Lessons Learned from the Minneapolis VA and the VA Palo Alto

Transcription

1 Lessons Learned from the Minneapolis VA and the VA Palo Alto Sara J. Landes, Ph.D. National Center for PTSD Dissemination & Training Division VA Palo Alto Health Care System Laura Meyers, Ph.D., ABPP Primary Care/Mental Health Integration Team Minneapolis VA Health Care System

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3 Staff education in DBT began Consultation group began 1 st women s skills group began 1 st men s skills group began 2 nd men s skills group began Replaced 3 gender specific groups with 2 gender neutral groups

4 In 1995, DBT self study group using main text and skills manual Met weekly for 6 months Staff attended 3 day DBT conference Staff with no behavioral training attended a 4 session in service training on basic behavioral principles Ongoing consultation for 6 months

5 Workshops kh in DBT applied to special populations Eating disorders and addiction disorders Psychology DBT training i seminar for 6 months Two day DBT skills workshop offered annually In , 09 8 staff completed a DBT intensive training program offered by Behavioral Tech Staff attendance at several Behavioral Tech 2 day trainings

6 Staff volunteered to serve as group therapists for the skills group on a rotating basis 2 group therapists; one who had presented all 4 modules and one who was new Initially i new patients and therapists started at the beginning of a new module; never during a module Separate male and female skills groups Coaching calls only during clinic i hours

7 Laura Meyers and Linda Van Egeren co lead DBT program 9 staff, 1 post doc, 2 interns, 4 practicum students Coaching calls Provided by individual therapists during regular hours M F, 8 4:30 PM After hour and weekend coaching calls provided by rotating staff who carry the DBT cell phone Elicit referrals of high risk suicidal patients by ongoing liaison with inpatient psychiatric unit and partial hospitalization programs

8 Inclusion Criteria Current or History of suicidal or self harm behaviors (not required) Recent Hospitalization (not required) Significant skills deficits Willing to attend 2 weekly appointments Commitment to skill development Willingness to address target behaviors Exclusion Criteria Primary substance abuse/dependence Acute psychosis Significant cognitive impairment Inability to tolerate groups Predatory or disruptive behaviors unwilling to target in individual therapy

9 Minimum of 2 Year Commitment of 3 5 clinical units 5 individual pts, 3 individual pts & 1 group Staff represent multiple MH disciplines 4 psychologists, 3 social workers, 2 clinical nurse specialists Staff are cross team 1 PC/MHI, 2 Women s Clinic, 3 Mood, 1 ADS, 2 PTSD

10 Comp time for providing 24/7 phone coaching 2 hours comp time for every week with phone 4 hours comp time for holiday weeks 15 minutes comp time per phone call Up to 90 minutes towards productivity for attendance of weekly consultation group

11 3 DBT skills groups of up to 10 Veterans (6 8 ideal) About 6 months to cover all 4 modules of skills Mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance DBT patients commit to 6 months with an option to re commit for another 6 months Most need 1 year For each group, the facilitators t are a staff tff member and an intern or trainee in the DBT seminar

12 N = 41 Age Range = Mean Age = 47.1 Gender Ethnicity Caucasian African American Asian 78 Didn't Answer Males Females

13 40.0% 35.0% 30.0% 0% 25.0% 24.4% Z=1.90, p= % 20.0% 15.0% 10.0% 14.6% 9.8% 17.0% 5.0% 0.0% 2.4% 1 Hospitalization 2 Hospitalizations Any Hospitalization PreTx Post Tx

14 Results for psychiatric i hospitalization ti were not significant but were in the desired direction Overall psychiatry admissions decreased from 34.2% to 17 % 24.4% were admitted once 1 year prior to starting DBT & the rate dropped to 14.6% the year following 9.8% had 2 psychiatry admissions one year prior & that dropped to 2.4% 1 year post DBT In DBT, when hospitalization is necessary, the goal is to get out of the hospital ASAP, so what about days hospitalized?

15 t(40)=4.03,p< t(40)=3.54,p= t(40)=2.15, p= Total Mental Health PPH Encounters Mental Health Encounters Encounters Excluding PPH,CWT Pre Tx Post Tx

16 Number of mental tl health encounters significantly decreased from an average of 92.8 to approximately 48.2 Estimate due to not being able to exclude individual DBT appointments When mental health encounters were excluded due to our intensive partial hospitalization & work therapy programs, encounters significantly decreased from an average of 57.1 prior to starting DBT to one year following DBT

17 Z= 1.62,p= Z= 1.69,p=.09 69p= Pre Tx Post Tx Total Primary Care Encounters Total Emergency Department Encounters

18 Medical service utilization was not significant but results were in the desired direction Non emergent medical visits decreased, from an average of 4 to 3.1 ER visits decreased, from an average of 2.3 to 1.6

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20 Implementing a DBT program at the Women s Prevention, Outreach, and Education Clinic (WPOEC) Using a gradual implementation approach 1 day workshop kh for staff + weekly skills kll training for 6 weeks Implementing skills kll group first

21 1FTE psychologist (split between 2 staff) 1 PT psychologist 1 FTE social worker 3 psychology trainees Practicum student, intern, and fellow (1 social work trainee)

22 2 hour group Keeping 4 miss rule Only applies to DBT group (won't be out of other services, but 4 miss includes 4 miss of anything) Wi Wait 6 months to return/reapply to group Offering group for a year, asking for 6 month commitment

23 Include clients who have Impulsive behavior bh the following types of Substance problems behaviors/problems: Chronic pain PTSD Suicide attempts Emotion regulation Self harm problems Bipolar Interpersonal Angry effectiveness problems Extreme Military Sexual Trauma Disruptive Borderline Personality Externalizing disorders Disorder

24 Clinic already has a standard battery of assessments Added d 2 measures for DBT Difficulties in Emotion Regulation Scale Borderline Symptom List 23

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26 Prioritize 1 hour a week for consultation time Use this time to read the text, discuss cases, and overcome logistical barriers Start a group Biggest barriers are I don t have time and I need more training before we start. Just jump in and get started!

27 Try to start with at least 3 team members Each commit to 1 hour consultation plus 3 clinical hours (e.g., group & 1 pt, 3 pts) weekly Need 2 group leaders and enough individual patient slots Do not see your existing patients as DBT patients t switch with other members Ideal for group leaders not to be individual therapists, t whenever possible

28 Consistent and appropriate space for skills group Length of group time and billing bll Available permanent staff to maintain program Different existing group culture

29 No evidence that group alone is helpful for Axis II patients Can be disruptive in group Need more intensive work to apply skills beyond what group alone can provide Group alone IS helpful for Axis I patients Can be a good start (with Axis I) to begin programming

30 Can meet weekly in individual therapy for Axis II pts when full model is not possible Group structure is important for teaching of skills Divide individual session time into two components: A structured skills acquisition component (teaching skills) Skill application to current life circumstances (standard dindividual d therapy session)

31 Essential to generalizing skill application Provide coaching during office hours Explore training after hours POD/crisis line staff in DBT principles Look for inroads with staff and admin to expand services

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34 Listings of VAMCsoffering DBT components DBT Forum/Discussion Board Therapy resources Diary cards, what to do in the first 4 sessions Training resources How to get training, presentations Implementation resources Descriptions of what other programs have done Research & evaluation resources Measures for evaluation, articles

35 The Minneapolis VA DBT staff are able to provide DBT training Please contact Laura Meyers for more information,

36 Linehan, Marsha. (1993). Cognitive behavioral bh treatment of Borderline Personality Disorder. New York, NY: The Guilford Press. Hardcover text with theoretical rationale & detailed description of Dialectical Behavior Therapy Linehan, Marsha. (1993). Skills training for treating Borderline Personality Disorder. New York, NY: The Guilford Press. Paperback workbook of skills, explanations of skills, p, p, and outlines for leading skills training groups

37 Dimeff, Linda & Koerner, Kelly (eds.). (2007). Dialectical Behavior Therapy in Clinical Practice. New York, NY: The Guilford Press. Adaptations of DBT for specific populations (e.g., substance abuse, eating disorders, inpatient, forensic, with families) Behavioral Tech, LLC, was developed by Dr. Linehan to provide mental health professionals with training and resources Behavioral Tech website: bh h