Dialectical Behavior Therapy – Adaptation for Family Physicians

UNIVERSITY OF TORONTO

Shelley McMain, PhD, C. PsychHead, BPD Clinic

Centre for Addiction and Mental Health and Department of Psychiatry

University of Toronto

Objectives

Be familiar with DBT’s biosocial theory of Be familiar with DBT’s biosocial theory of BPDBPD

Identify two core DBT strategies used to Identify two core DBT strategies used to effectively engage individuals with BPD effectively engage individuals with BPD

Be familiar with strategies to reduce Be familiar with strategies to reduce burnout and enhance self careburnout and enhance self care

BPD: Diagnosis

Personality Disorder: Personality Disorder: enduringenduring pattern of inflexible and pattern of inflexible and

maladaptive traits which causes maladaptive traits which causes impairment or distressimpairment or distress

arbitrary cutoff between BPD and traits: 5/9arbitrary cutoff between BPD and traits: 5/9 utility of diagnosisutility of diagnosis diagnosis not made by your own reaction to diagnosis not made by your own reaction to

the patientthe patient

Dialectical Behavior Therapy

““Standard DBT” is a comprehensive, Standard DBT” is a comprehensive, multimodal treatment originally multimodal treatment originally developed for people with BPDdeveloped for people with BPD

DBT has been adapted for various patient DBT has been adapted for various patient populations and across a variety of populations and across a variety of settings settings

Any professional can implement selected Any professional can implement selected strategiesstrategies

Vignette #1

• 42 year old single woman with chronic suicidal 42 year old single woman with chronic suicidal and self harm behaviorand self harm behavior

• Tx history includes numerous psychotropic Tx history includes numerous psychotropic medications, lengthy hospital stays and repeated medications, lengthy hospital stays and repeated ER visits, lengthy history of psychosocial ER visits, lengthy history of psychosocial treatments treatments

• Patient frequently presents in a state of emotional Patient frequently presents in a state of emotional – often angrily demanding more time and – often angrily demanding more time and additional appointmentsadditional appointments

Clinical Consideration

How do you understand this How do you understand this patient’s problems?patient’s problems?

If you believe that this patient meets If you believe that this patient meets criteria for BPD, should you criteria for BPD, should you

discuss the diagnosis?discuss the diagnosis?How should you engage this patient?How should you engage this patient?

Etiology of BPD:DBT’s Bisosocial Theory

High High EmotionEmotion

VulnerabilityVulnerability

High High EmotionEmotion

VulnerabilityVulnerability

EmotionEmotionModulationModulation

DeficitsDeficits

EmotionEmotionModulationModulation

DeficitsDeficits

ProblematicBehaviours (e.g. suicide, substance use)

Fruzzetti et al. (2005)

Emotion Vulnerability

Heightened Emotional Arousal

Inaccurate/Extreme Expression

Invalidating Responses from

Others

Pervasive History of

Invalidating Responses

DBT’s Biosocial Theory

Fruzzetti et al, 2005

Educate Patients about BPD diagnosis

• Helps to de-stigmatize diagnosisHelps to de-stigmatize diagnosis• Helps to increase hopefulness about Helps to increase hopefulness about

possibility for changepossibility for change• Encourages active participation in treatment Encourages active participation in treatment

planningplanning• Education about the diagnosis has been Education about the diagnosis has been

shown to reduce symptoms (Zanarini,2008)shown to reduce symptoms (Zanarini,2008)

Adopt a Clear Treatment Structure

Establish a treatment contract – clarify your roles, Establish a treatment contract – clarify your roles, responsibilities, treatment goalsresponsibilities, treatment goals

Clarify structure of appointments – frequency of Clarify structure of appointments – frequency of appointments, expectations about attendanceappointments, expectations about attendance

Be clear about your limits and availabilityBe clear about your limits and availability Anticipate and plan for crisesAnticipate and plan for crises

APA, 2001APA, 2001

Guidelines on Concomitant Treatments

Treatment by more than one clinician is Treatment by more than one clinician is viable however good collaboration is viable however good collaboration is essential essential (APA, 2001).(APA, 2001).

Someone should be identified as the Someone should be identified as the primary clinicianprimary clinician

(APA, 2001; Oldhman et la., 2001; Gabbard, 2000;(APA, 2001; Oldhman et la., 2001; Gabbard, 2000;

Gunderson, 2001; Linehan, 2003; Kernberg, ).Gunderson, 2001; Linehan, 2003; Kernberg, ).

Clinical Vignette #2

““I’ll kill myself if you don’t get me I’ll kill myself if you don’t get me admitted to the hospital for the weekend”admitted to the hospital for the weekend”

Patient’s parting words to therapist who Patient’s parting words to therapist who indicated that she didn’t think that indicated that she didn’t think that hospitalization would be helpfulhospitalization would be helpful

Clinical Considerations

Is this client being manipulative?Is this client being manipulative? How should you respond?How should you respond? If you attend to the suicide threat will you If you attend to the suicide threat will you

reinforce this behavior? reinforce this behavior? Should she be hospitalized?Should she be hospitalized?

Functions of Self-injurious Behaviour

FunctionFunction % of patients% of patients

To feel physical pain – to overcome To feel physical pain – to overcome psychic painpsychic pain

5959

To punish self for being “bad”To punish self for being “bad” 4949

To control feelingsTo control feelings 3939

To exert controlTo exert control 2222

To express angerTo express anger 2222

To feel-to overcome numbnessTo feel-to overcome numbness 2020

Gunderson, 2001 adapted from Shearer, 1994b

Opt For the Least Restrictive Safe

Treatment Setting

Hospitalization may be iatrogenic Hospitalization may be iatrogenic Hospitalization should be viewed as a vehicle for Hospitalization should be viewed as a vehicle for

maintaining safety maintaining safety Hospitalization should be considered if the risk of Hospitalization should be considered if the risk of

suicide outweighs the risk of inappropriate suicide outweighs the risk of inappropriate hospitalizationhospitalization

Focus on helping patients cope in their natural Focus on helping patients cope in their natural environmentenvironment

Validate and Emphasize Patient Control

Move flexibly from validating kernal of truth and Move flexibly from validating kernal of truth and helping patient take responsibility (APA, 2001)helping patient take responsibility (APA, 2001)

Don’t rush in and “take care of” patient”Don’t rush in and “take care of” patient” Don’t reinforce dysfunctional behavior with extra Don’t reinforce dysfunctional behavior with extra

attention (i.e., attention (i.e., avoid scheduling extra avoid scheduling extra appointments in response to self-harm)appointments in response to self-harm)

Validate patients capability of behaving Validate patients capability of behaving reasonably reasonably

Validation

Why Validate?Why Validate?

an essential need of an essential need of people with BPDpeople with BPD

the only way to build the only way to build alliancealliance

reduces distress reduces distress reduces polarization reduces polarization a prerequisite for a prerequisite for

cooperationcooperation

How to Validate?How to Validate?

listen, reflectlisten, reflect make educated guesses make educated guesses

at what she’s not at what she’s not saying (read her saying (read her thoughts and emotions)thoughts and emotions)

normalise normalise remember where she’s remember where she’s

coming fromcoming from find what is valid, right find what is valid, right

or understandableor understandable

Encourage Effective CopingAlways start by validating AND then paradoxicallyAlways start by validating AND then paradoxically

1.1. Cheerlead - validate her strength and ability to Cheerlead - validate her strength and ability to cope/survivecope/survive

2. Reinforce progress towards goal - reinforce the 2. Reinforce progress towards goal - reinforce the small stepssmall steps

3. Negotiate - offer the options you are willing to 3. Negotiate - offer the options you are willing to offer and have clear limitsoffer and have clear limits

4. Suggest alternatives to the behaviour if possible4. Suggest alternatives to the behaviour if possible

Vignette #3

Thinking of your patient or seeing your Thinking of your patient or seeing your patient evokes the following response:patient evokes the following response: hope that she’ll get admitted to hospitalhope that she’ll get admitted to hospital relief when she cancelsrelief when she cancels daydreaming about transferring her caredaydreaming about transferring her care Wish that you’d chosen another careerWish that you’d chosen another career feeling angry or irritated with her feeling angry or irritated with her

(comments to office staff)(comments to office staff)

Reducing Burnout

Validate yourself since stress is Validate yourself since stress is understandableunderstandable

Validate your patient – remind yourself of Validate your patient – remind yourself of why she is doing the best she canwhy she is doing the best she can

Seek support from colleaguesSeek support from colleagues Assume responsibility for observing your Assume responsibility for observing your

personal limitspersonal limits

Observing Your Personal Limits

Monitor your limits with your patientsMonitor your limits with your patients Be honest with yourself and clear with your Be honest with yourself and clear with your

patients about your limitspatients about your limits Observing limits is different than setting Observing limits is different than setting

boundariesboundaries When your client exceeds your limits, validate and When your client exceeds your limits, validate and

problem-solveproblem-solve negotiate a better arrangement for yourself negotiate a better arrangement for yourself

(more resources for the patient?)(more resources for the patient?)

Summary

DBT’s biosocial theoretical model can DBT’s biosocial theoretical model can increase understanding of symptoms.increase understanding of symptoms.

Educate patients about the diagnosisEducate patients about the diagnosis Treatment should be well structuredTreatment should be well structured Emphasis on validation in addition to Emphasis on validation in addition to

helping the client control behaviorhelping the client control behavior Observe your limits and get supportObserve your limits and get support