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