Dialectical Behaviour Therapy in an Outpatient Drug and Alcohol Setting

Dialectical Behaviour Therapy in an Outpatient Drug and Alcohol Setting

Distinguishing features of DBT Implementing DBT within Drug Health Services RPAH Case Study

Background to DBT Developed in early 1990 s by Dr Marsha Linehan, University of Washington for the treatment of chronically suicidal outpatient clients with BPD RCTS show reduction in suicide/self-harm, depression and anxiety psychiatric /emergency admissions increase in treatment completion Enhances practitioner resilience

Evidence base for treating severe, co-morbid patients with self-harming behaviors and affect dysregulation

Standard DBT - 4 Modes over 1 year Individual Therapy Peer Consultation Group Group Skills Training Phone Coaching

Stages of Treatment Stage 1: Behavioral Control Target 1 Decrease SUICIDAL BEHAVIOURS Target 2 Decrease THERAPY INTERFERING BEHAVIOURS Target 3 Decrease QUALITY OF LIFE INTERFERRING BEHAVIOURS Target 4 Increase BEHAVIOURAL SKILLS Stage 2:Dealing with trauma, fear of emotions Stage 3 - Building a life worth living Stage 4- Develop Sense of Self

Theoretical Underpinnings CBT Learning Theory Dialectical Philosophy Zen Philosophy

Dialectics Life is full of dialectical tensions or polarities to Key Dialectic: Acceptance Vs..... Change Dialectical Change comes from the ability to recognise the truth or validity of each position therefore becoming unstuck from extreme or polarized points of view

Zen Philosophy Non-judgmental observation of ALL activities of the mind Acknowledging reality just as it is, without expecting it to be different, censoring or denying, while being open to possibilities. Radical Acceptance reduces suffering

DBT- Biosocial Model Biological Vulnerability Invalidating Environment Self-Invalidation Pervasive emotion dysregulation Interpersonal conflicts Impulsivity Validation & Skills Training &

DBT Skills Training Overview PROBLEMS in BPD Identity confusion Impulsivity Emotional instability SKILLS in DBT Core mindfulness skills Distress tolerance Emotion regulation Relationship problems Interpersonal effectiveness Self-punishment Self-management

WHY USE DBT IN DRUG AND ALCOHOL? PD second most prevalent co-morbid condition in specialist D&A settings, ranging from 35% to 75% The presence of comorbid SUD and PD more severe substance dependence, shorter periods of abstinence/more frequent relapses elevated levels of psychological distress lower levels of social functioning early treatment dropout

WHY USE DBT IN DRUG AND ALCOHOL? DBT Evidence based practice greater reduction in psychopathology reduction in substance use greater treatment retention improvement in global and social adjustment Integrated Stepped Care approach

Challenges D&A treatment as Core Business Lack of infrastructure and resources Feasibility Adaptation to client population

Balancing Emotions Group 2013 commenced 10 week group program on ER offered 3 times per year Referrals from within the SLHD Inclusion Criteria early abstinence engaged in individual counselling/case management affect dysregulation contributing to relapse suitable for group therapy nil current SIB, acute or severe psychiatric disorders

Balancing Emotions Group Pre-group interviews 14 participants recruited in order to retain 8-10 group members Staffed by 2 counsellors on average 16 hours per week Quality Assurance exercise involving Pre and Post measures

Age range 21-61 and mean age 42 Females 60% Males 40% Attendance rate 7.3 (mean) Alcohol (47%) Heroin (23%), Cannabis (13%), Polydrug (7%), Benzo (5%), Nicotine (5%) 50% maintained individual counselling Substance use 52 % maintained their abstinence from drug of dependence during the program 39% harm minimisation 10% Relapsed

Kessler Psychological Distress Scale - K10 31.21052632 35 30 24.18421053 25 20 15 10 5 0 Pre-Group Post-Group P (two tail= 0.0005) - Severe to moderate mental disorder

Difficulties in Emotion Regulation Scale (DERS) 120 p=0.0003 100 80 60 40 p=0.01 p=.0003 p=0.008 p=0.10 p= 0.0004 p=0.02 20 0 Pre= 112.8 Post= 95.9 Pre-Group Post-Group

Australian Treatment Outcome profile (ATOP) 7 6 p=0.001 p=0.005 p = 0.11 5 4 3 2 1 0 Quality of Life Psychological Health Physical Health Pre-Group Post-Group

Client Satisfaction Questionnaire (CSQ) 1. How would you rate the quality of service you have received? 2. Did you get the kind of service you wanted? 3. To what extent has our program met your needs? 4. If a friend were in need of similar help, would you recommend our program to him or her? 5. How satisfied are you with the amount of help you have received? 6. Have the services you received helped you to deal more effectively with your problems? 7. In an overall, general sense, how satisfied are you with the service you have received? 8. If you were to seek help again, would you come back to our program? Mean = 27.74 out of 32

Susan 21 year Caucasian female Born in USA (Russian/Jewish parents) On a partner Visa/ Australian resident over the last 2 years Unemployed,not on any support benefits works in sex industry as a stripper

Personal History Early exposure to paternal alcohol and MDMA abuse, marital domestic violence Sexual assault in early teens Completed 3 years of 4 year Computer Science (Scholarship) in Robotics Polysubstance misuse from 13 (alcohol MDMA, Cocaine, Opioids, LSD, benzodiazepines) Cannabis dependence since 15 (3 grams daily) and nil periods of abstinence

Psychiatric History Major depressive disorder BPD Psychological interventions since age of 4 y.o. (context of parent s divorce) Previous admissions from 16 y.o. history of SIB, aggressive behaviour, suicide attempts (overdose, jumping out of vehicles) Range of pharmacological interventions currently (quetiapine, desvenlafaxine)

Presenting problems Cannabis dependence Long standing and current presentation of affective dysregulation, high expressed emotions, anger, impulsivity, interpersonal difficulties and crises Vulnerable to intense co-dependency, sexual assault/sexual exploitation

Stage 1 Target 1 Monitoring suicidality/sib Target 2 Decrease therapy interfering behaviour - episodic non-attendance to individual counselling Target 3 Increasing quality of life Address Cannabis dependence Attending to medical, legal and financial issues

Stage 1 Target 4 Increasing behavioural skills Individual counselling Behavioural analysis- examining problem behaviours and identifying the thoughts, mood, triggers and vulnerabilities Weekly attendance at group skills Skill generalisation increasing skill use in daily life

Axis Title K10 ATOP 40 40 9 8 35 30 26 7 6 5 25 20 15 10 5 0 4 3 2 1 0 Quality of life qual Psychological Health Physical Health Series1 Series2 DERS 160 140 120 100 80 60 40 Series1 Series2 20 0

FUTURE GOALS Interpersonal Effectiveness Emotion Regulation Mindfulness Emotion Regulation Distress Tolerance Distress Tolerance Building a Life worth living Interpersonal Effectiveness Mindfulness Identity and Self- Esteem Mindfulness