Transcript Dialectical Behavior Theory, Prolonged Exposure

DBT PE
Dialectical Behavior Theory,
Prolonged Exposure treatment model


Naked

A poem by Molly







You can expose all your skin and piece by piece remove your
clothes, from your head down to your toes
You can bare your outer self to so many eyes, yet not one of
them know the hurt that lies
Pain can be written in the soul and seen through another's heart
but if you bare yourself all wrong, you'll miss that part.
Being exposed should be a painful relief, when someone can
see you and not just leave
A bittersweet eye opener to the naked that nobody wants to
understand ‘cause physical seems to be a new level of demand.
Being viewed by thousands for a crafted body that’s been
worked on over time is nothing to the beauty crafted in the
complex mind
You can see all the physical curves the wounds all the wear and
tear, just look it’s right there.
But the mind, with all the demons and fears the crazy racing
battles, now that’s hard to bare
Being uncovered and open to invasion while allowing your
mind to feel the cold outside air and being held by trust with no
worries of judgment or care, now that’s being naked.
Get naked for the one deserving to see you. For the one who
knows that getting naked isn’t something you easily do.
Goal
• present the efficacy and applicability of DBT
PE in helping individuals with Borderline
Personality Disorder and severe active
symptoms of Post Traumatic Stress Disorder
Objectives
• Understand the theory and underpinnings of
DBT PE
• Understand the efficacy of DBT PE and
possible application
• Increase awareness of pending research with
DBT PE
Theory and underpinnings of
DBT PE
1. Prolonged Exposure
2. DBT
3. DBT PE
Major components of PE
Edna Foa
1. Education about common reactions to trauma
2. Breathing retraining, i.e., teaching the client
how to breath in a calming way
3. Repeated in vivo exposure to situations or
objects that the client is avoiding because of
trauma related stress an anxiety
4. Repeated, prolonged imaginal exposure to the
trauma memories – recounting the trauma
memory –telling the narrative
Emotional Processing Theory: the
conceptual backbone
• Fear is represented in memory as a cognitive
structure that is a program for escaping danger
• When no danger exists the fear becomes
pathological
• Pathological fear includes:
1. Fear causes inaccurate interpretation of environment
2. psychological escape/avoidance responses evoked
3. easily triggered, emotionally predisposed to fear
response, associated behavioral interference
4. harmless stimulus are erroneously associated with
threat meaning
• Two conditions are necessary for successful
modification of fear structure
1. Fear structure must be activated, or the unwanted
negative memories and emotions must be
engaged
2. New information, incompatible with the
erroneous information embedded in the fear
structure, must be available and incorporated into
the fear structure
– Systematic process engaged to safely accomplish
this
Foa’s research
1. Study one 1991( 45 female rape survivors
with chronic PTSD) : PE showed significant
improvement at end of treatment, similar to
Stress Inoculation training and better than
Supportive Counseling. Control group
showed no improvement. At One year follow
up PE subjects continued improving, the other
groups only maintained.
2. 97 female survivors of rape and non-sexual
assault with chronic PTSD.
– PE, SIT, PE+SIT, and control group
– PE alone was superior to all other groups with
only 35% of subjects retaining diagnosis of PTSD
– Foa expected the combined PE+SIT to be most
effective
3. Compared PE alone with PE + cognitive
restructuring (CR).
 CR – shown in past to be beneficial for Anxiety
disorders, therefore added to PE
 179 women with chronic PTSD, survivors of
rape, non-sexual assault, and childhood sex abuse
 Treatments were statistically equal post treatment
and at one year follow up. Effect sizes larger in
PE
Dialectical Behavior Therapy
Marsha Linehan
• Bio social theory of Borderline personality
Disorder
 Dialectical process, antithesis/ thesis/ synthesis
Transactional model: interplay of biology and the
environment
Invalidating environment combined with high
emotional sensitivity, intensity, and reactivity
There is no inherent flaw in individuals diagnosed
with BPD, biological tendency is not good or bad
here, it just is
Biology
Emotional sensitivity, intensity,
reactivity
I’m ok, I
like me
I’m bad/ wrong/
flawed
Validating
Invalidating
Environment
Major components of DBT
• Skills training groups 4 modules : Core
mindfulness, distress tolerance, emotional
regulation, interpersonal effectiveness
• Client commitment to ONE year of treatment
(one cycle of skills training takes 6 months)
• Individual weekly psychotherapy
• Diary card – not just an assignment it is essential
• Consultation Team
• Phone coaching
Levels of validation
1. Staying Awake: unbiased listening and observing
2. Accurate reflection
3. Articulating the unverbalized emotions,
thoughts, or behavior patterns
4. Validation in terms of past learning or biological
dysfunction
5. Validation in terms of present context or
normative function
6. Radical Genuineness
DBT assumptions about patients
I. Clients are doing the best they can
II. Clients want to improve
III. Individuals must learn new behaviors in all relevant
contexts
IV. Patients cannot fail in DBT
V. Individuals may not have caused all of their problems, but
they have to solve them anyway
VI. Clients need to do better, try harder, and /or be more
motivated to change
VII. The lives of suicidal, individuals with borderline
personality are unbearable as they are currently being
lived
DBT assumptions about therapy
 The most caring thing a therapist can do is help patients
change in ways that bring them closer to their own
ultimate goals
 Clarity, precision, and compassion are of the utmost
importance in the conduct of DBT
 The therapeutic relationship is a real relationship
between equals
 Principles of behavior are universal, affecting therapists
no less than patients
 DBT therapists can fail
 DBT can fail even when therapists do not
Stages and Targets of DBT
I. Pre-treatment – commitment and agreement
II. Stage 1: Severe Behavioral Dyscontrol



Safety – suicide, homicide, self harm, risky Bx
Behavioral control – dysregulated, erratic, life destructive
Stamp out threats to LIFE, THERAPY, QUALITY
III. Stage 2: Quiet Desperation

Processing grief and trauma
IV. Stage 3: Problems in Living



Ordinary happiness and unhappiness
Building a life worth living
Wise mind value consistent
V. Stage 4: Incompleteness

Capacity for joy
Additional DBT info
• Your clients are not fragile, do not treat them
this way
• Know your limits, and boundaries, be ethical
• Seek consultation
• Seek your own awareness
• Live DBT – be genuine
• Go where angels fear to tread
Linehan’s Initial DBT outcome trial (1991)
 47 Subjects diagnosed with BPD
 23 in Treatment as usual TAU and 24 in DBT
 Significantly less likely to engage in parasuicidal behavior
and less medically severe
 DBT only 16.4% drop out rate, standard of care was 5055%
 Inpatient days over one year: DBT=8.46, TAU=38.86
 Outcomes p= < .02 DBT good vs TAU good, good defined
as “no psychiatric hospitalization and no parasuicide
episodes during the last four months of treatment”
 Positive effect in reducing life interfering behaviors and
improving emotional regulation and interpersonal skills
Linehan Second study (1993)
• Compared full DBT to TAU psychotherapy +
DBT skills groups
• Standard DBT is more effective than TAU +
skills group
• Skills training only proven effective in full
DBT
• Integration of both types of treatment may be
critical to success of DBT
Therapeutic shortfall’s of DBT
alone and PE alone
1. PE not designed to treat severe complicated
trauma (safety concerns) as is often found in
DBT clients, in fact Foa advised against it.
2. DBT does not address how to process trauma
with clients, no specific techniques given by
Linehan. It occurs in stage two of DBT
PE
DBT
So what
happens if you
merge these
treatments?
Harned and Korslund
DBT PE EFFICACY
Eligibility Criteria:
open Trial and Pilot RCT
Inclusion Criteria
 Female
 Ages 18-60
 Meets criteria for BPD
 Meets criteria for PTSD
(any trauma type)
 Recent (past 2-3 months)
suicidal or serious nonsuicidal self injury
Exclusion Criteria
• Bipolar or Psychotic
disorder
• Mental retardation
• Mandated to treatment
Interesting Demographics of Open
Trial and Pilot RCT
• Severe dissociation: OT = 69.2% Pilot RCT 96.2%
• On average, clients reported a lifetime history of 12
types of trauma, with some type of trauma starting
before age 6 (childhood sexual abuse 54% of total
combined client trauma, 15% adult rape, physical abuse
and violence or sudden death of loved one, making up
the rest
• Any suicide attempt: OT= 23.1% Pilot RCT = 57.7
• Any non suicidal self injury: OT = 92.3% Pilot RCT =
96.2%
Note: All reasons PE was not recommended for DBT
clients with concomitant PTSD in the past
Exposure Rarely Causes Increases
in Suicidal and Self-Injury Urges
Urge to commit suicide
Urge to self- injure
Increase in urges
7.7%
8.2%
No change in urges
80.5%
78.2%
Decrease in urges
11.8%
13.6%
Note. Urges were rated immediately before an dafter each exposure task (n=701)
Further: No increases in suicide attempts, non-suicidal self-injury, Inpatient
psychiatric hospitalizations, ER visits for psychological reasons
And: no PTSD worsening noted
DBT PE findings
• PTSD remission rates for protocol completers
OT = 71% Pilot RCT = 80% Standard
DBT = 33%
• 3month follow up remained at 60% or Better
• Secondary Outcomes: Decrease suicidal
ideation, decrease trauma-related guilt
cognitions, decreased shame, dissociation,
depression, anxiety, and improve social
adjustment
Harned and Korslund Conclusions for
adding DBT PE protocol with standard DBT:
1. It is feasible to implement for the majority of
clients who complete one year of standard DBT
2. It can be delivered safely
3. I achieves rates of PTSD remission comparable
to other PTSD treatments and higher than
standard DBT
4. It is associated with large improvements in a
variety of BPD and trauma-related outcomes that
are greater than those found in standard DBT
DBT PE
Melanie Harned
• Adapts both therapies in one cohesive model
• Imaginal exposure on average of 13 weeks to full
remittance of PTSD symptoms
• No increase in suicidal and parasuicidal behavior, possible
decrease – remains safe for clients.
• Approaches fear associated with trauma, targets the worst
trauma’s first and builds a hierarchy of life situations to
build mastery in approaching unjustified fear
• Offers a safe structure and method
• Is very effective especially compared to standard DBT
• Is a reletively fast treatment modality
Major components of DBT PE
•
•
•
•
•
•
DBT
Skills training groups 4 modules :
Core mindfulness, distress
tolerance, emotional regulation,
interpersonal effectiveness
Client commitment to ONE year
of treatment (one cycle of skills
training takes 6 months)
Individual weekly psychotherapy
Diary card – not just an
assignment it is essential
Consultation Team
Phone coaching
1.
2.
3.
4.
PE
Education about common
reactions to trauma
Breathing retraining, i.e.,
teaching the client how to breath
in a calming way
Repeated in vivo exposure to
situations or objects that the
client is avoiding because of
trauma related stress an anxiety
Repeated, prolonged imaginal
exposure to the trauma
memories – recounting the
trauma memory –telling the
narrative
An Integrated Approach to Treating
PTSD in DBT
Stage 1:
Severe Behavioral
Dyscontrol
Behavioral
control and skill
acquisition
Stage 2:
Trauma and Quiet
Desperation
Emotional
Processing of
Trauma
DBT PE protocol
Standard DBT (1year)
Stage 3:
Problems in Living
Building a life
without PTSD
Melanie Harned’s adaptation
 Modified trauma interview
– Top two to three traumas
– Establish a narrative
 Imaginal and In vivo exposure rating form
•





Much expanded, emotions, radical acceptance, worst possible outcomes from
exposure, suicidality, self harm quit therapy, drink/drug
Merging with standard DBT
Diary cards included
Commitment to safety - reestablished
Two sessions: regular DBT and DBT PE sessions
Decreased wait time compared to standard DBT for treating trauma
(approximately two months – commitment to an established pattern
of no parasuicidal behavior the key)
 Becoming your own PE therapist – relapse prevention added
Avoidance includes
Avoidance
Emotional processing
theory stresses the need to
not engage in active or
passive avoidance of
trauma thought, memories,
emotions, content, objects,
places, etc.
Balance accepting the
moment and changing the
moment
1.
2.
3.
4.
5.
6.
7.
refusing to think about trauma
Pretending trauma never happened
Alcohol and drug use
Dissociation
Cutting (or similar self harm)
Eating disordered behavior
Excessive and potentially
dangerous sexual behavior
8. At times using skills to distract
when individual needs to be
emotionally engaged
9. Calling for help when not necessary
or too soon after exposure
10. Sleeping too soon after exposure
Counterintuitive to the Past
• No more onion peeling
• No more “retraumatizing”
• No more therapist fear and treating clients as fragile
(they have been through much worse than
psychotherapy). Psychotherapists are not perpetrators
after all
• Not building conference rooms in the mind, for alters
who emerged post-trauma to discuss their fate
• Not just listening, being nurturing and gentle to validate
them to health
• Not ignoring trauma details, focused on only the here
an now, using only distraction to cope with trauma
PE not for everyone
• Recent New York Times editorial: David J. Morris –
Marine
• Endured war related trauma in Iraq – nearly killed by
an I.E.D. (improvised explosive devise)
• Movie theater incident convinced him of his PTSD
• PE seemed to exacerbate his PTSD symptoms
• Did reference new therapist and therapist admitted
potential for making newbie errors
• He acknowledged many people are helped
• He is finding relief of symptoms through Cognitive
Processing Therapy
Minneapolis VA Effectiveness Trial
Journeys Program
• 33 veterans (51.5% male, 75.8% Caucasian, Mage =
43.2) with PTSD and BPD or BPD traits.
– Required to have previously dropped out or been
excluded from CPT or PE due to BPD-related behaviors
• 12-week intensive outpatient program with
(unsupervised) housing
• Standard DBT delivered concurrently with PE
• 22 (67%) completed the program
– 0 dropped out during the PE protocol
• Results indicated significant pre-post reductions in
PTSD, BPD, suicidal ideation, anxiety, depression.
Meyers, Meis, Thuras, Voller, Shallcross, & Velasquez, under review
Minneapolis VA Effectiveness Trial
PTSD Severity
Slope: p < .001
Meyers, Meis, Thuras, Voller,
Shallcross, & Velasquez, under
review
Intensively trained in both DBT and DBT PE.
Have had a DBT program for over 15 years
Approximately one half of our clients carry a PTSD diagnosis
concomitant with BPD
 We were trained by Linehan’s group.
Our program has positive outcomes for DBT
DBT PE is just beginning – answering a long time need
PARK CENTER DBT PE
References
• Foa, E. B., Hembree, E., & Rothbaum B. O. (2007)
Prolonged exposure therapy for PTSD: Emotional
processing of traumatic experiences. New York: Oxford
Press.
• Linehan, M.M. (1993). Cognitive-behavioral treatment of
borderline personality disorder. New York: Guilford Press.
• Harned M. S. & Korslund, K. E. (2015) Intensive Training
in the Dialectical Behavior Therapy Prolonged Exposure
Protocol for PTSD, March 2015, University of Washington,
Seattle, WA
• Morris, D.J (January 17, 2015), After PTSD, More Trauma.
New York Times, editorial