This 2-day workshop is directed at those working in mental health or those whose work brings them in contact with people who have a diagnosis of Borderline Personality Disorder.

Please note that the following information is copyrighted. Our library is made available to participants to support their work with individuals with BPD and emotion dysregulation difficulties. This information is not to be shared and distributed for reasons other than supporting your clinical practice.

PROGRAM OVERVIEW

PART 1 – OVERVIEW AND WHAT WORKS

  • Overview of BPD & other personality disorders
  • Overview of Management approaches for BPD
  • Skills and qualities of individuals who successfully work with individuals with emotion dysregulation/BPD
  • Gaining the commitment of an individual with BPD to engage in services and treatment
  • Teaching life skills including distress tolerance
  • Middle Path Skills for Staff: validation, behaviourism and moving away from black and white thinking

PART 2 – STRATEGIES FOR STAFF

  • Field Mentoring in the management of BPD
  • Phone calls and coaching when an individual is in crisis
  • Specific issues for management of BPD (past experiences and team brain storming session)
  • Psychological First Aid: supporting staff
  • Implementing a BPD Management Policy and supported decision making
  • Documentation: what do you need to record in your notes?

GRAMPIANS PIR SUPPORTED WORKSHOP SLIDES

AVOCA Tuesday 16 and Wednesday 17 June
Avoca Information Centre
122 High St, Avoca

BALLARAT Thursday 18 and Friday 19 June
Ballarat Community Health
12 Lilburne St, Lucas

HORSHAM Wednesday 1 and Thursday 2 July
Uniting Church meeting room
10 Pynsent St, Horsham

ADDITIONAL INFORMATION

CORE COMPENTANCIES

CORE SKILLS HANDOUTS

ADDITIONAL HANDOUTS

BOOKS DISCUSSED AT TRAINING

VALIDATION VIDEO



SUICIDE RISK

This below information focuses on the very real and clinically challenging process of suicidality in individuals with Borderline Personality Disorder. Using a combination of DBT and the CAMS approach (Collaborative Assessment and Management of Suicidality) this module explores safe clinical practices to manage emotions, understand the primary issues and using DBT contingencies in a collaborative approach with consumers.

Download an article explaining the CAMS approach (Collaborative Assessment and Management of Suicidality) – Jobes-CAMSRiskAx

Suicidal Behaviour in BPD

  • Patients cut themselves to relive tension, not die (Soloff, 2000)
  • Seeking to reduce emotion dysregulation and painful inner states
  • Patients more frequently present to EDs & OD when the are young (Soloff et al., 2000).
  • Repetitive attempts more common for women in 20s and decrease with time (Maris 1981).
  • ODs usually occur following stressful life events Motivation to OD = wish to “escape”
  • Lifetime mean of 3 attempts (Soloff, 2000)
  • Suicide completion up to 10% (Paris & Zweig-frank, 2001; Stone 1990)
  • Suicide completion rate 50 times higher than in the general population (APA, 2001).
  • Patients may contact people who are in a position to intervene before ODs (Gunderson & Links, 2008).
  • Suicides in BPD occur late in the illness and follow long courses of unsuccessful treatment (Paris, 2003).

DBT evidence for management of risk in BPD

  • TURNER, 2000: DBT (n=12) versus client-centered therapy, 12 month study. Reductions in parasuicide (suicide attempts and self-injury)
  • KOONS ET AL, 2001: DBT (n=10) versus veterans administration mental health TAU (n=10), 6 month study. Reduction in Parasuicide (suicide attempts and self-injury), frequency, suicide ideation, hopelessness, depression, anger expression
  • VAN DEN BOSCHE et al 2002: DBT (n=31) versus community drug75 abuse/mental health TAU (n=33), 1 year. Frequency of self-mutilation and suicide attempts, treatment retention, self-damaging impulsivity
  • LINEHAN ET AL, 2002: DBT (n=52) versus community treatment by psychotherapy experts in suicide and BPD (n=51), 1 Year. Suicide attempts, suicidality, medical risk and risk rescue rating of parasuicide (suicide attempts and self-injury), treatment retention, emergency and inpatient treatment, anger directed outward

VIDEO: Presentation at the 2011 Suicide Prevention Conference: “The CAMS Approach to Suicide Risk” by Dr. David Jobes

Principles of responding to BPD Crisis

  • Respond promptly
  • Listen to the person (Validate & allow person to ventilate)
  • Assess Risk (Any change in self-harm/suicidally patterns, new adverse life events & traumatic experiences)
  • Assess mental state & rule out other mental illnesses
  • Stay calm & avoid expressions of shock/anger
  • Focus on the present moment
  • Use a problem solving approach
  • Collaborate around a safety plan. How to seek support. What is effective?
  • Clearly explain your role and that of other staff members
  • Communicate and involve the person’s family, partner and carers where applicable
  • Offer options for support for the person’s family, partner and carers
  • Refer the person to other services when indicated, and make a follow-up plan!
  • Where possible liaise with health professionals involved in care (health professionals, CATT, mental health service, hospital & other supports)
  • Consider whether a brief ‘planned’ admission to a psychiatric inpatient service is needed.

Principles of responding when a consumer is at high risk of suicide

  • Do not leave the person alone. If need be use the Mental Health Act!
  • Prevent or reduce access to means of suicide
  • Do not use threats to try to make the person feel guilty
  • Consult Senior Staff
  • Contact all involved in care (health professionals, CATT, mental health service, hospital, family, partner, carers & other supports)
  • Find out what helped in the past
  • Clearly explain your actions
  • Make a management plan
  • Consider whether a brief ‘planned’ admission to a psychiatric inpatient service is needed.

Adapted from Project Air Team: Treatment for Personality Disorders Version 1.2 April 2011 NSW Health and Medical Research Institute; 2010. Available at www.projectairstrategy.org

Principles of responding after a crisis is over

  • Follow-up by exploring all safety issues, including their effect on you, within usual scheduled appointments
  • Actively interpret the factors that may have helped provide relief from crisis (e.g. feeling of being cared for or “heard”)
  • Help the person use a problem solving approach to identify alternatives in a crisis
  • Explore the reality & feasibility of depending on health professionals to be available “at all times”
  • Help deal with anger and identification of when it become apparent

Suicide risk and DBT: Emotions, understanding the issue, contingencies & collaboration

Research on suicidal individuals indicate DBT protocol for assessing and managing suicidal behaviours is a critical component in effective treatment. DBT addresses suicide risk by: recognising risk of suicide, use specific strategies for management of high risk situations and addressing a clinicians’ own distress and well-being while working collaboratively with clients to build a life worth living.

Focus on Emotion Regulation

  • Reduce emotional reactivity/sensitivity
      – exercise, and balanced eating and sleep
      – exposure therapy
  • Reduce intensity of emotion episodes
      – heavy focus on distraction early on, which is a less destructive form of avoidance
  • Increase emotional tolerance
      – mindfulness
      – block avoidance
  • Act effectively despite emotional arousal

Explore Alternatives to Self-Injury

  • Prevent, avoid, or solve interpersonal conflict
  • Reduce emotional reactivity to conflict
  • Regulate and tolerate emotions
  • Alternative short-term escape (e.g., distraction)
  • Behavioural control (e.g., highlight disadvantages, reduce opportunities/means)

Also address drug use and aggression using a similar approach

  • Reduce emotional reactivity to cues and reduce general emotion vulnerability (e.g., PLEASE skills)
  • Regulate and tolerate emotions – relaxation, activities, cognitive restructure, mindfulness, acceptance, ice
  • Alternative short-term escape/distraction as a last resort (e.g., denial, vacation, dissociation/suppression)
  • Stop relief – make the behavior have no benefit

Use DBT treatment strategies

  • Problem solving
  • Skills focus
  • Exposure and opposite action
  • Reinforcement of principles
  • Cognitive modification
  • Support (Motivational Interviewing/cheerleading)
  • Validation
  • Acceptance
  • Dialectical Strategies
  • Chain Analysis

Focus on understanding the problem

Engage in detailed behavioural analysis to discover:

  • Environmental triggers
  • Key emotional difficulties (& thoughts)
  • What has happened before the start of the urge?
  • What problems did the behaviour solve?

Conceptualise the problem

  • Identifying factors that interfere with problem solving
Identify factors that interfere with problem solving
  • Lack of ability for effective behaviour
  • Effective behaviour is not strong enough
  • Thoughts, emotions, or other stronger behaviours interfere with effective behaviours
Address Therapy interfering behaviours
  • Arriving late; leaving early; passive/helplessness; not participating; story telling; excessive anger/judgment/criticism

Address Behaviours in Session Using DBT Protocols

  • EXTINICTION: ‘Block Behaviours” “that’s ineffective” – broken record. Return to the trigger/first emotion
  • VALIDATE or use humour/irreverence
  • EXPLORE therapy interaction/processes. Explore the illusion of choice in the absence of alternatives
  • TURN THE TABLES – Seek collaboration
  • EXTINCTION – Don’t respond at all
  • OTHER CONSEQUENCES – Repair; Vacation from therapy; Therapy termination; Feeling judged by therapist

Observe Boundaries in DBT = Observing Limits

  • Hold natural limits rather than those determined by chance, whim, or impulse, and not by necessity, reason, or principle
  • Keep your own sanity in check
  • Model and reinforce effective interpersonal behaviour
  • Reinforce independent coping
  • Make sure you are not emotionally dysregulated

Common Contingencies in DBT

  • Observing limits
  • “Drag out new behaviour”
  • Explore, Explore, Explore “Talk about the behaviour until your point is across” (even if you miss out on other topics
  • Diary Card “make it useful”
  • Schedule phone calls (not always when in crisis)
  • Withdraw warmth/ add warmth
  • Minimise impact of hospitalisation
  • 24 hour rule

Application of DBT Contingencies

Consumer refuses to collaborate

  • confront (learn when to let go, but come back to it later)
  • illusion of choice in the absence of alternatives
  • change topic quickly (if client chose topic)
  • end session early

Recent parasuicidal behavior

  • do not increase positive behaviors
  • avoid heart-to-hearts
  • withdraw warmth (slight avoid)

Client gets suicidal to get into hospital

  • teach client to get admitted without suicidal behaviour
  • have client submit a hospital contingency plan to avoid reinforcement (don’t make it too nice)
  • help client get out soon