated the most beneficial aspect of skills training (Rathus et al., 2015). Drs. Pires & Pigon 9

10 Maladaptive behaviours Common underlying dysfunction is emotion regulation among various disorders and problem behaviours 28 American Psychological Association Division 12 Division 53 What we know so far is that having the family involved is really important to keeping kids safe. There are many effectiveness trials underway to evaluate individual therapies as well as dialectical behavior therapy (DBT). BPD in Adolescence? Both normal and disordered personality remain relatively fluid over the first three to five decades of life Drs. Pires & Pigon 10

11 BPD in Adolescence Research suggests that BPD is not uncommon in adolescents. It has been argued that it is primarily a disorder of young people, as BPD traits in young people appear to be at least as high, if not substantially higher, than in adults. In community settings, BPD is estimated to affect about 3% of adolescents, while in clinical settings it is higher, ranging between 11% (of adolescent outpatients) to 49% (of adolescent inpatients). Modifications to Standard DBT Protocol for Adolescents (Miller et al., 1997; 2007) Modifications: Treatment Length and Materials Shortened from 1 year to 20 weeks: More appealing to adolescents Offer a brief treatment, as a number of adolescents with NSSI or suicide attempts did not meet full criteria for BPD Access for clients who may not be able to afford longer therapy Parents have to be able to commit to group for that time Skills handouts are modified Modified diary cards, simplified terminology and visual layout Drs. Pires & Pigon 11

12 Example of Modified Diary Card Name: How often did you fill out this week? Filled out in session? Daily Yes / No 2-3 times Once Month Self-Harm Suicidal Restriction/ Dysregulatio n Lying Medication taken as Prescribed Alcohol/Dru Selfcompassion Dissoci s/ Angry Sad Lonely Happy Anxiou gs ation Fearful Skills* Date: Action Acti Action Action Action Action Action Urge Urge Urge Urge Urge Yes/ Urge on Urge Yes/No Yes/No Yes/No Yes/No Y/N No Y/N Tues Wed Thurs Fri Sat Sun Mon *USED SKILLS 0 = Not thought about or used 1 = Thought about, not used, didn t want to 2 = Thought about, not used, wanted to 3 = Tried, but couldn t use them 4 = Tried, could do, but didn t help 5 = Tried, could use them, helped 6 = Didn t try, used them, didn t help 7 = Didn t try, used them, helped Rating Scale for Emotions and Urges (above): 0=Not at all 1=A bit 2=Somewhat 3=Rather Strong 4=Very Strong 5=Extremely Strong Urge to Quit Therapy: 0-5 Misery Index: 0-5 Pleasurable events that happened during the week: ANYTHING ELSE?? Yes No Low on meds? Yes No Modification: Addition of Walking the Middle Path (WMP) Module Adolescent specific module, Walking the Middle Path (WMP) included WMP goal: move away from extreme responses WMP skills: Validation to self and others Behavioural principles Adolescent-family dialectical dilemmas WMP - VALIDATION (Acceptance) The grease for the wheels of change Is finding the kernel of truth or wisdom in the client s behaviour or point of view, and saying so. De-escalates emotional dysregulation Reduces isolation, stress, oppositional behaviour Strengthens client s ability to find own wisdom and confidence Strengthens relationship Increase willingness to change/problem-solve Drs. Pires & Pigon 12

13 Validation: How-To Look for how the feelings, thoughts, and actions make sense, given the other person s history and current situation. Reflect without judgment and be radically genuine It makes sense that you would feel like this too won t work, especially given that previous hasn t been helpful. therapy I get why you d be feeling like ending your life is the only solution. You are feeling miserable and don t know how to make life better. I can see why you d be so angry about being asked for money. You ve been trying to get your son to get a job for a long time and it has felt to you like he takes your money for granted. I understand why you wouldn t want to go to school in the mornings. You ve been bullied before and worry that it might happen again. Of course you don t want to go. Validation: I don t see anything to validate You do not have to: Agree with the client, approve of the behaviour, or convey warmth. Don t validate inappropriate behaviour (reinforces it/normalizes it) Focus on validating the emotion or the function, not the behaviour (e.g.,. validate what is understandable about self-harm (e.g., communicate, cope) AND discuss ways to stop) You re experiencing intense pain and you can t find any way out of it, so I understand why you d be having thoughts of killing yourself. So let s do something about it. I do understand that it makes you feel good to spend time with your friends, including when you get high. And, I think it is a bad idea for you to get high right now, given your depression and recent suicidal urges. Validation: Cheat-Sheet It makes sense that you feel (focus on emotion), because, because, and because. Drs. Pires & Pigon 13

14 WMP - Behaviourism (Change) Ways to increase behaviours: Reinforcement (positive and negative) Shaping Ways to decrease behaviours: Extinction (beware of behavioural burst and intermittent reinforcement) Punishment Use sparingly, because: does not teach new behaviour, can lead to resentment /demoralization, may lead to self-punishment Modification: Adolescent-Family Dilemmas Addition of three adolescent-family dilemmas Are secondary behaviour targets Adolescents and families tend to vacillate between these polarities extreme distress. Central dilemma of treatment is to help adolescents and parents move to a balanced position representing synthesis. Walking the Middle Path: Excessive Leniency vs. Authoritarian Control Being Too Loose Being Too Strict Have clear rules/values and follow them consistently, and at the same time be willing to negotiate on some issues. 42 Drs. Pires & Pigon 14

15 Walking the Middle Path: Normalizing Pathological Behaviors vs. Pathologizing Normative Behaviors Making Light of Problem Behaviours Making Too Much of Typical Adolescent Behaviours Recognize when a behaviour crosses the line and try to get help for that behaviour, and at the same time recognize which behaviours are part of typical adolescent development. 43 Walking the Middle Path: Forcing Autonomy vs. Fostering Dependence Holding on Too Tight Forcing Independence Too Soon Adolescents need guidance, support, and structure to help them figure out how to be responsible with his or her life, and at the same time slowly give your adolescent greater amounts of freedom and independence, while continuing to allow an appropriate amount of reliance on others. 44 Modification: Inclusion of Family Members Multi-family skills group 5-7 families in the group Consistent caregiver(s), typically parents Enhance generalization and reinforces skills and structure in adolescents environment Parents learn skills (serve as models and coaches) Opportunities to role play skills, support between families, reducing disruptive behaviors in group, enhancing treatment compliance Coaching calls for parents can be completed by group co-facilitator Drs. Pires & Pigon 15

16 Modification: Family Sessions On an as-needed basis Typically 3-4 sessions, though +/- as needed: When relationship with family member is source of conflict Address crises within the family To provide psychoeducation regarding skills, or understanding regarding adolescents vulnerability, To address contingencies in home that reinforce dysfunctional behaviour Improve family communication Address parent s emotion dysregulation Modification: Family Sessions Consider possible roles of adjunct family-based treatment: Emotion-Focused Family Therapy (EFFT) (LaFrance and Dolhanty) Parents complete two-day caregiver workshop where focus is on emotion coaching/validation, or 4 hour evening workshop Clinical Outreach Team Focus on supporting implementation of behavioural strategies, parent skills training Extends services to the home environment Family Check-Up (Dishion et al.) Strengths based assessment looking at parent/family well-being, child well-being and parenting skills, followed by Everyday Parenting curriculum Modification: Inclusion of a Second Phase of Treatment For clients who continue to exhibit difficulties following the first phase of therapy Examples: Optional graduation group Possibility of repeating multi-family skills skills group during when completing a prolonged exposure (PE) protocol for PTSD Drs. Pires & Pigon 16

17 DBT with Teens: Individual Therapy Tricky Issues & Tips Therapy Style with Adolescents Irreverence Up-regulation and down-regulation Radical Genuineness Openness to not having traditional office therapy (e.g., Walk and Talk ) Individual session: Cheat sheet Greet client Ask for diary card Review diary card & plan your session -set an agenda Review individual therapy homework (if applicable) Check progress of other modes (e.g., group, family therapy) Target stage 1 priorities Target in session dysfunctional behaviour Session ending strategies Drs. Pires & Pigon 17

18 Tricky Issues & Tips: Diary Card I didn t do it Do: Complete in session withdraw attention/warmth (behaviourism) If pattern treat as therapy interfering behaviour (chain to understand noncompletion) Validate what is valid, link completion to goals and personal values Problem-solve as needed (reminders, contingencies, etc.) Modify demands as needed (Too many columns? Avoidance of rating scales? Avoidance of rating emotion?) and shape Reinforce/praise completion Keep treatment hierarchy and therapeutic goals in mind, while being collaborative Tricky Issues & Tips: Diary Card I didn t do it. Don t: Forget to set an agenda for the session! Forget to ask if there s anything important that they would like to bring up (see hand-on-door, later) make time for that on the agenda Get caught in current crisis (more on venting, later) Forget that you too can be shaped out of diary card completion! Tricky Issues & Tips: Homework I didn t do that either. Do: (similar approach to diary card non-completion) Provide psychoeducation if needed, BUT consider other behavioural functions. validate and chain to understand the behaviour consider whether lack of skills or emotion are a barrier, and problem-solve accordingly Don t: Get caught in lecture-mode! Drs. Pires & Pigon 18

19 Tricky Issues & Tips: Progress in other modes I hate group ; My mom humiliated me, and I m not going back!! Do: Validate Chain and problem-solve according to treatment hierarchy Barriers: Skills (teach) VS. Emotion (tolerate) Reminder of 4 miss rule if needed (behavioural consequences) Don t: Get stuck on checking progress (plan according to hierarchy) Intervene on the client s behalf (instead, consult to the client) Tricky Issues & Tips: Targets (Shame and shut-down behaviour) Do: Validate emotion, tentatively guess if unsure (and be open to being wrong) Consider informal exposure this session, if shame is primary emotion in the room (tip: previous orientation to informal exposure, and asking permission to go there now) Don t: Avoid the emotion, rescue by avoiding the task, reinforce Consider that getting into a lecture (more psychoeducation) can serve to avoid the emotion (inadvertent reinforcement!) Tricky Issues & Tips: Targets This is stupid ; (eye rolling); (ANGER) Do: Validate anger Reinforce appropriate, skillful expression of anger Be directive/set boundaries/withdraw warmth for undesirable, inappropriate, ineffective behaviour Consider primary vs. secondary emotion (and validate and address it) Can use as a spring board for discussion on anger in daily life Don t: Rescue, avoid, get into confrontation/power struggle Drs. Pires & Pigon 19

20 Tricky Issues & Tips: Targets Uughhhhhhhhhhh! Can I just vent today?? Do: Validate desire to vent Reframe behaviour chains can be experienced as punitive, but they can also be validating and help gain an understanding of the client s crisis Negotiate to keep time at end of session Don t: Get caught spending the session on venting -time flies! Delay on targeting Stage 1 priorities. Tricky Issues & Tips: Targets Yes, I m still suicidal. Do: Assess suicidality is it a change from baseline? Notice change of behaviour in session (indicator) Validate the pain behind the suicidal ideation Praise attempts/use of skills/safety plan Don t: Complete comprehensive session on suicide risk assessment each time Go over session time due to suicidality (on the regular) make decision about next steps Tricky Issues & Tips: Targets NSSI, crumb-dropping (in-session dysfunctional behaviour) Do: Stay dialectic Notice: Identify and name the problem behaviour Link in-session behaviour with out-of-session behaviours Ask for and get commitment to do new behaviour in session (e.g., practice new response/coping skill) Trouble shoot possible barriers Regulate one s own emotions Don t: Remove cues or avoid Drs. Pires & Pigon 20

21 DBT with Teens: Behaviour Chain Analysis Tricky Issues & Tips Behaviour Chain Analysis Goal: Identify and accept the problem. How? Identify the problem. Describe the problem in behavioural terms. Reconstruct the sequence of events leading up and co-occurring with it (including pinpointing the prompting event ). Trick Issues & Tips: Skill Use These skills don t work Do: Validate frustration Behavioural chain matching skill to target (in terms of function and level of intensity) Practice skill(s) in session Teach Plus 1 Strategy (Koerner and Dimeff) Drs. Pires & Pigon 21

22 DBT with Teens: Ending the Session Tricky Issues & Tips Session Ending Strategies Agree on and troubleshoot homework for the upcoming week. Summarize the session, including cheerleading, soothing and reassuring Troubleshoot client s emotional reactions at the end of the session Engage in an ending ritual (i.e., Mindfulness exercise). Tricky Issues & Tips: Ending Sessions Oh, there s just this one thing I forgot to tell you Do: Validate importance, plan to address at next session (shape), and remember to do so Address imminent risk, but remove reinforcement as much as possible If pattern, plan for chaining at next session Consider this possibility when planning session Consult with colleagues as needed check own emotion, can be difficult Don t: Reinforce by extending session (as much as possible, e.g., considering risk) Drs. Pires & Pigon 22

23 DBT with Teens: Coaching & Other Calls Tricky Issues & Tips When to Use Between-Session Calls #1: BEFORE engaging in life threatening behavior (Coaching Calls). #2: To share good news with therapist (encourage this) #3: To repair the relationship Encourage call practice when not in crisis Coaching Calls: Rules & How-To Youth has not engaged in life-threatening behavior before coaching call (else - use emergency services) Youth willing to engage in coaching (not to chat or replace a session) principle of if asking for help, need to be willing to accept it Calls are brief approximately 5-10 minutes Help them identify skills to use, ask them to use them Call back, support as needed Drs. Pires & Pigon 23

24 Tricky Issues & Tips: Coaching Calls I m too anxious to call Do: practice in session using cell phone (exposure) I don t know ; I don t want to ; (willfulness regarding skill use) Do: Provide +++ validation, ask permission, and interweave with skills Chaining during next session as needed; conversely, reinforce appropriate use of coaching call Don t: Avoid skill use or engage in tangential conversation, unless geared at skill use (e.g., shaping a Distress Tolerance strategy) Tricky Issues & Tips: Coaching Calls (unavailability of therapist after hours) Do: Provide numbers for and exposure to using crisis lines as needed (e.g., call together if anxious to call) Coach to use crisis supports appropriately to get needs met (e.g., address issues around hanging up, expressing emotion, expressing needs) With consent/consultation to patient and where applicable, consider whether providing outline of go-to skills for crisis worker would be beneficial Resources Drs. Pires & Pigon 24

25 Resources Important DBT references Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M.M. (2015). DBT skills training manual. New York: Guilford Press. Linehan, M.M. (2015). DBT skills training handouts and worksheets. New York: Guilford Press. Miller, Rathus, & Linehan (2007). Dialectical behavior therapy with suicidal adolescents. New York: Guilford Press. Rathus & Miller (2014). DBT Skills Manual for Adolescents. New York: Guilford Press Van Dijk, S. Don t Let Your Emotions Run Your Life for Teens. Oakland, CA: New Harbinger Publications, For more information about DBT: pdf Drs. Pires & Pigon 25

26 DBT DIARY CARD Name: Filled out in session? Yes / No How often did you fill out this week? Daily 2-3 times Once Month Self-Harm Suicidal Restriction/ Dysregulatio n Lying Medication taken as Prescribed Alcohol/Dru gs Selfcompassion Angry Sad Lonely Dissoci ation Happy Anxiou s/ Fearful Skills* Date: Urge Action Yes/No Urge Action Yes/No Urge Action Yes/No Urge Action Yes/No Urge Action Yes/ No Urge Acti on Y/N Urge Action Y/N Tues Wed Thurs Fri Sat Sun Mon *USED SKILLS 0 = Not thought about or used 1 = Thought about, not used, didn t want to 2 = Thought about, not used, wanted to 3 = Tried, but couldn t use them 4 = Tried, could do, but didn t help 5 = Tried, could use them, helped 6 = Didn t try, used them, didn t help 7 = Didn t try, used them, helped Rating Scale for Emotions and Urges (above): 0=Not at all 1=A bit 2=Somewhat 3=Rather Strong 4=Very Strong 5=Extremely Strong Urge to Quit Therapy: 0-5 Misery Index: 0-5 Pleasurable events that happened during the week: ANYTHING ELSE?? Yes No Low on meds? Yes No

27 Instructions: Mark the days you worked on each skill. Core Mindfulness Distress Tolerance Walking the Middle Path Emotion Regulation Interpersonal Effectiveness 1. Wise Mind 2. Observe (just notice what s going on inside) 3. Describe (put words to the experience) 4. Participate (enter in to the experience fully) 5. Don t Judge (nonjudgmental stance) 6. Stay Focused (one-mindfully: in the moment) 7. Do What Works (be effective) 8. ACCEPTS (distract) 9. Self-soothe (five senses) 10. Pros and Cons 10.a. TIPP 11. Radical Acceptance/half-smile/turning the mind 12. Positive Reinforcement 13. Validate Self 14. Validate Someone Else 15. Think Dialectically (not Black/White) 16. Act Dialectically (walk middle path) 17. Identifying and Labeling Emotions/ THE WAVE 18. ABC PLEASE (reduce emotion mind) accum. Positive experi 19. MASTER (build mastery; feeling effective) 20. Engaging in Pleasant Activities 21. Working Toward Long-Term Goals 22. Building Structure // time, work, play 23. Acting Opposite to Current Emotion 24. DEAR MAN (getting what you want) 25. GIVE (improving the relationship) 26. FAST (feeling effective and keeping self-respect) 27. Cheerleading Statements M T W Th F St Sn NOTES Rate how well you achieved your goal areas each day. M T W Th F St Sn NOTES #1 #2 0=Not at all 1=A little bit 2=Sometimes yes, sometimes no 3=Mostly achieving them 4=Almost perfect 5=Perfect!