UNC-CH School of Social Work Clinical Lecture Series 10/17/2016

Transcription

1 UNC Chapel Hill School of Social Work Clinical Lecture Series DBT FOR ADOLESCENTS: WORKING WITH SUICIDAL, SELF-HARMING, AND EMOTIONALLY SENSITIVE YOUTH Lorie A. Ritschel, Ph.D. Assistant Professor, UNC Department of Psychiatry Trainer & Consultant, Behavioral Tech, LLC Private Practice, Durham DBT October 17, 2016 DISCLOSURES & NOTICES I receive compensation for my work as a trainer with Behavioral Tech, LLC. There are no specific conflicts to report vis à vis this training. I will share several books and resources with you I do not receive compensation for any of those resources. OBJECTIVES An overview of DBT Empirical support DBT as a transdiagnostic treatment for youth Behavioral targeting Specific adaptations and considerations for youth DBT for Adolescents presented by Lorie Ritschel, PhD 1

2 EVOLUTION OF THE TREATMENT AN OVERVIEW OF DBT GOAL OF TREATMENT: TEACH EMOTION REGULATION Decrease emotional arousal Re-orient attention Inhibit mood-dependent action Organize behavior in the service of effective (not mood-dependent) goals DBT for Adolescents presented by Lorie Ritschel, PhD 2

3 Standard DBT Treatment Modes Mode Individual Therapy Group Therapy Coaching Calls Consultation Team Frequency Weekly Weekly As needed Weekly Ancillary: Other Medical Treatments (pharmacology) PROBLEM AREAS AND SKILLS MODULES Emotional Dysregulation Rapidly shifting feelings and moods Problems with anger Self Dysregulation Fluctuating or absent sense of self Feelings of emptiness Interpersonal Dysregulation Chaotic relationships Fear of being left alone or abandoned Behavioral Dysregulation Self-harm or suicidal behaviors Impulsivity Cognitive Dysregulation Slowed, confused, or paranoid thinking PROBLEM AREAS AND SKILLS MODULES Emotional Dysregulation Emotion Regulation Self Dysregulation Mindfulness Interpersonal Dysregulation Interpersonal Effectiveness Behavioral Dysregulation Distress Tolerance Cognitive Dysregulation Middle Path DBT for Adolescents presented by Lorie Ritschel, PhD 3

4 ADOLESCENT GROUP SKILLS TRAINING Orientation/ Mindfulness Interpersonal Effectiveness Distress Tolerance Orientation/ Mindfulness Entry Points Orientation/ Mindfulness Emotion Regulation Orientation/ Mindfulness Walking the Middle Path DBT Multi-family Skills Training Group Format Length: 1.5 hours Mindfulness Homework Review Break Skills Training Assign HW, Wind Down 5 minutes 40 minutes 10 minutes minutes 5 minutes COACHING CALLS Skills Acquisition Help! I don t know what to do! Skills Generalization Skills Strengthening Relationship Repair I can do a DEAR MAN with you, but can t with my mom/boss/spouse! I know I need to do one of these skills, but I m having trouble choosing which one. I m sorry I walked out of our session today. DBT for Adolescents presented by Lorie Ritschel, PhD 4

5 EMPIRICAL SUPPORT DBT: RANDOMIZED CONTROLLED TRIALS 21 full protocol RCTs: 7 BPD 6 BPD + suicidal 4 BPD + drug 1 BPD + PTSD 1 BPD + eating disorders 1 MDD 1 bipolar teens 1 PTSD 1 Teens with BPD traits 15 skills only RCTs: 5 binge eating disorder/ disordered eating 2 MDD 2 ADHD 1 prison and childhood abuse 1 BPD 1 BPD + suicidal 1 bipolar disorder 1 high emotion dysregulation (non-bpd) 1 university students DBT for Adolescents presented by Lorie Ritschel, PhD 5

6 DBT: RCT OUTCOMES Increases: Adjustment (general & social) Positive self-esteem Treatment retention Lieb, K., et al. (2004). Borderline personality disorder. The Lancet, 364, pp Reduces: Suicidal behaviors NSSI Medical severity of NSSI Emergency service usage Depression Hopelessness Anger Eating disorders Substance dependence Impulsiveness ADOLESCENT DBT STUDIES 1 RCT (Mehlum et al., 2014) Quasi-experimental and adapted DBT studies: Inpatient adolescents (Katz et al., 2004, McDonnell et al., 2010) Suicidal adolescents (Rathus & Miller, 2002) Outpatient (Fleischaker et al., 2011; Hjalmarsson et al., 2008; Salbach-Andrae et al., 2008) Juvenile female offenders (Trupin et al., 2002) Residential (Beckstead et al., 2015; Wasser et al.,2008) Numerous uncontrolled studies and case reports ADOLESCENT DBT RCT DBT-A v Enhanced Usual Care (EUC) (n=77) > 2 episodes of NSSI plus 2 BPD criteria EUC: weekly individual therapy (dynamic or CBT) + prn pharmacology 19 weeks of treatment No significant differences between conditions on: Treatment retention, attendance ER usage DBT > EUC on: Reductions in NSSI, SI, depression Reductions in both conditions (non-sig) on: Hopelessness, BPD symptoms DBT for Adolescents presented by Lorie Ritschel, PhD 6

7 ADOLESCENT DBT RCT FOLLOW UP DBT-A>EUC on: NSSI frequency No differences on: SI, hopelessness, depression, BPD DBT-A maintained gains; EUC got better WHAT CAN WE CONCLUDE ABOUT THE GENERALIZABILITY OF FINDINGS? DBT AS A TRANSDIAGNOSTIC TREATMENT FOR YOUTH DBT for Adolescents presented by Lorie Ritschel, PhD 7

8 WHY DBT WORKS TRANSDIAGNOSTICALLY DBT targets emotional and behavioral dysregulation rather than specific disorders Ritschel, Miller, & Taylor, 2013 WHY DBT WORKS TRANSDIAGNOSTICALLY DBT relies on effective case conceptualization Ritschel, Miller, & Taylor, 2013 DBT for Adolescents presented by Lorie Ritschel, PhD 8

9 ELEMENTS OF CASE CONCEPTUALIZATION Demographic history and thorough symptom assessment Primary targets Secondary targets Theory of disorder Assessment of skills and skills deficits Case conceptualizations should be revised regularly WHY DBT WORKS TRANSDIAGNOSTICALLY DBT includes four stages of treatment and provides a comprehensive framework Ritschel, Miller, & Taylor, 2013 STAGES OF TREATMENT Stage Problem Goal 1 Severe behavioral Behavioral control dyscontrol 2 Quiet desperation Non-anguished emotional experiencing 3 Problems in living Ordinary happiness and unhappiness 4 Incompleteness Capacity for joy and freedom DBT for Adolescents presented by Lorie Ritschel, PhD 9

10 WHY DBT WORKS TRANSDIAGNOSTICALLY Different skills for different people or for the same person at different times Ritschel, Miller, & Taylor, 2013 Mindfulness Emotion Regulation Acceptance Change Distress Tolerance Middle Path Interpersonal Effectiveness WHY DBT WORKS TRANSDIAGNOSTICALLY Individual sessions are guided by a structured yet flexible target hierarchy Ritschel, Miller, & Taylor, 2013 DBT for Adolescents presented by Lorie Ritschel, PhD 10

11 BEHAVIORAL TARGETING IN DBT THE PROBLEM OF COMORBIDITY BPD Non-BPD # Current Axis I dx % with > 3 Axis I dx 69.5% 31.1% % with > 4 Axis I dx 47.5% 13.7% Zimmerman & Mattia, 1999 Disorder THE PROBLEM OF COMORBIDITY Current comorbidity (12- month; Grant et al.) Lifetime comorbidity (Grant et al.) Lifetime comorbidity (Zanarini et al.) Substance use 50.7% 72.9% 64.1% MDD 19.3% 32.1% 82.8% Bipolar I/II 23.9% (I) 31.8% (I) 9.5% (II) PTSD 31.6% 39.2% 55.9% GAD 22.9% 35.1% 13.5% Eating disorders % Grant, Chou, Goldstein, et al., 2008; Results from the National Epidemiologic Survey (n = 34,653) Zanarini, Frankenburg, et al., 1998; inpatients with personality disorders (n = 504) DBT for Adolescents presented by Lorie Ritschel, PhD 11

12 ADOLESCENT NSSI: DIAGNOSES Diagnosis Current Major depression 41.6% GAD 15.7% Conduct Disorder 49.4% ODD 44.9% PTSD 23.6% Substance Abuse 59.6% Borderline PD 51.7% Avoidant PD 31.0% Nock, Joiner, et al. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, PRIMARY TARGETS DBT INDIVIDUAL TREATMENT TARGETS HIERARCHY TO BE FOLLOWED IN EACH INDIVIDUAL SESSION Behaviors to decrease: Suicide and NSSI (thoughts, urges, and actions) Therapy-interfering behaviors Quality-of-life interfering behaviors Behaviors to increase: Core Mindfulness Distress Tolerance Dialectical Thinking Interpersonal Effectiveness Emotion Regulation Linehan, 1993 DBT for Adolescents presented by Lorie Ritschel, PhD 12

13 NSSI AND SUICIDE DELIBERATE ACTION WITH INTENT TO INJURE True suicide attempt Ambivalent suicide attempt Non-suicidal self-injury (NSSI) Bodily harm related to other disorders (substance use, eating disorders) Bodily harm not driven by negative affect (piercings, tattoos) Accidental injury SUICIDAL, LIFE-THREATENING, & SELF-HARM BEHAVIOR Overt suicidal acts Ambivalent suicide attempts Increased suicidal ideation or suicide practice behavior Homicide and/or increased risk of interpersonal violence Non-suicidal self-injury (NSSI) Linehan, 1993 THERAPY INTERFERING BEHAVIORS Anything that makes the patient not want to work with you and anything that makes you not want to work with the patient DBT for Adolescents presented by Lorie Ritschel, PhD 13

14 THERAPY INTERFERING BEHAVIORS of the patient: Behaviors that are non-collaborative, non-compliant, or inattentive Timeliness, attendance, HW non-completion, falling asleep, lying, showing up high, coaching calls Behavior that interferes with other patient s ability to receive treatment Being rude or aggressive to other patients or staff Behavior that compromises the therapist s ability to treat the patient Threats, limit crossing Linehan, 1993 THERAPY INTERFERING BEHAVIORS of the therapist: Lateness Being out of balance: focusing too much on change or acceptance Failure to return calls Extreme nurturing or withholding Extreme flexibility or rigidity Invalidating or disrespectful behavior Linehan, 1993 THERAPY INTERFERING BEHAVIORS of the family: Behavior that interferes with ability to get treatment Behavior that interferes with ability to use treatment effectively Behavior that disrupts the therapeutic relationship DBT for Adolescents presented by Lorie Ritschel, PhD 14

15 QUALITY-OF-LIFE INTERFERING BEHAVIORS Anything associated with Axes I, II, III, & IV High risk or unprotected sexual behavior Extreme financial and/or housing difficulties Criminal behaviors (especially those that may lead to jail) Severe interpersonal dysfunction (e.g., abusive relationships) Unemployment, severe school problems Dysfunctional behaviors related to physical health (e.g., not caring for diabetes) Linehan, 1993 ADOLESCENT QUALITY-OF-LIFE INTERFERING BEHAVIORS Dysfunctional relationships (especially abusive relationships) Dysfunctional school-related behaviors (truancy, skipping, lateness) Criminal behaviors (shoplifting) Drug-related behaviors Impulsive behaviors (outbursts, fighting, unprotected sex) Rathus & Miller SECONDARY TARGETS DBT for Adolescents presented by Lorie Ritschel, PhD 15

16 SECONDARY TARGETS Unrelenting crisis Emotional vulnerability Apparent competence Active passivity Inhibited grieving Self-invalidation ADOLESCENT SECONDARY TARGETS Normalizing pathological behavior Excessive leniency Forcing autonomy Fostering dependence Pathologizing normative behavior Authoritarian control ASSESSING THE FUNCTION AND CONTROLLING VARIABLES THAT MAINTAIN PROBLEM BEHAVIORS DBT for Adolescents presented by Lorie Ritschel, PhD 16

17 CHAINS: A MOMENT-TO-MOMENT ANALYSIS VULNERABILITY FACTORS PROMPTING EVENT LINKS (EVENTS, THOUGHTS, FEELINGS) PROBLEM BEHAVIOR CONSEQUENCES THE GOAL OF CONDUCTING CHAINS VULNERABILITY FACTORS PROBLEM BEHAVIOR PROMPTING EVENT EFFECTIVE BEHAVIOR CONSEQUENCES DBT for Adolescents presented by Lorie Ritschel, PhD 17

18 BEHAVIORAL CONCEPTUALIZATION OF PROBLEM BEHAVIOR Antecedent 1 Antecedent 2 Antecedent 3 Problem Behavior Consequence 1 Consequence 2 Behavior under control of antecedents Respondent/automatic Behavior under control of consequences Operant/functional ADAPTATIONS AND CONSIDERATIONS FOR YOUTH DBT-A ADAPTATIONS Targeting: Adolescent QOL targets Adolescent-family secondary targets Families in treatment: Multifamily skills training groups As needed or adjunct family therapy sessions Skills: Addition of the Walking the Middle Path module Dialectics, dialectical dilemmas, thinking mistakes, validation, behaviorism Communication strategies: Environmental intervention vs. consultation to the client DBT for Adolescents presented by Lorie Ritschel, PhD 18

19 GENERAL PRINCIPLES IN WORKING WITH EMOTIONALLY DYSREGULATED YOUTH Confidentiality/flow of information Voluntariness of treatment Court ordered kids Know the laws and reporting guidelines LOGISTICS STYLISTIC STRATEGIES Be creative with reinforcers Be vulnerable Balance acceptance and change Be willing to intervene on the environment but don t do it too much Skills training: Selling mindfulness Don t rely on handouts Make examples relevant Have families work together, but also have teens work with different parents DBT for Adolescents presented by Lorie Ritschel, PhD 19

20 MATERIALS AND LEARNING OPPORTUNITIES STANDARD DBT DBT FOR ADOLESCENTS DBT for Adolescents presented by Lorie Ritschel, PhD 20

21 TRAINING AND ACCREDITATION IN DBT Training: Webinars, 2-days, intensives Certification: THANK YOU! DBT for Adolescents presented by Lorie Ritschel, PhD 21