Still no more answers

Heard form Katelynd today, she doesn't know if the house is sound proofed. I suggested she needs to find out. Really annoying to get a call without any answers and totally pointless.

CJP reply to my email to them on Monday

Hi Julie,

I will read through the various points and get back with the most appropriate answers tomorrow. Many thanks for your vital input.

Cheers

Katrina

concerns sent to CJP

Hi
After reading through both the CJP draft plan and the SNRG there are a few point I would like to make.

In the draft plan it says that one of the reasons why Sue has improved functionality and been free of further criminal prosecution is due to the fact that Kanangra provides her with: "the ability to socialise and have day activities without leaving the grounds." (CJP Draft plan)

As discussed at the meeting I have some real concerns about Sue not hitting other clients or staff at the community based day program you have established for her. What will be the consequences for Sue if this occurs? If Sue's behaviour means she can not attend day activities what options do you have in place for her?

As Sue's service provider Lifestyle Solutions is a NGO what plans do you have in place if Lifestyle Solutions decide that Sue can no longer be one of their clients ?

Current staffing at Kanangra is 2:1 for Sue at Kanangra, they have a clear line of site to Sue and are in her space. At 6pm that changes to a staff ratio of 1:1 but that staff member cannot approach Sue on their own they have to get another staff member if Sue needs assistance. After looking at the space and seeing how Sue's space is separated from the staff office how do you propose to monitor Sue? Also it sounded like from what Kelly said that after 8pm Sue will not have staff directly. How do you propose to monitor Sue?

I would like some additional information to be attached to the SNRG. I would like it noted that the changes I have seen in Sue's intellectual functionality has occurred since her ECT treatment at James Fletcher. It has nothing to do with her depression or admission to James Fletcher. Please add this amendment to the Physical Health section of Sues SNRG.

In regards to her physical health I would also like it noted that she does have some low muscle tone due most likely to her diagnosis of Phelen McDermid Syndrome. Also Sue carries the Fragile X gene and I believe she also has some of the aggression traits associated with this disorder.

Also noted in the SNRG as a strengths of Sue's should be her honesty about her behaviour. She always admits to it.

In the SNRG recommendation you state she should not live close to neighbours and her accommodation should be soundproofed. As you are going to move her to a residential setting the section of house where Sue will be living needs to be sound proofed as a priority. This need to be done before she moves in so that her noise does not become a factor after she moves into her new accommodation. You do not want neighbours up in arms about her noise and soundproofing is one of the SNRG;s recommendation and so far it has not been done.

Also all glass and the ties on curtains need to be removed from the property as discussed at the property walk through.

the meeting

Our take on the meeting

Sue can't move with Kanangra. The decision has been made. It seems the funding for Sue has always come from CJP (and it's previous incarnations). She was at Kanangra because CJP didn't have suitable accommodation until now, and the space, I think and Sue's move has been pushed through because Kanangra is being closed.

At all the meeting about Kanangra's closure Sue was going to move with them but now that CJP has funding that cannot occur. CJP tried to say how they'd been there for Sue all along and they may view it that way seeing they are paying for her to be at Kanangra But as I said to them it was DADHC and therefore CJP that were refusing services to Sue when she was due for parole and at her release date saying that they would not meet her at the jail. That they were "wiping their hands of her." I don't understand why they would think that there past history with Sue should be forgotten or forgiven.

But after all of this the question that remains is whether Sue is capable at this point of participating in the scheme and whether the scheme will be suitable for Sue. But CJP assure us they will not let her fail. That all funding is specifically for Sue and therefore they will make sure that it works. That Sue is their responsibility for the rest of her life. We'll see.

Lifestyle Solutions will be the company running the centre and the name of the centre is Montrose. Lifestyle Solutions is run by Owen Campbell who was involved in closing the Watagan Centre. We were reassured he wasn't involved with running the centre.

We asked a lot of questions about the program and we are (mostly) reassured that Sue won't be forced through a program she would most likely fail at. They are expecting to keep her in secure accommodation for as long as necessary even if that is the rest of the life.

It is also extremely unlikely that the police will be called if Sue becomes violent as they are determined to prevent her from re-entering the criminal system.

Kanangra staff have made all the recommendations that will decide her program. It isn't CJP that has designed the framework. A lot of the things she has now such as the counselling and massage with continue. There is concern about her walks / exercise and their idea is that they will drive her to a park at a quiet time such as during school hours. They acknowledge they can't take her for walks in the streets of the suburb.

Sue will be driven up to Kanangra for special events but they can't give an idea about frequency at this stage. We suggested she make phone calls as well.

The staffing model is still a bit of a concern. 3 staff total at all times to about 5 clients, 2 staff all the time with Sue with 1 available for the others. 1 of Sue's staff will be RN. Lifestyle Solutions has a number of centres spread through the suburbs and so if any of her regular staff are off sick or on leave they will have a pool of other staff to call on. If the RN is off they will be replaced by another RN. At the meeting they didn't have enough comment on how it sometimes takes four staff to control Sue so they can give her a shot when she 'goes off'. They are starting recruitment now. They are looking at moving her into Montrose in December, date not yet set. We said she shouldn't be moved until after the Xmas party at Kanangra and they seem to think that's a good idea.

They are planning to drive Sue to day activities and they are talking about a couple of different places. Montrose staff will stay with her to minimise the possibility of trouble. They are also talking about bringing in activities to Montrose. I have some real concerns for how Sue will cope with day activities in the broader community and how the broader community will cope with Sue's behaviour. The SNRG recommendation say that the success of Sue at Kanangra is due to the fact that all activities can be on the grounds therefore minimising her contact with the police because of her behaviour. Sue better not end up in court again because the CJP decide to go against the recommendation and their own findings.


When we asked about possible objections from the neighbours to Sue making lots of noise they talked a lot of general ideas about consultation with the community. They gave examples of other spaces where there have been problems. They seemed a little worried about it. Consultation with the community doesn't happen until the staff move in.


Katelynd denied she'd been surprised to find out Sue has an official diagnosis or had had shock treatment. Julie says she expressed considerable surprise “Really?!?”. They said all her records have been studied.

We both seem to feel better about the move but we have worries, as we would expect even if we thought the move was perfect.

After reading the document referred to at the top of this email I think CJP has a lot going for it. This program would be excellent for someone just coming out of prison, because it would have to be an improvement. I just hope it's a good comparison to Kanangra.

We gave a few suggestions that we think will help with the move, foremost being that they have to start preparing Sue for the move very soon. They made a mistake by not consulting with us from the start but the only result of that was a few upset phone calls and the need for the rather intense meeting today. It went for about 2 ½ hours. The first thing we called them on was the lack of consultation and after a bit of to and froing (it was Kanangras responsibility, 'but it's in your own documentation that you consult with us', ok it's a joint responsibility and both of you could have) they apologised for not involving us. A few times. We pushed that button a few times.

We told them they need to be honest with Sue and she responds to that. Even if she reacts badly at first she will come back to the honesty. We suggested they tell her it's one step closer to living in the community (even if that doesn't happen) because she misses the independence. They should also say it's closer to us so we can visit more often.

CJP/DADHC meeting tomorrow

The meeting is tomorrow. Some of the staff from Kanangra are coming to it as well. Not sure who.

I was told that we would go and view the accommadation with the Kanangra staff tomorrow but when Katelynd called on Friday she said that wasn't happening. Bad move i think the staff at Kanangra should see the property. They understand Sue's needs better than anyone. They also know what hazards, safety features need to be addressed. As they have a whole lot of safety and hazard reduction options in her unit.

So I'm off to get a whole bunch of paper work printed out for the meeting.

New thought

a friend gave me another insight into this. She said: How much easier would Kanangra be to close if Sue wasn't there?

Well, seeing she would be the hardest to house and requires the most staff I'd imagine it would make it a whole lot easier.

Sue and her housing needs has been the big issue at the meetings I've been at concerning closing Kanangra. I know when i raised the issue that the DADHC staff just thought they could shove Sue into a ward/unit with other people. Thank god the head of Kanangra was there at the meeting and support me on what i was saying about Sue.

But hey if Sue is no longer there, then hey presto, problem solved.


BASTARDS.

If this is part of the plan then it is deplorable to manipulate and abuse someone that way.

SHAME on DADHC and the CJP.

DADHC worker Kelly

Kelly it would be nice if you answered emails i sent you, rather than getting Katelynd to call me. It is disrepectful.

Even if you did want to defer to Katelynd you should have at least had the courtsey to email and tell me.

It does nothing at all for my opinion of you.

they want to change the meeting

They want to bundle the two meetings into one. they want to change the meeting to the 11th. one and a bit days warning, great. Don't know if Julanna can get the day off changed at that short a notice.
Also they don't know if the guardian can come on the 11th. fabulous

Katelynd said the Kanangra staff have said they want to come to the meeting and they can come on the 11th which is why the shift. but we don't know who cause i forgot to ask.

But gezz makes sure everyone can come on the same day. Or are DADHC trying to separate those that oppose them.

DBT

Even though Katelynd said this training is for staff, I'm betting that they think that Sue will be able to understand this as well. After all why train the staff if the client isn't utilising the same training.

yep I'm sure that someone with an IQ of 62 will get this. (sarcasim)
STUPID DADHC STUPID CJP?

This program is not desgined for people with an intellectual disability. For people with normal IQ and no damage to learning centres in the brain which has been worsened from ECT this may be a good program.

But not for Sue

Dialectical behavior therapy wiki info

Dialectical behavior therapy
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Dialectical behavior therapy (DBT) is a system of therapy originally developed to treat persons with borderline personality disorder (BPD) by Marsha M. Linehan, a psychology researcher at the University of Washington.[1][2] DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD.[3][4] Research indicates that DBT is also effective in treating patients who present varied symptoms and behaviors associated with spectrum mood disorders, including self-injury.[5] Recent work suggests its effectiveness with sexual abuse survivors [6] and chemical dependency.[7]
Contents
[hide]

* 1 Overview
* 2 The four modules
o 2.1 Mindfulness
+ 2.1.1 Skills within the Mindfulness module
# 2.1.1.1 The "What" Skills
# 2.1.1.2 The "How" Skills
o 2.2 Distress Tolerance
+ 2.2.1 Skills within the Distress tolerance module
o 2.3 Emotion Regulation
+ 2.3.1 Skills within the Emotion regulation module
o 2.4 Interpersonal Effectiveness
+ 2.4.1 Skills within the Interpersonal effectiveness module
* 3 Tools
o 3.1 Diary Cards
o 3.2 Chain Analysis
o 3.3 Milieu
* 4 See also
* 5 References
* 6 Further reading
* 7 External links

[edit] Overview

Linehan created DBT in response to her observation of therapist burnout after coping with non-motivated patients who repudiated cooperation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments and required a climate of unconditional acceptance (not Carl Rogers’ humanistically "positive" version, but Thich Nhat Hanh’s metaphysically neutral one[citation needed]) in which to develop a successful therapeutic alliance. Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction.

DBT strives to avoid having the client/patient see the therapist as an adversary rather than an ally in the treatment of psychological issues. Accordingly, in DBT the therapist aims to accept and validate the client’s feelings at any given time while nonetheless informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives.[2]

Linehan united commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress, in which thesis + antithesis → synthesis, and proceeded to assemble a modular array of skills for emotional self-regulation, drawn from Western (e.g., cognitive behavioral therapy and an interpersonal variant, “assertiveness training”) and Eastern (e.g., Buddhist mindfulness meditation) psychological traditions. Arguably her signal contribution was to elide the adversarial paradigm implicit in the hierarchical modernist therapeutic alliance, using the deconstructive spirit of Hegel and Buddhism to substitute a postmodern alliance based on intersubjective tough love.

All DBT involves two components:

1. An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards, and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
2. The group, which ordinarily meets once weekly for two to two-and-a-half hours, learns to use specific skills that are broken down into four modules: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.

Neither component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.
[edit] The four modules
[edit] Mindfulness

Mindfulness is one of the core concepts behind all elements of DBT. Mindfulness is the capacity to pay attention, non-judgmentally, to the present moment. Mindfulness is all about living in the moment, experiencing one's emotions and senses fully, yet with perspective. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts.
[edit] Skills within the Mindfulness module
[edit] The "What" Skills

Observe
This is used to non-judgmentally observe one’s environment within or outside oneself. It is helpful in understanding what is going on in any given situation.

Describe
This is used to express what one has observed with the observe skill. It is to be used without judgmental statements. This helps with letting others know what you have observed.

Participate
This is used to become fully involved in the activity that one is doing. To be able to fully focus on what one is doing.

[edit] The "How" Skills

Non-Judgmentally
This is the action of describing the facts, and not thinking about what’s “good” or “bad”, “fair”, or “unfair.” These are judgments because this is how you feel about the situation but isn’t a factual description. Being non-judgmental helps to get your point across in an effective manner without adding a judgment that someone else might disagree with.

One-Mindfully
This is used to focus on one thing. One-mindfully is helpful in keeping your mind from straying into emotion mind by a lack of focus.

Effectively
This is simply doing what works. It is a very broad-ranged skill and can be applied to any other skill to aid in being successful with said skill.[8]

[edit] Distress Tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.

Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although this is a nonjudgmental stance, this does not mean that it is one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.
[edit] Skills within the Distress tolerance module

[8]

Distract with ACCEPTS
This is a skill used to distract oneself temporarily from unpleasant emotions. The acronym breaks into:

Activities: Use positive activities that you enjoy.

Contribute: Help out others or your community.

Comparisons: Compare yourself either to people that are less fortunate or to how you used to be when you were in a worse state.

Emotions (other): cause yourself to feel something different by provoking your sense of humor or happiness with corresponding activities.

Push away: Put your situation on the back-burner for a while. Put something else temporarily first in your mind.

Thoughts (other): Force your mind to think about something else.

Sensations (other) – Do something that has an intense feeling other than what you are feeling, like a cold shower or a spicy candy.

Self Soothe
This is a skill in which one behaves in a comforting, nurturing, kind, and gentle way to oneself. You use it by doing something that is soothing to you. It is used in moments of distress or agitation.

IMPROVE the Moment
This skill is used in moments of distress to help one relax. The acronym stands for:

Imagery: Imagine relaxing scenes, things going well, or other things that please you.

Meaning: Find some purpose or meaning in what you are feeling.

Prayer: Either pray to whomever you worship or if not religious, chant a personal mantra.

Relaxation: Relax your muscles, breathe deeply; use with Self Soothing.

One thing in the moment: Focus your entire attention on what you are doing right now. Keep yourself in the present.

Vacation (brief): Take a break from it all for a short period of time.

Encouragement: Cheer-lead yourself. Tell yourself you can make it through this.

Pros and Cons
Think about the positive and negative things about not tolerating distress.

Radical Acceptance
Letting go of fighting reality. Accept your situation for what it is.

Turning the Mind
Turn your mind towards an acceptance stance. It should be used with Radical Acceptance.

Willingness vs. Willfulness
Being willing and open to do what is effective. Let go of a willful stance which goes against acceptance. Keep your eye on the goal in front of you.

[edit] Emotion Regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:[9][10]

* Identifying and labeling emotions
* Identifying obstacles to changing emotions
* Reducing vulnerability to emotion mind
* Increasing positive emotional events
* Increasing mindfulness to current emotions
* Taking opposite action
* Applying distress tolerance techniques

[edit] Skills within the Emotion regulation module

[8]

Story of Emotion
Used to understand what kind of emotion one is feeling. To use this, list the following:

1. Prompting event
2. Interpretation of the event
3. Body sensations
4. Body language
5. Action urge
6. Action
7. Emotion name, based on previous items on list.

PLEASE MASTER
Having ineffective health habits can make one more vulnerable to emotion mind. This skill is used to maintain a healthy body so one is more likely to have healthy emotions. It is an acronym that stands for the following:

PhysicaL Illness (treat): If you are sick or injured, get proper treatment for it.

Eating (balanced): Make sure you eat a proper healthy diet, and eat in moderation.

Avoid Mood-Altering Drugs: Do not take non-prescribed medication or illegal drugs. They are very harmful to your body, and can make your mood unpredictable.

Sleep (balanced): Do not sleep too much or too little. 8 hours of sleep is recommended per night for the average adult.

Exercise: Make sure you get an effective amount of exercise as this will both improve body image, and release endorphins (making you happier).

MASTERy (build): Try to do one thing a day to help build competence and control.

Opposite Action
This skill is used when you have an unjustified emotion, one that doesn’t belong in the situation at hand. You use it by doing the opposite of your urges in the moment. It is a tool to bring you out of an unwanted or unjustified emotion by replacing it with the emotion that is opposite.

Problem Solving
This is used to solve a problem when your emotion is justified. It is used in combination with other skills.

Letting Go of Emotional Suffering
Observe and experience your emotion, accept it, then let it go.

[edit] Interpersonal Effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.

Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing his or her own situation.

The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.
[edit] Skills within the Interpersonal effectiveness module

[8]

DEARMAN - to get something
Acronym for the skillset used to aid you in getting what you want when you ask:

Describe your situation.

Express why this is an issue and how you feel about it.

Assert yourself by asking clearly for what you want.

Reinforce your position by offering a positive consequence if you were to get what you want.

Mindful of the situation by focusing on what you want and ignore distractions.

Appear Confident even if you don’t feel confident.

Negotiate with a hesitant person and come to a comfortable compromise on your request.

GIVE - giving something
This is a skill that can aid you with maintaining your relationships, whether they are friendships, coworkers, family, romantic, etc. It is to be used in conversations. It is another acronym that stands for the following:

Gentle: Use appropriate language, no verbal or physical attacks, no put downs, avoid sarcasm unless you are sure the person is alright with it, and be courteous and non-judgmental.

Interested: When the person you are speaking to is talking about something, act interested in what they are saying. Maintain eye contact, ask questions, etc. Do not use your cell phone while having a conversation with another person!

Validate: Show that you understand a person’s situation and sympathize with them. Validation can be shown through words, body language and/or facial expressions.

Easy Manner: Be calm and comfortable during conversation, use humor, smile.

FAST - keeping self respect
This is a skill to aid you in maintaining your self-respect. It is to be used in combination with the other Interpersonal Effectiveness skills. It is another acronym, and it stands for the following:

Fair: Be fair to both yourself and the other person.

Apologies (few): Don’t apologize more than once for what you have done ineffectively, or apologize for something which was not ineffective.

Stick to Your Values: Stay true to what you believe in and stand by it. Don’t allow others to get you to do things against your values.

Truthful: Don’t lie. Lying can only pile up and damage relationships and your self-respect.

[edit] Tools
[edit] Diary Cards

Specially formatted cards for tracking Therapy interfering behaviors that distract or hinder a patient's progress.
[edit] Chain Analysis

Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining.[11] Growing body of research supports the use of behavior chain analysis with multiple populations.
[edit] Milieu

The milieu or the culture of the group involved plays a key role in the effectiveness of DBT.
[edit] See also

* Mindfulness (psychology)
* Cognitive behavioral therapy
* Rational emotive behavior therapy
* Nonviolent Communication
* Emotional dysregulation
* Social skill
* Behavioral psychotherapy

[edit] References

1. ^ Janowsky, David S. (1999). Psychotherapy indications and outcomes. Washington, DC: American Psychiatric Press. pp. 100. ISBN 0-88048-761-5.
2. ^ a b Linehan, M. M. & Dimeff, L. (2001). Dialectical Behavior Therapy in a nutshell, The California Psychologist, 34, 10-13.
3. ^ Linehan, M. M.; Armstrong, H. E.; Suarez, A.; Allmon, D.; Heard, H. L. (1991). "Cognitive-behavioral treatment of chronically parasuicidal borderline patients". Archives of General Psychiatry 48: 1060–64.
4. ^ Linehan, M. M.; Heard, H. L.; Armstrong, H. E. (1993). "Naturalistic follow-up of a behavioural treatment of chronically parasuicidal borderline patients". Archives of General Psychiatry 50: 971–974.
5. ^ Brody, J. E. (2008, May 6). The growing wave of teenage self-injury. New York Times. Retrieved July 1, 2008.
6. ^ Decker, S.E.; Naugle, A.E. (2008). "DBT for Sexual Abuse Survivors: Current Status and Future Directions". Journal of behavior Analysis of Offender and Victim: Treatment and Prevention 1 (4): 52–69. http://www.baojournal.com/JOBA-OVTP/JOBA-OVTP-VOL-1/JOBA-OVTP-1-4.pdf.
7. ^ [1]
8. ^ a b c d Lisa Dietz (2003). "DBT Skills List". http://www.dbtselfhelp.com/html/dbt_skills_list.html.
9. ^ Stone, M.H. (1987) In A. Tasman, R. E. Hales, & A. J. Frances (eds.), American Psychiatric Press review of psychiatry (Vol. 8, pp. 103-122). Washington DC: American Psychiatric Press.
10. ^ Holmes, P., Georgescu, S. & Liles, W. (2005). Further delineating the applicability of acceptance and change to private responses: The example of dialectical behavior therapy. The Behavior Analyst Today, 7(3), 301-311.[2]
11. ^ Sampl, S. Wakai, S., Trestman, R. and Keeney, E.M. (2008).Functional Analysis of Behavior in Corrections: Empowering Inmates in Skills Training Groups. Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention, 1(4), 42-51 BAO

* http://www.namimc.org/PDF/Ed%20Mtg/NAMI%20Ed%20Mtg%20-%20Wake%20Feb%202008%20Presentation.pdf
* Linehan,M.M., Armstrong,H.E., Suarez,A., Allmon,D., Heard,H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.
* Linehan,M.M., Heard,H.L. (1993) "Impact of treatment accessibility on clinical course of parasuicidal patients": Reply. Archives of General-Psychiatry, 50(2): 157-158.
* Linehan,M.M., Heard,H.L., Armstrong,H.E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971-974.
* Linehan,M.M., Tutek,D.A., Heard,H.L., Armstrong,H.E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151, 1771-1776.
* Linehan,M.M., Schmidt,H., Dimeff,L.A., Craft,J.C., Kanter,J., Comtois,K.A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addiction, 8(4), 279-292.
* Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13-26.
* Koons, C.R., Robins, C.J., Tweed, J.L., Lynch, T.R., Gonzalez, A.M., Morse, J.Q., Bishop, G.K., Butterfield, M.I., Bastian, L.A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371-390.
* van den Bosch, L.M.C., Verheul, R., Schippers, G.M., van den Brink, W. (2002). Dialectical Behavior Therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27(6), 911-923.
* Verheul, R., van den Bosch, L.M.C., Koeter, M.W.J., de Ridder, M.A.J., Stijnen, T., van den Brink, W. (2003). Dialectical behaviour therapy for women with borderline persoality disorder: 12-month, randomised clinical trial in the Netherlands. British Journal of Psychiatry, 182, 135-140.
* Linehan et al (2006) NIMH 3 Two-Year Randomized Control Trial and Follow up of DBT

[edit] Further reading

* The Miracle of Mindfulness by Thich Nhat Hanh. ISBN 0-8070-1239-4.
* Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan. 1993. ISBN 0-89862-034-1.
* Cognitive Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan. 1993. ISBN 0898621836.
* Fatal Flaws: Navigating Destructive Relationships with People with Disorders of Personality and Character by Stuart C. Yudovsky. ISBN 1585622141.
* The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation by Alan E. Fruzzetti. ISBN 157224450X.
* Dialectical Behavior Therapy with Suicidal Adolescents by Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan. Foreword by Charles R. Swenson. ISBN 978-1593853839.
* Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (New Harbinger Self-Help Workbook) by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley. ISBN 978-1572245136.
* Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control (New Harbinger Self-Help Workbook) by Scott E. Spradlin. ISBN 978-1572243095.
* Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression & Anxiety by Thomas Marra. ISBN 978-1572243637

Dialectical Behaviour Therapy

An Overview of Dialectical Behaviour Therapy in the Treatment of Borderline Personality Disorder

by Barry Kiehn and Michaela Swales

Patients showing the features of Borderline Personality Disorder as defined in DSM-IV are notoriously difficult to treat (Linehan 1993a). They are difficult to keep in therapy, frequently fail to respond to our therapeutic efforts and make considerable demands on the emotional resources of the therapist, particular when suicidal and parasuicidal behaviours are prominent.

Dialectical Behaviour Therapy is an innovative method of treatment that has been developed specifically to treat this difficult group of patients in a way which is optimistic and which preserves the morale of the therapist.

The technique has been devised by Marsha Linehan at the University of Washington in Seattle and its effectiveness has been demonstrated in a controlled study, the results of which will be summarised later in this paper.
BORDERLINE PERSONALITY DISORDER

Dialectical Behaviour Therapy is based on a bio-social theory of borderline personality disorder. Linehan hypothesises that the disorder is a consequence of an emotionally vulnerable individual growing up within a particular set of environmental circumstances which she refers to as the 'Invalidating Environment'.

An 'emotionally vulnerable' person in this sense is someone whose autonomic nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to baseline once the stress is removed. It is proposed that this is the consequence of a biological diathesis.

The term 'Invalidating Environment' refers essentially to a situation in which the personal experiences and responses of the growing child are disqualified or "invalidated" by the significant others in her life. The child's personal communications are not accepted as an accurate indication of her true feelings and it is implied that, if they were accurate, then such feelings would not be a valid response to circumstances. Furthermore, an Invalidating Environment is characterised by a tendency to place a high value on self-control and self-reliance. Possible difficulties in these areas are not acknowledged and it is implied that problem solving should be easy given proper motivation. Any failure on the part of the child to perform to the expected standard is therefore ascribed to lack of motivation or some other negative characteristic of her character. (The feminine pronoun will be used throughout this paper when referring to the patient since the majority of BPD patients are female and Linehan's work has focused on this subgroup).

Linehan suggests that an emotionally vulnerable child can be expected to experience particular problems in such an environment. She will neither have the opportunity accurately to label and understand her feelings nor will she learn to trust her own responses to events. Neither is she helped to cope with situations that she may find difficult or stressful, since such problems are not acknowledged. It may be expected then that she will look to other people for indications of how she should be feeling and to solve her problems for her. However, it is in the nature of such an environment that the demands that she is allowed to make on others will tend to be severely restricted. The child's behaviour may then oscillate between opposite poles of emotional inhibition in an attempt to gain acceptance and extreme displays of emotion in order to have her feelings acknowledged. Erratic response to this pattern of behaviour by those in the environment may then create a situation of intermittent reinforcement resulting in the behaviour pattern becoming persistent.

Linehan suggests that a particular consequence of this state of affairs will be a failure to understand and control emotions; a failure to learn the skills required for 'emotion modulation'. Given the emotional vulnerability of these individuals this is postulated to result in a state of 'emotional dysregulation' which combines in a transactional manner with the Invalidating Environment to produce the typical symptoms of Borderline Personality Disorder.

Patients with BPD frequently describe a history of childhood sexual abuse and this is regarded within the model as representing a particularly extreme form of invalidation.

Linehan emphasises that this theory is not yet supported by empirical evidence but the value of the technique does not depend on the theory being correct since the clinical effectiveness of DBT does have empirical support.
PATIENTS' CHARACTERISTICS

Linehan groups the features of BPD in a particular way, describing the patients as showing dysregulation in the sphere of emotions, relationships, behaviour, cognition and the sense of self. She suggests that, as a consequence of the situation that has been described, they show six typical patterns of behaviour, the term 'behaviour' referring to emotional, cognitive and autonomic activity as well as external behaviour in the narrow sense.

Firstly, they show evidence of 'emotional vulnerability' as already described. They are aware of their difficulty coping with stress and may blame others for having unrealistic expectations and making unreasonable demands.

On the other hand they have internalised the characteristics of the Invalidating Environment and tend to show 'self-invalidation'. They invalidate their own responses and have unrealistic goals and expectations, feeling ashamed and angry with themselves when they experience difficulty or fail to achieve their goals.

These two features constitute the first pair of so-called 'dialectical dilemmas', the patient's position tending to swing between the opposing poles since each extreme is experienced as being distressing.

Next, they tend to experience frequent traumatic environmental events, in part related to their own dysfunctional lifestyle and exacerbated by their extreme emotional reactions with delayed return to baseline. This results in what Linehan refers to as a pattern of 'unrelenting crisis', one crisis following another before the previous one has been resolved. On the other hand, because of their difficulties with emotion modulation, they are unable to face, and therefore tend to inhibit, negative affect and particularly feelings associated with loss or grief. This 'inhibited grieving' and the 'unrelenting crisis' constitute the second 'dialectical dilemma'.

The opposite poles of the final dilemma are referred to as 'active passivity' and 'apparent competence'. Patients with BPD are active in finding other people who will solve their problems for them but are passive in relation to solving their own problems. On the other hand, they have learned to give the impression of being competent in response to the Invalidating Environment. In some situations they may indeed be competent but their skills do not generalise across different situations and are dependent on the mood state of the moment. This extreme mood dependency is seen as being a typical feature of patients with BPD.

A pattern of self-mutilation tends to develop as a means of coping with the intense and painful feelings experienced by these patients and suicide attempts may be seen as an expression of the fact that life is at times simply does not seem worth living. These behaviours in particular tend to result in frequent episodes of admission to psychiatric hospitals. Dialectical Behaviour Therapy, which will now be described, focuses specifically on this pattern of problem behaviours and in particular, the parasuicidal behaviour. DIALECTICAL BEHAVIOUR THERAPY The term 'dialectical' is derived from classical philosophy. It refers to a form of argument in which an assertion is first made about a particular issue (the 'thesis'), the opposing position is then formulated (the 'antithesis' ) and finally a 'synthesis' is sought between the two extremes, embodying the valuable features of each position and resolving any contradictions between the two. This synthesis then acts as the thesis for the next cycle. In this way truth is seen as a process which develops over time in transactions between people. From this perspective there can be no statement representing absolute truth. Truth is approached as the middle way between extremes. The dialectical approach to understanding and treatment of human problems is therefore non-dogmatic, open and has a systemic and transactional orientation. The dialectical viewpoint underlies the entire structure of therapy, the key dialectic being 'acceptance' on the one hand and 'change' on the other. Thus DBT includes specific techniques of acceptance and validation designed to counter the self-invalidation of the patient. These are balanced by techniques of problem solving to help her learn more adaptive ways of dealing with her difficulties and acquire the skills to do so. Dialectical strategies underlie all aspects of treatment to counter the extreme and rigid thinking encountered in these patients. The dialectical world view is apparent in the three pairs of 'dialectical dilemmas' already described, in the goals of therapy and in the attitudes and communication styles of the therapist which are to be described. The therapy is behavioural in that, without ignoring the past, it focuses on present behaviour and the current factors which are controlling that behaviour. THERAPIST CHARACTERISTICS IN DBT The success of treatment is dependant on the quality of the relationship between the patient and therapist. The emphasis is on this being a real human relationship in which both members matter and in which the needs of both have to be considered. Linehan is particularly alert to the risks of burnout to therapists treating these patients and therapist support and consultation is an integral and essential part of the treatment. In DBT support is not regarded as an optional extra. The basic idea is that the therapist gives DBT to the patient and receives DBT from his or her colleagues. The approach is a team approach. The therapist is asked to accept a number of working assumptions about the patient that will establish the required attitude for therapy: 1. The patient wants to change and, in spite of appearances, is trying her best at any particular time. 2. Her behaviour pattern is understandable given her background and present circumstances. Her life may currently not be worth living (however, the therapist will never agree that suicide is the appropriate solution but always stays on the side of life. The solution is rather to try and make life more worth living). 3. In spite of this she needs to try harder if things are ever to improve. She may not be entirely to blame for the way things are but it is her personal responsibility to make them different. 4. Patients can not fail in DBT. If things are not improving it is the treatment that is failing. In particular the therapist must avoid at all times viewing the patient, or talking about her, in pejorative terms since such an attitude will be antagonistic to successful therapeutic intervention and likely to feed into the problems that have led to the development of BPD in the first place. Linehan has a particular dislike for the word "manipulative" as commonly applied to these patients. She points out that this implies that they are skilled at managing other people when it is precisely the opposite that is true. Also the fact that the therapist may feel manipulated does not necessarily imply that this was the intention of the patient. It is more probable that the patient did not have the skills to deal with the situation more effectively. The therapist relates to the patient in two dialectically opposed styles. The primary style of relationship and communication is referred to as 'reciprocal communication', a style involving responsiveness, warmth and genuineness on the part of the therapist. Appropriate self-disclosure is encouraged but always with the interests of the patient in mind. The alternative style is referred to as 'irreverent communication'. This is a more confrontational and challenging style aimed at bringing the patient up with a jolt in order to deal with situations where therapy seems to be stuck or moving in an unhelpful direction. It will be observed that these two communication styles form the opposite ends of another dialectic and should be used in a balanced way as therapy proceeds. The therapist should try to interact with the patient in a way that is: 1. accepting of the patient as she is but which encourages change. 2. centred and firm yet flexible when the circumstances require it. 3. nurturing but benevolently demanding. The dialectical approach is here again apparent. There is a clear and open emphasis on the limits of behaviour acceptable to the therapist and these are dealt with in a very direct way. The therapist should be clear about his or her personal limits in relations to a particular patient and should as far as possible make these clear to her from the start. It is openly acknowledged that an unconditional relationship between therapist and patient is not humanly possible and it is always possible for the patient to cause the therapist to reject her if she tries hard enough. It is in the patient's interests therefore to learn to treat her therapist in a way that encourages the therapist to want to continue helping her. It is not in her interests to burn him or her out. This issue is confronted directly and openly in therapy. The therapist helps therapy to survive by consistently bringing it to the patient's attention when limits have been overstepped and then teaching her the skills to deal with the situation more effectively and acceptably. It is made quite clear that the issue is immediately concerned with the legitimate needs of the therapist and only indirectly with the needs of the patient who clearly stands to lose if she manages to burn out the therapist. The therapist is asked to adopt a non-defensive posture towards the patient, to accept that therapists are fallible and that mistakes will at times inevitably be made. Perfect therapy is simply not possible. It needs to be accepted as a working hypothesis that (to use Linehan's words) "all therapists are jerks". PATIENTS' AND THERAPISTS' AGREEMENTS This form of therapy must be entirely voluntary and depends for its success on having the co-operation of the patient. From the start, therefore, attention is given to orienting the patient to the nature of DBT and obtaining a commitment to undertake the work. A variety of specific strategies are described in the Linehan's book (Linehan 1993a) to facilitate this process. Before a patient will be taken on for DBT she will be required to give a number of undertakings: 1. To work in therapy for a specified period of time (Linehan initially contracts for one year). and, within reason, to attend all scheduled therapy sessions.

2. If suicidal or parasuicidal behaviours are present, she must agree to work on reducing these.

3. To work on any behaviours that interfere with the course of therapy ('therapy interfering behaviours').

4. To attend skills training.

The strength of these agreements may be variable and a "take what you can get approach" is advocated. Nevertheless a definite commitment at some level is required since reminding the patient about her commitment and re-establishing such commitment throughout the course of therapy are important strategies in DBT.

The therapist agrees to make every reasonable effort to help the patient and to treat her with respect, as well as to keep to the usual expectations of reliability and professional ethics. The therapist does not however give any undertaking to stop the patient from harming herself. On the contrary, it should be make quite clear that the therapist is simply not able to prevent her from doing so. The therapist will try rather to help her find ways of making her life more worth living. DBT is offered as a life-enhancement treatment and not as a suicide prevention treatment, although it is hoped that it may indeed achieve the latter.
MODES OF TREATMENT

There are four primary modes of treatment in DBT :

1. Individual therapy
2. Group skills training
3. Telephone contact
4. Therapist consultation

Whilst keeping within the overall model, group therapy and other modes of treatment may be added at the discretion of the therapist, providing the targets for that mode are clear and prioritised.

The individual therapist is the primary therapist. The main work of therapy is carried out in the INDIVIDUAL THERAPY sessions. The structure of individual therapy and some of the strategies used will be described shortly. The characteristics of the therapeutic alliance have already been described.

Between sessions the patient should be offered TELEPHONE CONTACT with the therapist, including out of hours telephone contact. This tends to be an aspect of DBT balked at by many prospective therapists. However, each therapist has the right to set clear limits on such contact and the purpose of telephone contact is also quite clearly defined. In particular, telephone contact is not for the purpose of psychotherapy. Rather it is to give the patient help and support in applying the skills that she is learning to her real life situation between sessions and to help her find ways of avoiding self-injury. Calls are also accepted for the purpose of relationship repair where the patient feels that she has damaged her relationship with her therapist and wants to put this right before the next session. Calls after the patient has injured herself are not acceptable and, after ensuring her immediate safety, no further calls are allowed for the next twenty four hours. This is to avoid reinforcing self-injury.

SKILLS TRAINING is usually carried out in a group context, ideally by someone other that the individual therapist. In the skills training groups patients are taught skills considered relevant to the particular problems experienced by people with borderline personality disorder. There are four modules focusing in turn on four groups of skills:

1. Core mindfulness skills.
2. Interpersonal effectiveness skills.
3. Emotion modulation skills.
4. Distress tolerance skills.

The 'core mindfulness skills' are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment.

The 'interpersonal effectiveness skills' which are taught focus on effective ways of achieving one's objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people.

'Emotion modulation skills' are ways of changing distressing emotional states and 'distress tolerance skills' include techniques for putting up with these emotional states if they can not be changed for the time being.

The skills are too many and varied to be described here in detail. They are fully described in a teaching format in the DBT skills training manual (Linehan, 1993b).

The therapists receive DBT from each other at the regular THERAPIST CONSULTATION GROUPS and, as already mentioned, this is regarded as an essential aspect of therapy. The members of the group are required to keep each other in the DBT mode and (among other things) are required to give a formal undertaking to remain dialectical in their interaction with each other, to avoid any pejorative descriptions of patient or therapist behaviour, to respect therapists' individual limits and generally are expected to treat each other at least as well as they treat their patients. Part of the session may be used for ongoing training purposes.
STAGES OF THERAPY AND TREATMENT TARGETS

Patients with BPD present multiple problems and this can pose problems for the therapist in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organised into a number of stages and structured in terms of hierarchies of targets at each stage.

The PRE-TREATMENT STAGE focuses on assessment, commitment and orientation to therapy.

STAGE 1 focuses on suicidal behaviours, therapy interfering behaviours and behaviours that interfere with the quality of life, together with developing the necessary skills to resolve these problems.

STAGE 2 deals with post-traumatic stress related problems (PTSD)

STAGE 3 focuses on self-esteem and individual treatment goals.

The targeted behaviours of each stage are brought under control before moving on to the next phase. In particular post-traumatic stress related problems such as those related to childhood sexual abuse are not dealt with directly until stage 1 has been successfully completed. To do so would risk an increase in serious self injury. Problems of this type (flashbacks for instance) emerging whilst the patient is still in stages 1 or 2 are dealt with using 'distress tolerance' techniques. The treatment of PTSD in stage 2 involves exposure to memories of the past trauma.

Therapy at each stage is focused on the specific targets for that stage which are arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy but it is essential for therapists working in each mode to be clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking.

The hierarchy of targets in individual therapy for example is as follows:

1. Decreasing suicidal behaviours.
2. Decreasing therapy interfering behaviours.
3. Decreasing behaviours that interfere with the quality of life.
4. Increasing behavioural skills.
5. Decreasing behaviours related to post-traumatic stress.
6. Improving self esteem.
7. Individual targets negotiated with the patient.

In any individual session these targets must be dealt with in that order. In particular, any incident of self harm that may have occurred since the last session must be dealt with first and the therapist must not allow him or herself to be distracted from this goal.

The importance given to 'therapy interfering behaviours' is a particular characteristic of DBT and reflects the difficulty of working with these patients. It is second only to suicidal behaviours in importance. These are any behaviours by the patient or therapist that interfere in any way with the proper conduct of therapy and risk preventing the patient from getting the help she needs. They include, for example, failure to attend sessions reliably, failure to keep to contracted agreements, or behaviours that overstep therapist limits.

Behaviours that interfere with the quality of life are such things as drug or alcohol abuse, sexual promiscuity, high risk behaviour and the like. What is or is not a quality of life interfering behaviour may be a matter for negotiation between patient and therapist.

The patient is required to record instances of targeted behaviours on the weekly diary cards. Failure to do so is regarded as therapy interfering behaviour.
TREATMENT STRATEGIES

Within this framework of stages, target hierarchies and modes of therapy a wide variety of therapeutic strategies and specific techniques is applied.

The core strategies in DBT are 'validation' and 'problem solving'. Attempts to facilitate change are surrounded by interventions that validate the patient's behaviour and responses as understandable in relation to her current life situation, and that show an understanding of her difficulties and suffering.

Problem solving focuses on the establishment of necessary skills. If the patient is not dealing with her problems effectively then it is to be anticipated either that she does not have the necessary skills to do so, or does have the skills but is prevented from using them. If she does not have the skills then she will need to learn them. This is the purpose of the skills training.

Having the skills, she may be prevented from using them in particular situations either because of environmental factors or because of emotional or cognitive problems getting in the way. To deal with these difficulties the following techniques may be applied in the course of therapy:

1. Contingency management
2. Cognitive therapy
3. Exposure based therapies
4. Pharmacotherapy

The principles of using these techniques are precisely those applying to their use in other contexts and will not be described in any detail. In DBT however they are used in a relatively informal way and interwoven into therapy. Linehan recommends that medication be prescribed by someone other than the primary therapist although this may not be practical.

Particular note should be made of the pervading application of contingency management throughout therapy, using the relationship with the therapist as the main reinforcer. In the session by session course of therapy care is taken to systematically reinforce targeted adaptive behaviours and to avoid reinforcing targeted maladaptive behaviours. This process is made quite overt to the patient, explaining that behaviour which reinforced can be expected to increase. A clear distinction is made between the observed effect of reinforcement and the motivation of the behaviour, pointing out that such a relationship between cause and effect does not imply that the behaviour is being carried out deliberately in order to obtain the reinforcement. Didactic teaching and insight strategies may also be used to help the patient achieve an understanding of the factors that may be controlling her behaviour.

The same contingency management approach is taken in dealing with behaviours that overstep the therapist's personal limits in which case they are referred to as 'observing limits procedures'.

Problem solving and change strategies are again balanced dialectically by the use of validation strategies. It is important at every stage to convey to the patient that her behaviour, including thoughts feelings and actions are understandable, even though they may be maladaptive or unhelpful.

Significant instances of targeted maladaptive behaviour occurring since the last session (which should have been recorded on the diary card) are initially dealt with by carrying out a detailed 'behavioural analysis'. In particular every single instance of suicidal or parasuicidal behaviour is dealt with in this way. Such behavioural analysis is an important aspect of DBT and may take up a large proportion of therapy time.

In the course of a typical behavioural analysis a particular instance of behaviour is first clearly defined in specific terms and then a 'chain analysis' is conducted, looking in detail at the sequence of events and attempting to link these events one to another. In the course of this process hypotheses are generated about the factors that may be controlling the behaviour. This is followed by, or interwoven with, a 'solution analysis' in which alternative ways of dealing with the situation at each stage are considered and evaluated. Finally one solution should be chosen for future implementation. Difficulties that may be experienced in carrying out this solution are considered and strategies of dealing with these can be worked out.

It is frequently the case that patients will attempt to avoid this behavioural analysis since they may experience the process of looking in such detail at their behaviour as aversive. However it is essential that the therapist should not be side tracked until the process is completed. In addition to achieving an understanding of the factors controlling behaviour, behavioural analysis can be seen as part of contingency management strategy, applying a somewhat aversive consequence to an episode of targeted maladaptive behaviour. The process can also be seen as an exposure technique helping to desensitise the patient to painful feelings and behaviours. Having completed the behavioural analysis the patient can then be rewarded with a 'heart to heart' conversation about the things she likes to discuss.

Behavioural analysis can be seen as a way of responding to maladaptive behaviour, and in particular to parasuicide, in a way that shows interest and concern but which avoids reinforcing the behaviour.

In DBT a particular approach is taken in dealing with the network of people with whom the patient is involved personally and professionally. These are referred to as 'case management strategies'. The basic idea is that the patient should be encouraged, with appropriate help and support, to deal with her own problems in the environment in which they occur. Therefore, as far as possible, the therapist does not do things for the patient but encourages the patient to do things for herself. This includes dealing with other professionals who may be involved with the patient. The therapist does not try to tell these other professionals how to deal with the patient but helps the patient learn how to deal with the other professionals. Inconsistencies between professionals are seen as inevitable and not necessarily something to be avoided. Such inconsistencies are rather seen as opportunities for the patient to practice her interpersonal effectiveness skills. If she grumbles about the help she is receiving from another professional she is helped to sort this out herself with the person involved. This is referred to as the 'consultation-to-the-patient strategy' which, among other things, serves to minimise the so-called "staff splitting" which tends to occur between professionals dealing with these patients.

Environmental intervention is acceptable but only in very specific situations where a particular outcome seems essential and the patient does not have the power or capability to produce this outcome. Such intervention should be the exception rather than the rule.
EMPIRICAL EVIDENCE

The effectiveness of DBT has been assessed in two major trials. The first (Linehan et al, 1991) compared the effectiveness of DBT relative to treatment as usual (TAU). The second (Linehan et al, in press) examined the effectiveness of DBT skills training when added to standard community psychotherapy.

In the first randomised controlled trial, there were three main goals:

Firstly, to reduce the frequency of parasuicidal behaviours. This is clearly of importance because of the distressing nature of the behaviour but also because of the increased risk of completed suicide in this group (Stone, 1987).

Secondly, to reduce behaviours that interfere with the progress of therapy ('therapy interfering behaviours'), as the attrition rate from therapy in borderline women with a history of parasuicidal behaviours is high.

Finally, to reduce behaviours that interfere with the patients' quality of life. In this study this latter goal was interpreted more specifically as a reduction in in-patient psychiatric days, which is hypothesised to interfere with the patient's quality of life.

Participants all met DSM-IIIR criteria for BPD, and were matched for number of lifetime parasuicide episodes, number of lifetime admissions to hospital, age and anticipated good or poor prognosis.

There were 22 patients in each group. The experimental group received standard DBT as outlined above. The experience of the patients in the treatment as usual group was variable; some received regular individual psychotherapy, others dropped out of individual therapy whilst continuing to have access to in-patient and day-patient services. All participants were assessed on number of parasuicidal episodes and a range of questionnaire measures of mood. Patients were blindly assessed at pre-treatment, 4, 8 and 12 months and followed up at 6 and 12 months post-treatment. Measures of treatment compliance and other treatment delivered (e.g. in patient psychiatric days) were also taken. At pre-treatment there were no significant differences on any of the measures between the control and experimental groups including demographic criteria.

With regard to the first aim of the trial (i.e. the reduction of suicidal behaviour), during the year of treatment patients in the control group engaged in more parasuicidal acts than DBT patients at all time points. The medical risk for parasuicidal acts was higher in the control group than in the DBT group.

Patients in the DBT group were more likely to start therapy and were more likely to remain in therapy than those in the control group. The one year attrition rate in the DBT group was 16.7% compared to 50% for those in the control group who commenced the year with a new therapist. The DBT patients reported more individual and group therapy treatment hours per week than the TAU group, which reflects the intensive nature of DBT treatment. However, the control patients reported more day treatment hours per week.

With regard to the third goal of the trial, patients in the control group had significantly more inpatient psychiatric days per person than those receiving DBT (38.6 days per year as compared to 8.46 days per year for the DBT group).

These results were considered to indicate the superiority of DBT over treatment as usual. However, one major criticism of the trial is that the variable and patchy therapeutic experience of the control group may be considered to favour DBT. This criticism can be challenged, however, since one of the treatment aims of DBT is to keep the patient in therapy. This it seems to have succeeded in doing. However, it is still pertinent to enquire how well DBT would compare to a consistent treatment alternative. An attempt was made to explore this by comparing the DBT patients with those in the TAU group who received regular individual therapy. It was found that the gains of the patients in the DBT group over the TAU group remained even using this more rigorous comparison.

Despite the more intensive nature of DBT it remained cheaper than TAU, largely because of the reduction in the number of in-patient and day-treatment days received by the DBT patients.

It is of interest that, although the DBT patients showed significant gains across the three areas of interest (number of parasuicides, treatment compliance and inpatient days), there were no between-group differences on any of the questionnaire measures of mood and suicidal ideation. During the follow-up year, patients in the DBT group had higher Global Assessment Scores and a better work performance than the patients in the TAU group. In the first 6 months, DBT patients had fewer suicidal acts, lower anger scores and better self-reported social adjustment than TAU patients. In the final 6 months, DBT patients had fewer in-patient days treatment and better interviewer rated social adjustment than TAU patients.

The second trial had two parts. Firstly, it compared standard community psychotherapy (SCP) plus the group skills component of DBT with SCP alone without added skills training. Secondly, it compared the SCP group from the first part of the present study with the experimental group in the previously described randomised control trial. In this latter comparison, assignment to conditions was not random. However, all subjects were screened in the same way, during the same time frame and were all subject to blind assessment.

The results of the first part of this study indicated that the addition of DBT skills training to SCP for this group of parasuicidal borderline women did not confer any additional therapeutic benefit. In this part of the study the skills training was truly ancillary in that there were no meetings between the individual therapists and the group therapists, nor were any attempts made to assist the patient to generalise the skills learnt in the group to her everyday life.

In the second part of the study there were some pre-treatment differences between the two groups. The DBT patients were less depressed than the control group and reported higher levels of unemployment. These differences were not considered to be particularly important for three reasons. Firstly, depression was not correlated with any of the outcome variables. Secondly, although the lower depression scores favoured the DBT group, the lower unemployment favoured the SCP group. Finally, the levels of depression did not differ between the two groups after the pre-treament point.

During the treatment year there were no significant differences between the groups with regard to staying in therapy. There were some slight differences in the distribution of therapeutic hours, with DBT patients reporting more group treatment hours than the SCP group. Most importantly, however, there were no significant relationships between number of treatment hours and any of the outcome variables. Over the treatment year, standard DBT patients compared to SCP patients had fewer parasuicidal episodes, fewer episodes leading to medical treatment and fewer psychiatric in-patient days. DBT patients also reported less anger than the SCP patients.

This research then provides some evidence for the therapeutic efficacy of DBT. This evidence is primarily derived from one randomised control trial in which DBT was found to be superior on a number of variables to treatment as usual. Clearly this finding requires replication. There is also some evidence to suggest that DBT is superior to other forms of psychotherapy with this group of patients. However, this result comes from a comparison made using only a sub-sample of patients in the randomised trial (Linehan et al, 1991) and from a further comparison between two groups from different studies (Linehan et al, in press). Consequently, the effectiveness of DBT compared to other alternative treatments awaits further exploration. This will remain a challenge, particularly given the high drop-out rates from treatment of this group of patients.
SUMMARY AND CONCLUSIONS

Dialectical Behaviour Therapy then is a novel method of therapy specifically designed to meet the needs of patients with Borderline Personality Disorder and their therapists. It directly addresses the problem of keeping these patients in therapy and the difficulty of maintaining therapist motivation and professional well-being. It is based on a clear and potentially testable theory of BPD and encourages a positive and validating attitude to these patients in the light of this theory. The approach incorporates what is valuable from other forms of therapy, and is based on a clear acknowledgement of the value of a strong relationship between therapist and patient. Therapy is clearly structured in stages and at each stage a clear hierarchy of targets is defined. The method offers a particularly helpful approach to the management of parasuicide with a clearly defined response to such behaviours. The techniques used in DBT are extensive and varied, addressing essentially every aspect of therapy and they are underpinned by a dialectical philosophy that recommends a balanced, flexible and systemic approach to the work of therapy. Techniques for achieving change are balanced by techniques of acceptance, problem solving is surrounded by validation, confrontation is balanced by understanding. The patient is helped to understand her problem behaviours and then deal with situations more effectively. She is taught the necessary skills to enable her to do so and helped to deal with any problems that she may have in applying them in her natural environment. Generalisation outside therapy is not assumed but encouraged directly. Advice and support available between sessions and the patient is encouraged and helped to take responsibility for dealing with life's challenges herself. The method is supported by empirical evidence which suggests that it is successful in reducing self-injury and time spent in psychiatric in-patient treatment.

REFERENCES

Linehan, M.M. (1993a) Cognitive Behavioural Treatment of Borderline Personality Disorder. The Guilford Press, New York and London.

Linehan, M.M. (1993b) Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press, New York and London.

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. & Heard, H.L. (1991) Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

Linehan, M.M., Heard, H.L. & Armstrong, H.E. (in press) Dialectical behaviour therapy, with and without behavioural skills training, for chronically parasuicidal borderline patients.

Stone, M.H. (1987) The course of borderline personality disorder. In Tasman, A., Hales, R.E. & Frances, A.J. (eds) American Psychiatric Press Review of Psychiatry. Washington DC; American Psychiatric Press inc. 8, 103-122.

Barry Kiehn, Consultant Child and Adolescent Psychiatrist, Gwynfa Adolescent Service, Pen-y-Bryn Road, Upper Colwyn Bay, Clwyd, North Wales, LL29 6AL.
e-mail: b.kiehn@bbcnc.org.uk

Michaela Swales, Chartered Clinical Psychologist, Gwynfa Adolescent Service and Lecturer in the Psychology of Adolescence, University College of North Wales, Bangor, Gwynedd, LL57 2DG.
e-mail: pss051@bangor.ac.uk

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DADHC are idiots

was told today that in Sue's new housing model if she assaults staff police will be called.

HOW FUCKING STUPID IS DADHC AND THE CJP?

OF COURSE SUE WILL ASSAULTS STAFF. Sue is violent, extremely violent.

i told them that means they are actually opening Sue up to be once again sent to JAIL.
ANd then they go onto to talk about Behaviour modification. STUPID STUPID PEOPLE> THEY JUST DON"T GET IT.
Sue is super aggresive.
She is not trainable.

Where she is now police are not called if she hits staff. DADHC and the CJP are just willfully dis-regaurding Sue's dangerous behaviour. She's a fucking guinea pig for this project.

FUCKING IDIOTS?

oh and that this is part of the training that staff will have to do and enforce on Sue and some of the training they expect SUe to do
http://www.wesleymission.org.au/community_services/counselling/Behaviour_Therapy_Training.asp
http://priory.com/dbt.htm
http://en.wikipedia.org/wiki/Dialectical_behavior_therapy




All good and well, but Sue has an intellectual disability. Also she can no longer learn new skills since the ECT.

WHAT THE FUCK ARE THEY THINKING?

was told i can not have copy of the report. Sue's guardian can release it to me but DADHC can't.

once again DADHC don't know they're own policy. It's a stupid policy, family should have the same right as the guardian in regaurd to assessments findings.

DADHC staff

I'm going to give Katelynd the benefit of doubt and assume she is not in the office as she always responds quickly to my emails.

I'm also do believe Katelynd when she says that she is just the front person.
So i emailed to Katelynd's boss about the DADHC assessment. Just in case it needs to run past her before they send it to me.

Let's see how long it takes her to respond and if she will scan the assessment for me.

still waiting on assesment

ok now I'm a little pissed.

2nd request for this info

"Hi Kelly

We have a meeting with you on Thursday at 2pm. I am still waiting to receive the copy of the assesment that DADHC have done on Sue.

I'm assuming that Kateylnd is not in the office as she is very quick to respond to emails.

The document was meant to have been posted to me on the 24th Sept.

Can you scan it and send it to me? I need it prior to the meeting.

Thank you

Julie"


One could start to think they don't want me to see this report.

DADHC assesment

I sent an email to Katelynd yesterday to let her know I haven't received the copy of DADHC assessment they did on Sue about her suitability to move. She told me she was sending it on the 24th Sept 2010.

Can't work out how they did an assessment on someone they have never meet. Very strange.

That's one very big question that remains unanswered. How'd you do that assessment?
What do you read a file?
How's that work?
I'm guessing the file that DADHC is using is old because Katelynd didn't know about Sue's diagnosis. So how valid is your assessment?
Not very is the answer.

Unbelievable. And very scary.

I wonder how these people would feel if a stranger walked into their lives, never took the time to meet them and then started making decisions about where they lived based on old and out of date information. Even worse is that they are doing it against all the advice of your carers, medical staff and family. So much for consultation with all involved.

How arrogant and stupid can one organisation be, I give you DADHC.