Advancing-Recovery-DBT-Marsha-Linehan

Dialectical Behavior TherapyA story of Success ThroughFailureWhere DBT Started: 1980Marsha Linehan, Ph.D.University of WA 20151

Suicide: A Definite NationalPublic Health Problem–41,149 U.S. deaths in 2013–112 per day,1.6% of total U.S. deaths–Over 1 million reported attempts–in 2011 (in U.S.)• 10 th leading cause of death in U.S. in 2008–National rate: 13 per 100,000(CDC, 2014; SAMHSA,2012)3Ward-Ciesielski

Yes Indeed. It Is a DefiniteProblem–Suicide rate among middle-age Americans rose30 percent from 1999 to 2010, with more peoplenow dying of suicide than in car accidents.– U.S. suicide rate is at its highest in 25 years–Suicide Rates Among Black Children–Have Skyrocketed(NYTimes)Ward-Ciesielski

Where DBT Started: 1980• Patients: high risk for SUICIDE withmultiple suicide attempts/self-injuries• Funding: NIMH treatment developmentgrant for suicidal behavior• Starting point: behavior therapyMarsha M. Linehan, Ph.D. 20155

Immediate Problems to Solve1. Extreme sensitivity to rejection andinvalidation made a change focusedtreatment untenable.2. Extreme suffering made an acceptancebased approach also untenable. (aren’tyou going to help me?)Marsha M. Linehan, Ph.D. 20156

New Therapist Strategies• Synthesis of:– Technology of Change and– Technology of ACCEPTANCE• Spaciousness of Mind– To “dance” with movement, speed and flow• Radical ACCEPTANCE of:– Client– Slow and Episodic Rate of Progress– Risk of Suicide• Humility– To see the transactional nature of the enterpriseMarsha M. Linehan, Ph.D. 20157

Solution Was to ApplyA Dialectical Approach BalancingChangeStrategiesAcceptanceStrategiesDialecticsMarsha M. Linehan, Ph.D. 20158

Immediate Problems to Solve3. Low distress tolerance and frequentcrises and high arousal made sustainedwork on change very difficult.Marsha M. Linehan, Ph.D. 20159

New Client Targets• Radical ACCEPTANCE of:– One set of problems to work on another– The Past– The Present– Limitations on the Future• Distress Tolerance:– Ability to tolerate distress without impulsivelyor destructively reducing it• Experience of:– Connection– Essential “goodness”– Essential validityMarsha M. Linehan, Ph.D. 201510

Solution Was to DevelopA Dialectical Approach, TeachingChangeSkillsAcceptanceSkillsDialecticsMarsha M. Linehan, Ph.D. 201511

Immediate Problems to Solve4. Ever changing clinical presentationtogether with frequent crises resulted inconfused therapists and a chaotictherapyMarsha M. Linehan, Ph.D. 201512

Percent DSM Diagnoses:BPD Chronically Suicidal PatientsDiagnosisLifetime CurrentMajor depression 96.7% 75.0%Dysthymic disorder N/A 14.3%Substance abuse 15.2% 5.4%Substance dependence 56.5% 26.1%PTSD 56.5% 51.1%Social phobia 21.7% 16.3%Panic disorder 52.2% 40.2%OCD 23.9% 19.8%Eating disorder 41.3% 23.9%Linehan et al., 200613

Adolescent DSM Diagnoses:DiagnosisSuicidal PatientsLifetimeGreater the 3 disorders 60.6%Major depression 53.8%Alcohol abuse 43.2%Conduct disorder 42.6%Substance abuse 32.9%Simple phobia 30.8%Social phobia 28.8%PTSD 27.1%Knock & Kessler, 200614

Solution Was to ProvideA Dialectical BalanceTarget-basedAgendaProtocol-basedAgendaDialecticsMarsha M. Linehan, Ph.D. 201515

The Immediate Problem to Solve5. Treating individuals at chronic high riskis both scary and leads to burnout.Standard of care has no data that it iseffectiveCompetency reduces burnout BUT therewas no evidence- based treatment tofall back on.Marsha M. Linehan, Ph.D. 201516

Solution Was to ProvideA Dialectical BalanceStandard ofCareDBT RiskAssessment andManagementProtocolDialecticsMarsha M. Linehan, Ph.D. 201517

The Problem Further5. Therapist emotion dysregulation ledto excessive fear, anger and hostilityresulting in attempts to control thepatient, rejection and attack…….orexcessive empathy leading to fallinginto the pool of despair with the clientand abandoning therapyMarsha M. Linehan, Ph.D. 201518

DBT ModelSuicidal Behavior =Problem Solving(for the client)andA Problem(for the therapist)19

Solution Was to ProvideA Dialectical BalanceTEAMLramp(Linehan suicide riskassessment andmanagement protocol)Team+ExpertiseMarsha M. Linehan, Ph.D. 201520

Next Problem to Solve6. Getting an NIMH RO1 grant required atleast one mental disorder as aninclusion criteriaMy choices were BPD or MDD as bothwere related to suicideI chose BPDMarsha M. Linehan, Ph.D. 201521

•Solution Was to ProvideA Dialectical BalanceDSMDiagnosisProblemBehaviorMechanismsof disorderMarsha M. Linehan, Ph.D. 201522

Next Problem to Solve7. Develop a model of BPD– Capable of guiding effective therapy– Non-pejorative, engenderingcompassion– Compatible with current research dataMarsha M. Linehan, Ph.D. 201523

BPD is a Pervasive Disorderof the Emotion RegulationSystemBPD criterion behaviors function toregulate emotions orare a natural consequence ofemotion dysregulationMarsha M. Linehan, Ph.D. 201524

Solution Was to ProvideA Dialectical Model of PathogenesisBiologicalRegulationDisorderInvalidatingSocial EnvironmentTransactionMarsha M. Linehan, Ph.D. 201525

Next Problem to Solve8. Patient populations differ due todifferential diagnosis andproblems, differential context andenvironment and also due todifferent cultures26

Example8. Adolescents differ from adults– Targets must be developmentallyappropriate– Liability issues differ– They live with parents & family– Capabilities differ– Cognitive processing differsMarsha M. Linehan, Ph.D. 201527

Solution Was to Stretch DBT withoutChanging it to non-DBTModify Only WhereAbsolutelyNecessaryKeepEverythingElseEB DBTMarsha M. Linehan, Ph.D. 201528

DBT for Adolescents: PrimaryChanges• Targeting:– Adolescent Quality of Life targets– Adolescent & Family secondary targets• Participants in treatment:– Inclusion of parents in treatment of suicidal and out-ofcontrolbehaviors– Multi-family skills• Modification of both Communication and Case ManagementStrategies– Environmental Intervention more frequent– Style of interaction adolescent appropriateMarsha M. Linehan, Ph.D. 201529

DBT for Substance Dependence•• Targeting:– Drug use at top of quality of living targets• Participant maintence in treatment:– Attachment strategies• Modification of Contingency Management Strategies– UAs 3x week– Replacement medication• Skills– Addiction skills setMarsha M. Linehan, Ph.D. 201530

Next Problem to Solve9. Standard DBT is very good attreating Axis I disorders with“out-of-control” behaviorsDBT anxiety disorders not ordinarilytargeted with suicidal clients and, if nottargeted outcomes not as good asbehavioral treatments treating anxietydisorders in non-suicidal individualsMarsha M. Linehan, Ph.D. 201531

% Remitted100908070605040302010087%SubstanceDependenceDisordersWorking to Improve DBT68%MajorDepression64%EatingDisordersOutcomes for DSMDisorders:47%PanicDisorderOther AnxietyDisorders(Harned, Chapman, Dexter-Mazza, Murray, Comtois, & Linehan, 2008)Marsha M. Linehan, Ph.D. 201539%PTSD35%32

The problem further9. High risk individuals maynot be able to tolerate the stress ofexposure-based treatments foranxiety without escalatingsuicidality or Non Suicidal Self-Injury(NSSI)Marsha M. Linehan, Ph.D. 201533

Solution Was to CombineDBT ContingencyManagementDBT ExposureProtocolEB DBTMarsha M. Linehan, Ph.D. 201534

Next Problem to Solve10. DBT + intensive case management:– Intensive case management +– On-call crisis intervention +– DBT Skills Group +– Weekly therapist/supervision meetings +– Suicide risk assessment & managementprotocolHad good outcomes:How to interpret?NIMH Symposium, Association for Behavioral and Cognitive Therapies, San Francisco, 2010Marsha M. Linehan, Ph.D. 201535

Solution is to Put a Higher Emphasis onDBT Skills:EB DBTMarsha M. Linehan, Ph.D. 201536

Next Problem to Solve11. DBT as treatment for BPD only– Data indicated it was useful for otherdisorders– Stigma of DBT kept people outof DBTMarsha M. Linehan, Ph.D. 201537

Solution is to FurtherDBT Research:Axis I/Low RiskSkills TrainingAloneBPD/High RiskIndividual + SkillsEB DBTMarsha M. Linehan, Ph.D. 201538

Next Problem to Solve12. Original bio-social theory developed asmodel for development andmaintenance of BPD, chronic suicidalityand severe emotion dysregulation.Marsha M. Linehan, Ph.D. 201539

Solution is to Provide Models MatchingDisorder:BPD Bio-socialModelDisorder-specificBio-social modelsEB DBTMarsha M. Linehan, Ph.D. 201540

Next Problem to Solve13. DBT as treatment for mental disordersonly– Experience indicated it could be useful forgeneral public, i.e., those withoutdiagnosed mental disorders– Stigma of mental disorder kept people outof DBTMarsha M. Linehan, Ph.D. 201541

Solution is to FurtherDBT Research:DBT focused ondisorderDBT Skills forfriends, family andschoolsEB DBTMarsha M. Linehan, Ph.D. 201542

Next Problem to Solve14. DBT demand is higher thanresources to provide adequatetreatment . Not enough trainedtherapists, not enough trainersLinehan 201543

Current Problem to Solve15. Many people and treatment programswith little to no training in DBT Advertisethemselves a providing DBT treatment.Individuals not associated with DBTtreatment developer or identified by treatmentdeveloper as DBT experts are offering DBTCertificationLinehan 201544

Solution is toDevelop Linehan Approved CertificationDBT LinehanBoard ofCertificationRaise Money to fundsustainability ofcertification programEB DBT45

Never Ending Problem to SolveIs DBT Effective?Linehan 201546

Solution is toDevelop Linehan Approved CertificationConductResearch;Encourage othersto do also alsoStay Loyal to DataEB DBT47

Is DBT Effective?Yes, across a variety ofcoutcomes48

How Well Does DBT ReduceSuicidal Behaviors?49

Mean # of ActsSuicidal & Intentional Self-injuriousActs By Condition and Time(Linehan et al., 1991, 1999, 2002, 2006)50

% Attempting SuicidePercent Attempting Suicide ByCondition and Time(Linehan et al., 1991, 1999, 2002, 2006; van den Bosch et al., 2005)51

Can someone besides thetreatment developer and herteam do the treatment?52

17 RANDOMIZED CONTROLLEDTRIALS FOR DBT9 Independent Sites•10 RCTs with DBT training and supervision•3 RCTs Compared DBT to Alternative ManualsLinehan, Koons, Telch, Safer, van den Bosch, Verheul, Lynch, Bohus,McMain, Pisterello, Carter * Turner*, Clarkin* *no expert DBT supervision or adherenceratings53

Are DBT gains due simply toexpert psychotherapy?54

RCT: Internal Validity Trial• Designed to Control For:– Therapist expertise and experience– Therapist gender– Therapist allegiance to treatment– Institutional prestige– Availability of supervision– Availability of affordable treatment– Assistance to connect with therapist– Hours of individual therapy–55Non-specific factors

RCT: Internal Validity Trial• Compared:DBT treatmentvs.Control Treatment withCommunity Experts– Experts were:• Elected by peers (other psychologists) as experts intheir own treatment• No behavioral therapists used in control treatment56

DBT compared toExpert Community Therapy• Suicide attempts: 50%• ER visits for suicidality: 53%• Inpt. admits for suicidality: 73%– All remain 50% lower during follow-up– Linehan et al 200657

Are DBT gains due simply toexpert psychotherapy?No58

It is not enough tobe compassionate,we must act.- Dali Lama

Contacts of interestCertification http://dbt-lbc.org/Marsha Linehan Facultyhttp://faculty.washington.edu/linehanBRTC (My clinic) http://blogs.uw.edu/brtc/Linehan Institutehttp://www.linehaninstitute.org/Behavioral Tech http://behavioraltech.org/60

Thank You61