Introduc7on to DBT DBT. Dialec7cal Behavior Therapy (DBT) Michele Galie*a, Ph.D. Associate Professor John Jay College of Criminal Jus7ce

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1 Introduc7on to DBT Michele Galie*a, Ph.D. Associate Professor John Jay College of Criminal Jus7ce DBT DBT is a cogni,ve-behavioral therapy designed for the severe and chronic mul,-diagnos,c, difficult-to-treat pa,ents Dialec7cal Behavior Therapy (DBT) Incorporates theory about where problem behaviors originated Explains the rela,onship of trauma to current difficul,es in individuals life, but also emphasizes what needs to be done to sensi,vely change current behaviors Provides behavioral tools to assess the specific factors are currently maintaining problem behaviors Provides therapists with specific tools to align therapist and pa,ent goals and to target factors maintaining problem behaviors Offers HOPE for those who have been unsuccessful in other less intense treatments

2 A Story to Begin Female Pa,ent treated in maximum-security facility Hospitalized since age 9 Extreme trauma history Extreme self-abuse and violence for many years Within 6 months of DBT treatment, self-abuse stopped; violence stopped shortly therealer Transferred to less secure, then outpa,ent residence, amending college Pa7ents with Complex Needs Extensive Trauma Histories Mul,ple Psychiatric Diagnoses, including PERSONALITY DISORDERS Medically Complicated Cogni,ve Disabili,es Problema,c Behaviors (Suicide, Self-Harm, Violence) Problems Associated with Complex Pa7ents Do not respond to psychopharmacological interven,ons alone Polypharmacy OLen have difficulty in structured environments Frustra,on for Providers Frequent crises Exacerba,on of symptoms with worsening course over,me OLen EXTREME self-abuse, serious problem behaviors including violence

3 DBT was developed by Marsha Linehan (1993) for the treatment of chronic and severe suicidality and self-harm in outpa,ents It has since been adapted successfully for many popula,ons DBT Research DBT Research (Civil SeKngs) >14 Randomized Trials Completed o At least 10 independent sites o Linehan et al. (1991) o Linehan et al.( 1999) o Koons et al. (2001) o Telch (2001) o Safer (2001) o Linehan et al. (2002) o van den Bosch (2002) o Lynch (2003) o Linehan et al. (2006)

4 DBT Civil Research-Con7nued o McMain (2009) o University of Oslo(Mehlem et al., 2014)-Adolescents o University of Heidelberg (Bohus et al., 2013) o University of Washington (Harned, Korlsund, Linehan, 2014) o John Jay College/Fordham University (GalieMa & Rosenfeld-in progress) General Outcomes Reduc,ons in o Suicidal behaviors o Inten,onal self-harm o Depression o Hopelessness o Anger o Ea,ng disorders o Substance dependence o Impulsivity Increases in o Adjustment (general and social) o Posi,ve self-esteem Michele Galietta-do not reproduce without permission DBT Research Summary o Suicide amempts was main inclusion criteria (behavioral inclusion criteria; few exclusion criteria) o Treatment ini,ally itera,vely developed- CBT, then acceptance technology, dialec,cs added o Methodologies: RCTs as well as quasi-experimental designs, case studies o First wave, RCT: DBT vs. Treatment as Usual (TAU) o Par,cipants had mul,ple comorbid diagnoses o DBT superior to TAU for reducing suicidal behaviors, selfharm, severity of self-harm, inpa,ent hospital days

5 Waves of Research o Replicated different lab (Koons et al., 2001) o Adapta,ons developed and tested (e.g., Swenson et al., 2001) o Early RCTs: (Telch, 2001; Safer, 2001, Linehan, 2002; van den Bosch, 2002, Lynch, 2003) o Quasi-experimental: (Rathus & Miller, 2002) o Second wave, DBT vs. Treatment by Experts (TBE; Linehan, 2006) o Ac,ve components? o Addi,onal Replica,ons o Stage 2/Trauma (DBT-PE; Harned Korslund, & Linehan, 2014) Juvenile Jus7ce Banks, Kuhn, & Blackford, 2015 Drake & Barnoski, 2006 Shelton, Kesten, Zhang, & Trestman, 2011 Trupin, Stewart, Beach, & Boesky, 2002 Correc7onal DBT Implementa7ons o Correc,onal (DBT-CM) (Trestman et. al) o Federal Bureau of Prisons (Springfield, MO)* o Correc,onal Service of Canada* o California Dept. of Correc,ons o Female Prison-Women s Huron Valley (GalieMa)* o Montgomery County Correc,onal Facility (MCCF) in Boyds, Maryland (Sollock)* *=comprehensive

6 DBT Theory DBT Theoretical Background Acceptance: Communicate acceptance via validation Biosocial Theory Push client to Change via Behavioral Principles Dialectics DBT Acceptance Strategies Convey acceptance through VALIDATION Valida,on is: o Trea,ng the client as if they and their problems are worthy of amen,on and respect o Finding the kernel of truth or wisdom in the client s behavior o Seeing the world from the client s point of view, and saying so o It is as important to validate as it is NOT to validate invalid, dysfunc,onal behavior, cogni,ons

7 Valida7on o Emo,ons o Cogni,ons o Behavior or Ac,ons o Physiological Responses o Precision (level) important o Also important to note what NOT to validate! o Refraining from valida,on is NOT the same thing as punishing Valida7on Can o De-escalate a dysregulated individual o Reduce isola,on, stress and opposi,on o Strengthen client s ability to find his or her own wisdom and confidence o Strengthen the rela,onship o Increase willingness to solve problems and change behavior Behaviorism o Assessment (using chain analysis) o Uses tradi,onal CBT tools to target: o Skills Training o Cogni,ve Restructuring o Con,ngency Clarifica,on o Con,ngency Management o Exposure

8 DBT & Dialec7cs o Tension of opposites (thesis & an,thesis) o Failure to synthesize results in stagna,on o Synthesis produces growth and movement o Emphasizes both and rather than either or o Speed, movement, and flow Sound like most organiza,ons? Dialec7cs: Synthesis Balance is goal and balance built into treatment 1. Skills teach both acceptance and change 2. Therapists use dialec,cal strategies to avoid impasses 3. Therapists/teams use dialec,cal communica,on as way of communica,ng/problem solving Pathology in Emo,on Regula,on System Biosocial Theory explains the development of the host of behavioral problems seen in individuals with BPD (or PED) As well as what maintains these problems Biological vulnerability transacts over,me with invalida,ng environment to produce pervasive emo,on dysregula,on (DEFICITS IN ER)

9 What about ASPD? Biological Vulnerabili,es (Research suggests 2 separate contribu,ons) o Poor controls, impulsivity, sensi,ve and reac,ve similar to BPD (secondary psychopathy) o Too limle emo,on (cold, callous or unemo,onal) low sensi,vity, reac,vity, restricted range of affect (primary) o Can have one or both as separate vulnerabili,es transac,ng with environment Environment and ASPD For those with poor controls: Invalida,ng environment similar to BPD along with o Environment that models an,social rather than prosocial behaviors o That reinforces aggression, models poor controls o That responds to prosocial behaviors by ignoring or with punishing Environment and Cold Callous Traits For those with low sensi,vity: o Environment can punish underlying lack of emo,on (you are bad) o Environment can reinforce shuvng down, ignoring emo,on (having no emo,on adap,ve in face of extreme punishment, nega,vely reinforced) o Environment provides reinforcement of feigned emo,on (inauthen,c apologies) o Reinforced by self for gevng over

10 DBT Structure MODES 1. Individual Therapy 2. Group Skills Training 3. Coaching 4. Consulta,on Team DBT is a Package of Treatment Components FUNCTION 1. Improve Mo,va,on 2. Increase client capabili,es 3. Generaliza,on 4. Increase therapist capabili,es, support 5. Structure Environment DBT INPATIENT ADAPTATION o Primary adapta,on includes strong emphasis on structuring the environment o Egregious Behaviors Protocol o Avoids dualism of illness/behavioral problem o Highly structured, principle-driven milieu (mee,ngs use dialec,cal process to resolve differences; emphasis on avoidance of crisis-driven behavior) o Behaviorism AND valida,on o Emphasis on whole client o Use DBT principles for case conceptualiza,on (e.g., hierarchical organiza,on of clear targets) o Set of agreements/assump,ons for all staff o Common behavioral language

11 DBT Assump7ons About Therapy 1. The most caring thing therapists can do is to help clients get to their own goals. 2. Clarity, precision, and compassion are of the utmost importance in DBT. 3. The rela,onship between therapists and clients are real rela,onships, between equals. 4. Principles of behavior are universal, affec,ng staff no less than clients. 5. DBT staff can fail (to implement DBT). 6. DBT can fail even if it is done perfectly. 7. Therapists trea,ng clients with BPD need support. DBT Assump7ons About CLIENTS 1. Clients are doing the best they can. 2. Clients want to improve. 3. Clients must learn new behaviors in all relevant contexts. 4. Clients cannot fail in DBT. 5. Clients may not have caused all of their own problems, but they have to solve them anyway. 6. * Clients need to do bemer, try harder, and/or be more mo,vated to change. 7. * The lives of suicidal, BPD individuals are unbearable as they currently being lived. DBT Stages of Treatment Pre-Treatment Commitment and Agreement Stage 1: Severe Behavioral Dyscontrol Behavioral Control Stage 2: Quiet Despera,on Non-anguished Emo,onal Experiencing Stage 3: Problems in Living Ordinary Happiness/Unhappiness Stage 4: Incompleteness Capacity for Joy and Freedom

12 Stage 1 Primary Targets Decrease I. Life-threatening behaviors II. Therapy-interfering behaviors III. Quality of life interfering behaviors Increase behavioral skills o Mindfulness o Distress Tolerance o Interpersonal Effec,veness o Emo,onal Regula,on Skills Groups: Structure o Only clients commimed to comprehensive DBT o 2.25 hours 5-10 minutes mindfulness prac,ce 45 minutes -1 hr. homework review 15 minute break (with snacks) minutes new content 5 minutes present new homework 5 minutes wind down o Leader and Co-leader Skills Groups: Structure o Classroom style (around table, whiteboard) o Clients have notebooks and pens o Orient clients to style, importance prac,ce o Rota,on of Modules Mindfulness (2 weeks) Distress Tolerance (6 weeks) Mindfulness (2 weeks) Interpersonal Effec,veness (6 weeks) Mindfulness (2 weeks) Emo,on Regula,on (6 weeks)

13 Targets for Skills Groups 1. Stop Therapy-Destroying Behaviors 2. Increase Behavioral Skills (mindfulness, distress tolerance, interpersonal effec,veness, emo,on regula,on) 3. Decrease Therapy-Interfering Behaviors DBT Skills Modules 1. Mindfulness 2. Distress Tolerance 3. Emo,on Regula,on 4. Interpersonal Effec,veness 5. Middle Path (Dialec,cs & Behaviorism) Overarching skill of self-management Consulta7on Team o Backbone of the treatment o All must be commimed to do DBT (voluntary) o All must agree to follow CT Agreements o Use an agenda o Teams require work

14 Summary Why DBT? o Exis,ng methods not successful o Tragedies (suicide, violence) o Some individuals do not respond well to standard MH interven,ons o Largely crisis driven responses are problema,c and olen manage problems rather than treat or emeliorate those problems o Small number of individuals u,lize dispropor,onate resources Ques7ons? Thank you very much mgaliema@gmail.com