Dialectical Behaviour Therapy (DBT) for Borderline ... - Onehealth.ca

Dialectical Behaviour
Therapy (DBT) for
Borderline Personality
Disorder
Dr. Kathy Fitch, Psychiatrist
Janice Wingrave, , RPN, Clinical Supervisor
Janice Wingrave, , RPN
‣ Clinical supervisor to comprehensive DBT
outpatient program with 9 therapists, 2
psychiatrists, and allied supports (OT, ILS),
CCMHC
‣ Maintaining our program’s s participation in
ongoing formal training and research with BTech
‣ Organizing educational opportunities for
clinicians outside the clinic
‣ DBT Intensive Training (BTech(
BTech), Parts 1 & 2,
and ongoing BTech supervision
Dr. Kathy Fitch
‣ Psychiatrist in DBT program (25% of time),
CCMHC
‣ Psychiatrist on general adult psychiatry inpatient
unit, Foothills Medical Centre (75% of time)
‣ Involved in training and supervision of medical
students and residents
‣ DBT Fellowship, DBT Foundational Training
(BTech), Beck Institute CBT External Fellowship
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“Standard” DBT Program
‣ DBT individual therapy (weekly)
‣ DBT skills group (weekly when in group)
‣ DBT consult group (therapists only)
‣ Telephone coaching (ideally 24/7)
‣ 12 month commitment
‣ +/- DBT generalization group (approaching
graduation)
‣ +/- DBT family education series
DBT Skills Group
‣ 4 Skills Training Modules:
• Mindfulness skills
• Emotion Regulation skills
• Distress Tolerance skills
• Interpersonal Effectiveness skills
What is Borderline Personality
Disorder
(DSM-IV
IV-TR definition)
A pervasive pattern of instability of
interpersonal relationships, self-
image, and affects, and marked
impulsivity beginning by early
adulthood and present in a variety of
contexts, as indicated by 5 (or more)
of the following:
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What is BPD
1. Frantic efforts to avoid real or imagined
abandonment. *Not (5)
2. Pattern of unstable and intense
interpersonal relationships characterized by
alternating between extremes of idealization
and devaluation.
3. Identity disturbance: markedly and
persistently unstable self-image or sense of
self.
What is BPD
4. Impulsivity in at least two areas that are
potentially self-damaging (e.g., spending,
sex, substance abuse, reckless driving,
binge eating). *Not (5)
5. Recurrent suicidal behaviour, , gestures, or
threats, or self-mutilating
behaviour.
6. Affective instability due to a marked
reactivity of mood (e.g., intense episodic
dysphoria, , irritability, or anxiety usually
lasting a few hours and only hours and only
rarely more than a few days).
What is BPD
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty
controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical
fights).
9. Transient, stress-related related paranoid ideation
or severe dissociative symptoms.
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Objectives
1. Gain an understanding of the Biosocial
Theory of Borderline Personality
Disorder
2. Gain an understanding of the key
components of a DBT approach: Core
Strategies and Dialectical Assumptions
3. Leave the session with one clear
strategy that can be used with a client
and/or loved one
Objectives
1. Gain an understanding of the
Biosocial Theory of Borderline
Personality Disorder
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Bio-Social Theory
EMOTION DYSREGULATION
Emotionally
Vulnerable
individual
Invalidating
Environment
Linehan 1993
‣ Communication can be verbal or non-
verbal, and often it is both.
What is an invalidating
environment
‣ Core features:
• Indiscriminately rejects communication of
private experiences and self-initiated
behaviours
• Intermittently reinforces escalation of
emotional responses and display
• Oversimplifies ease of problem solving and
meeting goals
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What is an invalidating
environment
‣ The private experience of an individual is
negated by the environment
• E.g. You don’t t really think that.
• E.g. You’re doing that on purpose. I didn’t t even
mean it that way.
• E.g. That’s s not how you really feel.
• Eg. . You’re being stupid/ridiculous/silly.
• E.g. You’re not really hurt.
What is an invalidating
environment
‣ The private experience of an individual
isn’t t accurately recognized or reflected by
the environment
• E.g. emotionally sensitive child with a
busy/preoccupied parent
Internalized invalidating
environment
‣ Stop trusting your own emotions.
‣ Stop trusting your own perspective.
‣ Tendency to judge yourself and others.
‣ Lack of skills in managing your
thoughts/feelings/behaviours
behaviours.
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Objectives
1. Gain an understanding of the Biosocial
Theory of Borderline Personality
Disorder
2. Gain an understanding of the key
components of a DBT approach: Core
Strategies and Dialectical
Assumptions
DBT Core Strategies
Acceptance/validation
Change
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Successful Validation: Reduces
arousal
‣ Validation has succeeded when arousal
associated with invalidation is reduced
Highly aroused
Ready to learn
Too relaxed
What to validate
“ Validation does not automatically imply
liking, approval or preference”
MM Linehan 1997
What to validate
‣ Recognizing the kernel of truth in the
person’s s experience.
‣ Remember: emotions are one of the
easiest things to validate
• E.g. You seem really hurt/mad/affected by that.
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Remember!
‣ Match the verbal and nonverbal message
‣ NB: If the tone of voice is mismatched,
then words intended to “validate” the
person’s s feelings may be experienced as
invalidating
• E.g. (irritable instead of concerned) “You
seem really angry about that.”
• E.g. (cheerful instead of concerned) “You
seem really sad.”
Challenges of validating the
sensitive individual
‣ Quicker reaction to events than expected
‣ Higher than expected intensity of reactions
‣ Slower settling of emotions
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Mindfulness
‣ “The repetitive act of directing your attention to
only one thing in this one moment” means
training your mind to pay attention to what you
choose to pay attention to instead of letting your
mind hijack you.
‣ Whatever your attention is on, that’s s what life is
for you at any given moment.
‣ Considered the core skill required to develop
other DBT skills.
‣ Metaphors:
• Untrained puppy
• TV channel surfing
• Clouds in the sky
Mindfulness
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Change strategies
‣ Based on thought/emotion/behaviour
change techniques used throughout
cognitive-behaviour
therapy (CBT)
‣ Strong emphasis on validation to balance
the strain of change
‣ Mindfulness skills allow for clear
observation, and contemplation of
alternatives for change
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DBT Assumptions about Patients
‣ Patients are doing the best they can
‣ Patients want to improve
‣ The lives of suicidal BPD patients are unbearable as
they are being currently lived
‣ Patients must learn new behaviours in all relevant
contexts
‣ Patients cannot fail in DBT
‣ Patients did not cause all their own problems, but
they are responsible for solving them
‣ Patients need to do better, try harder and/or be
more motivated to change
Dialectics
‣ A dialectic is finding synthesis in opposing
experiences and points of view
‣ “Dialectics” involves several assumptions about
the nature of reality: 1) everything is connected
to everything else; 2) change is constant and
inevitable; and 3) opposites can be integrated to
form a closer approximation to the truth (which is
always evolving).
‣ Nothing is just black and white.
Dialectic: an example
‣ 2 people standing on opposite ends of an
elephant will offer very different
descriptions of what an elephant looks like
‣ The “synthesis” of these descriptions
incorporates both points of view
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Objectives
1. Gain an understanding of the Biosocial
Theory of Borderline Personality
Disorder
2. Gain an understanding of the key
components of a DBT approach: Core
Strategies and Dialectical Assumptions
3. Leave the session with one clear
strategy that can be used with a client
and/or loved one
What strategy will you
take away from today’s
session
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Summary
1. Gain an understanding of the Biosocial
Theory of Borderline Personality
Disorder
2. Gain an understanding of the key
components of a DBT approach: Core
Strategies and Dialectical Assumptions
3. Leave the session with one clear
strategy that can be used with a client
and/or loved one
Contact Information
‣ Referrals: Access Mental Health (943-
1500), private clinic Inner Solutions
‣ Website information: behavioraltech.org,
borderlinepersonalitytoday.com,
bpdcentral.com
‣ Staff recruitment: CHR website
‣ For more information:
• DBT Clinic phone number: 297-7311
7311
2006 CHR People First Awards: Dialectical
Behaviour Therapy Treatment Team
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Community Education Service
To register for notification or an upcoming
education session go to:
www.fcrc.sacyhn.ca
For general CES enquiries Email:
ces@sacyhn.ca
Call: 403-955
955-7420
Funding generously provided by Encana
Corporation and the Alberta Children’s
Hospital Foundation
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