DBT for Adolescents presented by Lorie Ritschel, PhD 1 · ADOLESCENT DBT RCT FOLLOW UP •DBT-A>EUC on: •NSSI frequency •No differences on: •SI, hopelessness, depression, BPD

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

DBT for Adolescents presented by Lorie Ritschel, PhD 1

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

UNC Chapel Hill School of Social Work Clinical Lecture Series

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



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



Mode Frequency

Individual

TherapyWeekly

Group Therapy Weekly

Coaching Calls As needed

Consultation Team

Weekly

Standard DBT Treatment Modes

Ancillary: Other Medical Treatments (pharmacology)

PROBLEM AREAS AND SKILLS MODULES

Emotional

DysregulationSelf

Dysregulation

Interpersonal

Dysregulation

•Fluctuating or absent sense of self

•Feelings of emptiness

•Chaotic relationships

•Fear of being left alone or abandoned

•Slowed, confused, or paranoid thinking

•Self-harm or suicidal behaviors

•Impulsivity

Behavioral

Dysregulation

Cognitive

Dysregulation

•Rapidly shifting feelings and moods

•Problems with anger

PROBLEM AREAS AND SKILLS MODULES

Emotional

DysregulationSelf

Dysregulation

Interpersonal

Dysregulation

•Mindfulness •Interpersonal Effectiveness

•Middle Path•Distress Tolerance

Behavioral

Dysregulation

Cognitive

Dysregulation

•Emotion Regulation



ADOLESCENT GROUP SKILLS TRAINING

Orientation/

Mindfulness

Distress Tolerance

Orientation/

Mindfulness

Walking the Middle

Path

Orientation/

Mindfulness

Emotion Regulation

Orientation/

Mindfulness

Interpersonal Effectiveness

Entry Points

Length: 1.5 hours

Mindfulness 5 minutes

Homework Review 40 minutes

Break 10 minutes

Skills Training 30-40 minutes

Assign HW, Wind

Down5 minutes

DBT Multi-family Skills Training Group Format

Skills Acquisition

Help! I don’t know what to do!

Skills General-

ization

I can do a DEAR MAN with you, but can’t with my mom/boss/spouse!

Skills Strength-

ening

I know I need to do one of these skills, but I’m having trouble choosing

which one.

Relationship Repair

I’m sorry I walked out of our session today.

COACHING CALLS



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

http://www.linehaninstitute.org/resources/fromMarsha/

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



Reduces:• Suicidal behaviors• NSSI• Medical severity of NSSI• Emergency service usage• Depression• Hopelessness • Anger• Eating disorders • Substance dependence• Impulsiveness

DBT: RCT OUTCOMES

Lieb, K., et al. (2004). Borderline personality disorder. The Lancet, 364, pp. 453-461.

Increases:

• Adjustment (general & social)• Positive self-esteem• Treatment retention

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



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 TREATMENTFOR YOUTH



WHY DBT WORKS TRANSDIAGNOSTICALLY

DBT targets emotional and behavioral dysregulation rather than specific disorders

Ritschel, Miller, & Taylor, 2013


DBT relies on effective case conceptualization




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


DBT includes four stages of treatment and provides a comprehensive framework


STAGES OF TREATMENT

Stage Problem Goal

1 Severe behavioral

dyscontrol

Behavioral control

2 Quiet desperation Non-anguished

emotional experiencing

3 Problems in living Ordinary happiness

and unhappiness

4 Incompleteness Capacity for joy and

freedom




Different skills for different people or for the same person at different times


Distress

Tolerance

Interpersonal

Effectiveness

Emotion

Regulation

Mindfulness

Middle

Path

Acceptance Change


Individual sessions are guided by a structured yet flexible target hierarchy




BEHAVIORAL TARGETING IN DBT

THE PROBLEM OF COMORBIDITY

BPD Non-BPD

# Current Axis I dx 3.4 2.0

% with > 3 Axis I dx 69.5% 31.1%

% with > 4 Axis I dx 47.5% 13.7%

Zimmerman & Mattia, 1999

THE PROBLEM OF COMORBIDITY

Disorder 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 -- -- 53.0%

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)



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, 65-72.

PRIMARY TARGETS

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

DBT INDIVIDUAL TREATMENT TARGETSHIERARCHY TO BE FOLLOWED IN EACH INDIVIDUAL SESSION

Linehan, 1993



NSSI AND SUICIDEDELIBERATE 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




•…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


•…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


…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



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



SECONDARY TARGETS

Emotional vulnerability

Self-invalidation

Apparent

competence

Active passivity

Unrelenting crisis

Inhibited grieving

ADOLESCENT SECONDARY TARGETS

Excessive leniency

Authoritarian control

Forcing autonomy

Fostering dependence

Normalizing

pathologicalbehavior

Pathologizing

normative behavior

ASSESSING THE FUNCTION AND CONTROLLING VARIABLES THAT MAINTAIN

PROBLEM BEHAVIORS



CHAINS: A MOMENT-TO-MOMENT ANALYSIS

PROMPTING EVENT

VULNERABILITY FACTORS

PROBLEMBEHAVIOR

CONSEQUENCES

LINKS(EVENTS, THOUGHTS, FEELINGS)

THE GOAL OF CONDUCTING CHAINS

PROMPTINGEVENT

VULNERABILITY FACTORS PROBLEM

BEHAVIOR

CONSEQUENCES

EFFECTIVEBEHAVIOR



Antecedent

2

Antecedent

3Problem

Behavior

Consequence

1

Antecedent

1Consequence

2

Behavior under control

of antecedents

Respondent/automatic

Behavior under control

of consequences

Operant/functional

BEHAVIORAL CONCEPTUALIZATION OF PROBLEM BEHAVIOR

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



GENERAL PRINCIPLES IN WORKING WITH EMOTIONALLY DYSREGULATED YOUTH

LOGISTICS

•Confidentiality/flow of information

•Voluntariness of treatment

•Court ordered kids

•Know the laws and reporting guidelines

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



MATERIALS AND LEARNING OPPORTUNITIES

STANDARD DBT

DBT FOR ADOLESCENTS



TRAINING AND ACCREDITATION IN DBT

•Training: www.behavioraltech.org•Webinars, 2-days, intensives

•Certification: https://dbt-lbc.org/

THANK [email protected]

Documents

DBT for Adolescents presented by Lorie Ritschel, PhD 1 · ADOLESCENT DBT RCT FOLLOW UP •DBT-A>EUC on: •NSSI frequency •No differences on: •SI, hopelessness, depression, BPD