2. What is DBT?
DBT is Dialectical Behavioral Therapy.
A model of therapy that uses skills training and the
therapeutic relationship to manage strong emotions and
behavioral dyscontrol.
Originally created for treatment of symptoms of Borderline
Personality Disorder,
Primarily suicide and self-harm
Has been modified for a variety of treatment settings
A bio/psycho/social model that builds on traditional
behavioral approaches
Uses group work (skills training), individual therapy and self-
monitoring to change target behaviors.
Provides support for clinicians to be able to work with a
difficult population.
3. DBT as Evidence Based Practice
DBT vs TAU comparison group
DBT had higher global functioning scales
DBT had fewer parasuicidal (self-injurious) behaviors
DBT had fewer psychiatric inpatient days
Multiple Randomized Control Trials and Meta-Analyses Conducted
Two separate meta-analysis reviewed effect sizes
Evidence strongest for Suicidal Behaviors/Attempts, Self-Injury, Dropout
Conflicting evidence for Axis I conditions – depression, anxiety, bi-polar
Counterindicated for schizophrenia/psychosis, developmental delays, manic episodes
Replicated across treatment conditions and different treatment manuals
Substance Abuse (DBT-S)
Eating Disorders
Inpatient Settings, Forensics & Older Adults - not supported by RCT
Evidence for clinicians
Reduces clinician drop-out and clinician burnout
4. DBT requires fidelity
DBT is a Manualized Treatment Program requiring treatment
fidelity
Use of Linehan DBT treatment manual (others have not been tested)
Intensive training for providers
Must use all four components
Individual Therapy
Skills Training Group
24 Hour access to skills coaching
Consultation Team for providers
Can only claim to be doing DBT with all of these components
Skills training alone does not constitute DBT as an EBP
“DBT Light”
No consultation or fidelity checks required to implement program
5. What is Dialectics:
The idea that two opposite or contradictory ideas can
exist simultaneously.
Emotions
Behaviors Thoughts
Similar to CBT and behavior modification with addition of
recognition of emotion on thoughts and behaviors (and
VALIDATION of emotion)
7. Stages of Treatment
Stage I Treatment
Stage IV Life Threatening Behavior
Incompleteness Therapy Interferring Behavior
Life Interferring Behaviors
Stage III Quiet Desperation
Problems in Living
Inhibited Grieving
Re-Learning to Experience
Stage II
Emotions
Quiet Desperation
Problems in Living
Stage I “Ordinary Unhappiness”
Life In Hell Incompleteness
Capacity for Joy (Existential)
8. Individual Treatment Strategies
Every session follows the stages of treatment:
“Let’s start with your diary card.”
“Any life threatening behaviors this week?”
Diary cards
Ways to record impulses and behaviors
Rewards for using skills
Transitional Object – continues relationship outside office
Behavior Chains
Maps out rewards/consequences of certain behaviors
Focused way for therapist and client to think about behaviors
Can serve as negative reinforcement…
Skills Review and in-session practice for life situations
Role play skills for life situations
Problem solving
Therapist as participant
Observes and addresses violations of personal boundaries
Offers opinion, disappointment, uses relationship as both reward and consequence
Allows patient to express all emotions, re-teach appropriate emotional response through relationship
Middle ground solutions to dialectical dilemmas
9. Group Skills Training
Skills Training – NOT Group therapy
In CONJUNCTION with individual therapy – the
two compliment each other.
Serves purpose of:
Skill Acquisition
Skills Strengthening
Skills Generalization
Builds relationship with skills groups leaders through therapist
modeling and reinforcement of skills.
11. DBT Group Skills
Mindfulness Skills Distress Tolerance Skills
Wise Mind Wise Mind ACCEPTS
The intersection of Emotion Improve the Moment
and Rational Mind Self-Soothe
The What and How Skills Pros/Cons
Observe Breathing Exercises
Describe Half-Smile
Participate Radical Acceptance
One mindfully Willingness vs.
Effectively Willfulness
Non-Judgementally Turning the Mind
12. DBT Group Skills
Interpersonal
Effectiveness Emotional Regulation
DEAR MAN Model for Describing
To make requests Emotions
GIVE Check the Facts
To maintain relationship
ABC Please
FAST
To maintain self-respect Mindfulness of Emotions
Intensity and Options for Opposite Action
Asking Brainstorming and
Provides Middle Ground for
when, how and if to ask
Problem solving
13. To complete the full program
For DBT fidelity, clients must:
Be able to develop “behavioral” goals
Participate in weekly individual therapy
Attend group sessions for minimum of 6 months
It is recommended that clients repeat and do two rounds for a year
of time
Complete diary cards on a daily basis
Commit to creating a “life worth living”
14. DBT for children
Appropriate for children?
DBT requires insight, impulse control and ability to notice and control one’s
thought patterns
Children under 10-12 years old have not yet developed necessary skills
No treatment manual with differing literacy levels
Modified treatment manuals (those using images rather than text) have limited
evidence as to their use
Perepletchikova, F. Axelrod, S.R., Kaufman, J., Rounsaville, B.J.,
Douglas, H., & Miller, A.L. (2011). Adapting dialectical behaviour
therapy for children: Toward a new research agenda for pediatric
suicidal and non-suicidal self-injurious behaviours. Child &
Adolescent Mental Health, 16,(2) 116-121.
Beginning stages of creating treatment manual
Very small sample
Found that it may be more effective as parent training strategy than for the
children themselves
15. DBT for adolescents
Miller, A.L., Rathus, J.H., Linehan, M.M., &
Swenson, C.R. (2007). Dialectical Behavioral
Therapy with suicidal adolescents. New York:
Guilford Press.
Book about possibility of implementing DBT with
adolescents
Not a treatment manual
Suggests different components to treatment
Suggests different dialectics
16. Differences from standard DBT
Treatment Manual Adolescent Dialectics
Shorter modules
Excessive
Less time in treatment Leniency
Force Normalize
How groups are conducted
Pathological
Autonomy Behavior
Implementation of a
“Graduate Group” Pathologize
Normal
Foster
Dependency
Behaviors
Involvement of the parents Authoritarian
Control
17. Issues using DBT with adolescents
No specific treatment manual
Miller book primarily theory based, not like specific steps to
treatment like Linehan model
Cannot diagnose adolescents with BPD
Personality does not stabilize until after adolescence
Most “typical” adolescent behavior could be considered BPD
Recent concerns with using group treatment methods
with adolescents
Can reinforce deviant/negative behaviors
Many providers moving to Multi-Family Group, where parents are
involved
Not evidence based
No RCT’s
18. Recent publications in DBT-A
Klein, D.A. & Miller, A.L. (2011). Dialectical behavior therapy
for suicidal adolescents. Child & Adolescent Psychiatry Clinics
of North America, 20(5), 205-216.
“Although research to date on dialectical behavior therapy (DBT) for
adolescents has its limitations, growing evidence suggests that DBT is a
promising treatment for adolescents with a range of problematic
behaviors.”
Backer, H.S., Miller, A.L., & van den Bosch, L.M. (2009).
Dialectical beahviour therapy for adolescents; a literature
review. Dutch Journal of Psychiatry, 51(1) 31-41.
“There were no rct's involving dbt in adolescents, but we did find one
quasi-experimental design and several other studies with a pre-post
treatment design. However, the studies were difficult to compare. In
some cases it was doubtful whether the treatment could still be called
dbt.”
19. Recent publications in DBT-A
Fleischhaker, et. al (2011). Dialectical Behavioral
Therapy for Adolescents (DBT-A): a clinical Trial for
patients with suicidal and self-injurious behavior
and borderline symptoms with a one-year Follow-up.
Child and Adolescent Mental Health, 28(1) 3-10.
Pre-post with improvements directly related to suicide
attempts
One year follow up with still no attempts
Only 12 participants in study, no comparison group
20. So what does this all mean?
DBT is effective in reducing suicide and self-injurious
behaviors in adults
Must have fidelity to model to say using DBT
DBT is not appropriate for children at this time
Unlikely that it will be any time soon – work is too far out and not
appropriate developmentally
It is unknown if DBT is effective with adolescent
population
A “promising practice”
Further evidence should be available in next few years, but to date,
no large scale studies done
Understanding of Dialectics. Because people with Borderline PD tend to see things in black and white, the concept of dialectics is one of the grounding theories of this treatment. While standard CBT incorporates thoughts and behaviors, DBT also accounts for the emotions. Validation that emotions are tied to thoughts and behaviors is one of the first concepts presented. With an understanding of the theory behind BPD, contradiction and validation are what make this treatment different.
DBT treatment first requires patients and therapists to define target behaviors in Stage I of treatment. Within life in hell are three areas that must be addressed in this order. By following this path, therapists are better able to control the sessions and focus on target behaviors without getting thrown off track. Stage I is currently the only stage that is well developed. Research is beginning to address treatment strategies for Stages II & III.
Refer Back to DSM Criteria
Skills can be found in DBT workbook; can use individual skills with any client – do not need full treatment to do specific skills