March 13 th 2018 2018 Oregon Suicide Prevention Conference 5200 SW Macadam Portland OR 97239 wwwpdbtiorg Andrew White PhD Associate Director Portland DBT Institute Topics for Today ID: 706488
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Working Well with the Suicidal Patient: An Overview of Dialectical Behavior Therapy and Research Informed Approaches to Suicide ManagementMarch 13th, 20182018 Oregon Suicide Prevention Conference
5200 SW Macadam Portland OR 97239
| www.pdbti.org
Andrew White, PhD, Associate Director Portland DBT InstituteSlide2
Topics for TodayOverview of suicide data in the USClinical populations at risk for suicideSuicide Research and HospitalizationDBT as an Evidence based interventionsA high level view of DBT, and how you know if it is DBT when you refer!Slide3
Current (2016) Suicide StatisticsData Sources: Center for Disease Control Data and Statistics Fatal Injury Report for 2016, McIntosh & Drapeau, 2015
44,965
reported deaths by suicide per year
Over 1 million
estimated
suicide attempts per yearSlide4
Data Source: Center for Disease Control Data and Statistics Fatal Injury Report for 2016Suicide is the 10th leading cause of death in the US…
..and the 2nd leading cause of death in individuals aged 15 to 34
The estimated economic cost of suicide deaths is $50.8 billion dollarsCurrent (2016) Suicide StatisticsSlide5
Suicide and AdolescentsSecond leading cause of death (CDC, 2016).Alaska Native/Native American youth have the highest rate of suicide, 1.5 times greater than the national average (CDC, 2015)Gay and lesbian youth (grades 9-12) suicide attempt rate:15%-34% (
vs. 4%-10% for heterosexual youth) (Kann
et. al, 2009)45% of transgender youth age 18-24 have attempted suicide (Haas, Rodgers, Herman, 2014)Slide6
Suicide and Mental Health DiagnosisRisk versus general populationSlide7
Suicide and Borderline Personality DisorderBetween 8-10% mortality rate50 times greater than general population.Slide8
Prevalence Rates of BPDA large scale community survey in 2008 (SAMHSA, 2008) found a lifetime prevalence of 5.9% (18 million individuals) with no significant difference across gender in the United States. By comparison, the lifetime provenance rate for schizophrenia is .4%, PTSD is 7.8%, and Bipolar Disorder is 1.4%Slide9
Health Service Utilization Among Individuals Seeking Mental Health CareBPD accounts for…8-11% of outpatients14-20% of inpatientsUp to 40% of highest utilizersSlide10
Prevalence Rates of BPD in TeensLimited data is available, however, current research suggests:1.4% prevalence in under 16 year olds3.2% prevalence in individuals 16-22Up to 11% prevalence in pediatric outpatient psychiatric locations, 50% in pediatric inpatient locations
Kaess, Brunner, & Chanen, 2014Slide11
People with BPD have MANY Complex and PAINFUL Problems
non-suicidal self-injury
u
nrelenting crises
repeated suicide attempts
trouble making therapy work
relationship problems
dissociation
extreme emotions
eating disorders
Drug addiction
psychiatric hospitalization
Intimate Partner Violence
Medical problems
self loathing/self-disgust
Childhood sexual abuse
Unemployment
Few friends
Many MH disordersSlide12
Health Service Utilization Among Individuals Meeting BPD Criteria 97% receive outpatient treatmentFrom an average 6.1 therapists 72% receive inpatient treatmentCompared to MDD, individuals with BPD receive:
4.7 x individual, 2.7 x group, 2.8 x day treatment5 x inpatient treatment, 2.1x antidepressants6.2x mood stabilizers, 10.5 anti-psychotics2.2x anti-anxiety medications
Slide13
Outcomes of Treatment-as-UsualHealth Service UtilizationSevere impairment in:Employment (52%)Global satisfaction (55%)Social adjustment (71%)Overall functioning (47%)Slide14
BPD is a Systemic Emotion Regulation DisorderBPD criterion behaviors function to regulate emotions or are a natural consequence of emotion dysregulation.Slide15
Biosocial Theory of BPD Biological Dysregulation in Emotion Regulation System
Invalidating EnvironmentPervasive Emotion DysregulationSlide16
Many problems caused and/or exacerbated by Pervasive Emotion
DysregulationSlide17
Mental Health Professionals have Historically STRUGGLED with HOW to Effectively Treat BPDMultiple diagnoses/problems
Poor client retentionEasily emotionally dysregulated
in session Often non-compliant or quit treatmentEngage (sometimes often) in life-threatening behaviorsDon’t demonstrate usual clinical progress
17Slide18
Hospitalization and Suicide People with BPD are approximately 28% more likely to complete suicide if they have had any ER contact.They are 44.3% more likely to complete suicide if admitted to inpatient, than if they have not been hospitalized Reference: Hjorthoj, et al 2014Slide19
Borderline Personality Disorder and Hospitalization A recent study found admissions to the psychiatric emergency room while in treatment for women with BPD was a strong predictor of subsequent suicide attemptsBeing in Dialectical Behavior Therapy (DBT) led to less suicide attempts, possibly due to actively blocking emergency room visits.Reference: Coyle, Shaver, & Linehan, 2018Slide20
So if hospitalization is not as effective as we would like it to be, where do we go from here in outpatient care?Slide21
Use Validated Risk Assessment and Management ProtocolsExamples:Linehan Risk Assessment and Management Protocol (LRAMP)Collaborative Assessment and Management of Suicidality (CAMS)Dialectical Behavior Therapy (DBT)Slide22
DBT was developed for multi-diagnostic, severe, difficult-to-treat chronically suicidal individuals with
both Axis I & Axis II disorders,
including those with BPD.Slide23
DBT is a principle-driven treatment that includes protocols.
DBT isFlexible, personalized, and ideographic in approach.
Slide24
What is DBT?DBT Treatment Modes & FunctionsDBT Stages & TargetsBuilding a Life Worth LivingSlide25
DBT Assumptions about PatientsPatients are doing the best they can.Patients want to improve.Patients must learn new behaviors in all relevant contexts.Patients cannot fail in DBT.
Patients may not have caused all of their own problems, but they have to solve them anyway.Patients need to do better, try harder, and/or be more motivated to change.
The lives of suicidal individuals with BPD are unbearable as they are currently being lived.Slide26
DBT Assumptions about TherapyThe 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.Therapists need supportSlide27
Standard DBT ModesOutpatient Individual PsychotherapyOutpatient Group Skills Training (and parent/multifamily for teens)Telephone ConsultationTherapists’ Consultation Meeting
Uncontrolled Ancillary Treatments Pharmacotherapy
Acute-Inpatient PsychiatricSlide28
1. Enhance capabilities2. Improve motivational factors3. Assure generalization to natural environment
4. Structure the environment 5. Enhance therapist capabilities and motivation to treat effectively
DBT Treatment FunctionsSlide29
Overarching Goal in DBTSlide30
DecreaseLife-threatening behaviorsTherapy-interfering behaviorsQuality-of-life interfering behaviors
Increase MindfulnessDistress Tolerance
Emotion Regulation Interpersonal Effectiveness skills Stage 1 Primary Targets Slide31
Skills Structure
Distress Tolerance (8 weeks)
Emotion Regulation (8 weeks)
Interpersonal Effectiveness
(8 weeks)
Each Module:
2 Weeks Orientation Mindfulness
6 Weeks SkillsSlide32
Adolescent/Family Skills Structure
Distress Tolerance (6 weeks)
Walking the Middle Path
(6 weeks)
Emotion Regulation (6 weeks)
Interpersonal Effectiveness
(6 weeks)
Each Module:
2 Weeks Orientation Mindfulness
4 Weeks SkillsSlide33
Reduces:Suicidal behaviorsNon-suicidal self-injurious behaviors (NSSI)DepressionHopelessness
AngerEating disorders (binge eating, bulimia) Substance dependence
ImpulsivenessSTD/HIV high risk behaviorsIncreases:Adjustment (general & social)Positive self-esteem
Treatment retention
DBT Outcomes at a GlanceSlide34
Mental Health Center of Greater Manchester, New Hampshire’s DBT ProgramRecipient of APA’s Gold Award 77% decrease in hospital days76% decrease in partial hospital days
56% decrease in crisis beds80% decrease in ER contactsAnnual Cost Savings for 14 Patients (pre/post): $645,000 to $273,000Slide35
What do we know matters when doing DBT?Slide36
What Matters?
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Treatment Fidelity
Ethics of providing care
Watching out for increasing hopelessness
Skills, Skills, Skills!Slide37
DBT for High Suicide Risk in Individuals with BPD: A Randomized Clinical Trial and Component AnalysisLinehan, Korslund, Harned, Gallop, et al., 2015Objective: To evaluate importance of skills training mode.
Design: RCT (N=99); 1 year treatment + 1 follow up year.Conditions: Comprehensive DBT (DBT; n=33)DBT Skills Training
(DBT-S; n=33)DBT Individual Therapy (DBT-I; n=33)Slide38
Findings from Linehan 2015 Component Analysis StudyAll 3 conditions significantly reduce:Suicide attemptsSuicide ideationMedical severity of NSSICrisis services due to suicidality
And…Reasons for Living INCREASE.HOWEVER…Slide39
Findings from Linehan 2015 Component Analysis StudyStandard DBT was not superior to DBT-S or DBT-I for any suicide-related outcome, and no differences detected between DBT-S and DBT-I.“All 3 versions of DBT were comparably effective at reducing suicidality among individuals at high risk for suicide.” Slide40
Findings from Linehan 2015 Component Analysis StudyConditions that included skills training (DBT, DBT-S) were more effective in reducing NSSI acts and improving other MH problems.Those without skills training were
slower to improve in depression and anxiety during treatment year.Slide41
Referring WellSlide42
Making Sure it’s the Real ThingInitial Questions to ask:Are clinicians (or the clinic) certified through DBT-LBC?Are all of the modes of treatment offered?Is there a clear length of treatment agreement made?
Does the program apply standard DBT rules (e.g. 24-hour rule, 4-miss rule, etc.)Slide43
Making Sure it’s the Real ThingInitial Questions to ask:Are clinicians (or the clinic) certified through DBT-LBC?Are all of the modes of treatment offered?Is there a clear length of treatment agreement made?
Does the program apply standard DBT rules (e.g. 24-hour rule, 4-miss rule, etc.)Slide44
Resources to Use When Making ChoicesDBT Program Structure Questionnaire (in your packets)Certification website: https://dbt-lbc.org/Linehan Behavioral Tech website:
https://behavioraltech.org/Slide45
For more information about us, please visit our website at: www.pdbti.org.Portland DBT Program InstitutePhone: 503.231.7854