Handout day 2 Copenhagen 21.8.17 - Wattar Gruppen
Transcript of Handout day 2 Copenhagen 21.8.17 - Wattar Gruppen
21/08/17
1
CBTpd Day 2
Professor Kate Davidson 2017
Feedback from yesterday
• Think of two pieces of knowledge that you gained from yesterday?
• In what way might this change how you think
about PD?
Plan: applicaGon of CBT to pd
Day 2 • ImplicaGons of formulaGon for change • Phases and structure of therapy
• RegulaGon of emoGons, behaviour and thinking • Generic Structured Clinical Care • CBTpd for ASPD
• Hints to help families and staff
APer agreeing the formulaGon
What next?
What are the implicaGons fo the formulaGon? What would you prioriGse?
Developmental perspecGve
Under-‐
developed
behaviours
Core
beliefs
Structured
Interpersonal
focus
Formula>on
CBTpd
Cognitive therapy for PD
Differences from standard CBT
Greater emphasis on therapeutic relationship
Narrative formulation
Past history more important
More session over longer time period
Levels of affect higher during sessions focused on
core beliefs
More emphasis on developing new ways of
behaving and thinking
21/08/17
2
Aims of therapy
Enhance quality of life, reduce self -‐harm & improve interpersonal funcGoning by
developing new ways of thinking
&
new ways of behaving
Aims
• Build therapeutic alliance
• Motivational enhancement of change
• Promote more adaptive and coherent
view of self and others
• Managing emotions and behaviour
• Improved self nurturance
• Improved communication
Targets of CBTpd
Behavioural regulaGon
EmoGonal regulaGon
Interpersonal sensiGvity
Develop new beliefs about
self and others
Interpersonal
problem solving
Empathic shared
formulation
Changes in
interpretation of view of self
& others
changes emotional
response
Behavioural experiments to test out assumptions self & others
General principles of change
Therapy alliance – Empathy, posiGve regard, respect, limits set but also some flexibility.
– Therapist honest about own limitaGons – Clarity about what the treatment is and is not.
Shared understanding of problem development through formulaGon Shared agreement in treatment goals
Therapy change procedures
• Focus on core beliefs
• Focus on under-developed behaviours
• Focus on change but balance with empathy regarding how change is difficult to come about
• Promote more positive and adaptive ways of thinking and behaving
• Work with others if possible to promote and reinforce change
Initial phases of therapy
Engagement.
IdenGfy core beliefs & over-‐developed behaviours.
Develop & agree formulaGon. Agree problems & goals
Decrease self destrucGve behaviour.
Develop new ways of behaving (under-‐developed behaviours) and the skills needed to maintain these. PracGce in daily life
Work on new ways of thinking about self and others to improve relaGonships (core beliefs work). Work done in session.
21/08/17
3
Middle and end of therapy
Client gains experience of new ways of thinking & new ways of behaving in their day to day life. Therapist reinforces new behaviours & thinking about self and others. PracGce pracGce pracGce! May involve significant others at this stage to reinforce changes.
Review & encourage new sense of self and accompanying behaviour change. Therapist summarises changes in wriGng for the client to reinforce change.
Ending therapy
General psychiatric management
Compared to DBT
DBT vs GPM (McMain et a. 2009)
DBT General Psychiatric
management
TheoreGcal basis
Learning theory, Zen & dialecGcal philosophy.
Psychodynamic (Gunderson)
Underlying problem Deficit in emoGonal regulaGon Disturbed acachment relaGonships related to emoGonal dysregulaGon
Treatment structure MulGmodal: individual session + skills group + coaching (5 hours per week) Team consultaGon (2 hours)
One hour individual session per week includes medicaGon management using structured drug algorithm. 90 mins therapist supervision per week.
Hierarchy of targets suicide treatment interfering, quality of life interfering behaviors.
PaGent preference. No hierarchy of targets Focus moves away from suicidal behaviors and self harm
DBT vs GPM McMain et al. 2009
DBT GPM
Primary strategy PsychoeducaGon BPD Helping relaGonship Here and no focus ValidaGon and empathy EmoGon focus
PsychoeducaGon BPD Helping relaGonship Here and no focus ValidaGon and empathy EmoGon focus
DialecGcal strategies Irreverent and reciprocal communicaGon style Formal skills training Behavioural techniques : Exposure, conGngency management, diary cards behavioral analysis.
AcGve listening for signs of negaGve transference
Crisis Manages on OutpaGent basis preferred/ coaching
HospitalizaGon if indicated
MedicaGon Skills over pills Meds for specific symptoms
Generic Structured Clinical Care
Knowledge of … • personality disorders
• value and content of structured care (clear roles, consistency etc)
Skill to…
• assess problems including client’s motivation for change and understanding of therapy
• formulate problems
• discuss the content of the intervention with the client
• develop a care plan
Kate Davidson PD workshop 2017 17
Therapeutic stance
Patience, compassion, and sensitivity
Maintain a focus on hope
- especially in the face of the client’s
subjective experience of adversity
Maintain a consistently “inquisitive” stance
in relation to the client
Kate Davidson PD workshop 2017 18
21/08/17
4
Therapeutic stance
o Authentic and open therapeutic stance e.g. reflect on own mental state and actions (including non-verbal behaviours) and the impact that this may have on clients
o Accepting that they won’t always be able to comprehend the client’s subjective experience, and being open and honest about this
o Acknowledging and “owning” errors made during the course of the intervention
Kate Davidson PD workshop 2017 19
Therapeutic stance
An ability to foster the client’s sense of self-efficacy
Examples
o Refrain from taking a ‘knowing’ stance (e.g. by providing solutions to the client’s problems or offering “interpretations’ of their behaviour)
o Reinforcing examples of the client’s positive coping skills
o Helping clients to increase their problem-solving skills
Kate Davidson PD workshop 2017 20
Therapeutic alliance
o An ability to employ active listening techniques
including:
o listening attentively
o encourage reflection and exploration by using open
questions
o clarifying and summarising the content of sessions
regularly throughout a session
o An ability to maintain positive regard by adopting a
warm and responsive non-judgemental approach
Kate Davidson PD workshop 2017 21
Developing a therapeutic alliance
Monitor alliance. Quality may vary
Build by taking an active interest in the client’s life
circumstances, interests and strengths by:
o Ensuring the client is clear about the rationale for the
intervention
o Being active & remaining flexible, respectful, open and
interested in the client
o Answering questions about the intervention in a
straightforward manner, non-defensive manner
o Showing an understanding of the impact that any
previous problematic contacts with services
Kate Davidson PD workshop 2017 22
Maintain alliance
Responding to negative events in treatment
and using such events to:
o revisit the rationale for treatment
o seek out and clarify any
misunderstandings about treatment
o refocus on the tasks and goals which are
seen as relevant to the client
Kate Davidson PD workshop 2017 23
21/08/17
5
Summary main BOSCOT findings
Outcome p
Number of suicidal acts 0.02
Anxiety 0.013
Beliefs (YSQ) 0.0064
BSI – Positive Symptoms
Distress Index 0.0047
Central problems in BPD
EmoGonal regulaGon
CogniGve regulaGon/ Interpersonal
Behavioural regulaGon
Kate Davidson PD workshop 2017 27
Different categories of suicidal/self-‐harming behaviour have different causes, different funcGons, different maintaining factors (Silverman & Maris, 1995)
About self harm
Mclean Longitudinal study BPD 20 year follow up in 2012 (50%)
Self muGlaGon decreases over Gme decreases Reasons: angry, frustrated, gekng acenGon control emoGonal pain. Prevent being harmed in worse way.
Mary Zanarini et al 2013 ISSPD Copenhagen
Mclean Longitudinal study BPD 20 year follow up in 2012 (50%)
Self muGlaGon decreases over Gme decreases Reasons: angry, frustrated, gekng acenGon control emoGonal pain. Prevent being harmed in worse way.
Mary Zanarini et al 2013 ISSPD Copenhagen
21/08/17
6
Self harm & regulation of affect
NegaGve
affect
Self harm
Affect improves
Problem with Self harm
§ It works very well in helping regulate emoGons
§ But only for that Gme -‐ short term only § Stops people solving their problems in a non destrucGve way.
Change in suicidal self harm with CBTpd at follow up Average episodes per month CBTpd
0
1
2
3
4
5
6
year 1 year 3-6
DSH
Self harm
20% repeat within a year (return to same hospital)
1 in 25 die by suicide in year aPer S-‐H (>50% general populaGon risk of DH)
> 50% of people dying by suicide have a history of self-‐harm.
15% of those have presented at hospital the year before die by suicide.
Specialist services Approximately 1/3 of people who end their lives by suicide are under the care of specialist mental health services.
Professor Louis Appleby told SC
“You have to do crisis teams properly; they have to be 24-‐hour services; they have to be services that provide the right level of skill in their frontline staff and the right level of contact. They cannot just be an occasional drop-‐in to check that someone is taking their medicaGon; they have to be a proper subsGtute, an alternaGve, as they were originally designed, to in-‐paGent care. What appears to have happened in some parts of the country is that crisis teams are not now providing an adequate alternaGve to in-‐paGent care: they do not have the seniority of staff; they are taking on a lot of paGents who are at a very high degree of risk who probably need something more protecGve “ Single riskiest >me in the 3 days following discharge from inpa>ents services.
Consensus statement on sharing informaGon with families
• Powerful evidence from those bereaved by suicide that professionals should be sharing informaGon with families of those who are suicidal.
PaGents have a legal right to confidenGality BUT encouraging the opGon to involve trusted family or friends can improve support and aid recovery.
21/08/17
7
Hamish Elvidge on gaining consent
One way is to say “Do we have your consent to share informaGon with a family member, friend or colleague?” The chances are that the answer will be, “No.”
Or you could say, “In our experience, it is always much becer to involve a family member, friend or colleague whom you trust in your treatment and recovery, and we know the triangle of care is likely to result in a greater chance of successful recovery. This will result in you recovering much quicker. Would you like us to make contact with someone and would you like us to do this with you now?”
The Machew Elvidge Trust
House of Commons report 300
Assessment of Risk of SH
• There is no evidence that assessing risk of self harm prevents SH
• Use as a risk management tool
• We need to manage SH
• Hawton et al Lancet 2012 379: 2373-‐2382
Which intervenGons are best at reducing S-‐H
Strongest evidence
CBT-‐based psychological therapy -‐ can result in fewer individuals repeaGng S-‐H
Lower quality of evidence for DBT for people with mulGple episodes of SH/probable personality disorder -‐ may lead to a reducGon in frequency of S-‐H
No evidence of benefit for reducing S-‐H for Case management / remote contact intervenGons did not appear to have any benefits in terms of reducing repeGGon of SH.
Brief CBT based interven>ons for self-‐harm in adults
suicidal idea>on at 6 months
Cochrane Database of Systema>c Reviews 12 MAY 2016 DOI: 10.1002/14651858.CD012189 hcp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012189/full#CD012189-‐fig-‐00115
Brief therapies more effective than intensive
therapies
Most therapies under 10 sessions
Between 4 and 6 sessions.
No clear evidence supporting prolonged exposure
to DBT or long term psychotherapy
• Cochrane Review 2016
Kate Davidson PD workshop 2017 41
In Depression Williams, Crane, Barnhofer & Duggan, 2005
NegaGve thinking during episodes of depression
Hopelessness & suicidal ideaGon
Events related to humiliaGon, defeat, entrapment
21/08/17
8
If depressed mood, reacGvaGon
APer several episodes depression, even mild low mood sufficient to act as context to reinstate habitual suicidal configuraGons
Depressed
mood Hopelessness
&
Suicidal idea>on
Relationship between psychological and social problems
and self-harm (adapted from Horrocks, 2002)
increased life stress
interpersonal difficulties
poor social support
attachment problems
rejecting or overprotective parental styles
sexual, physical emotional abuse in early life
hopelessness
poor interpersonal problem solving
autobiographical memory style
Psychological Factors
Memory style
Suicidal individuals take longer to retrieve positive autobiographical memories but not negative events memories than non-depressed control (like depressed). (Williams & Broadbent, 1986)
Retrieve more overgeneral (as opposed to specific) autobiographical memories compared to controls. (Evans et al., 1992)
Over-general memories associated with frequency of parasuicidal acts but borderline patients with greatest n overgeneral memories reported fewest acts – Is this a protective factor ? Do borderline patients avoid distressing memories (Startup et al, 2001)?
Autobiographical Memory task (adapted)
• In pairs
• One person writes down answers from partner. Other respond to cue word
• I will Gme – tell you when to start and when to stop. You will have 1 minute for each cue word.
Task
When you see the cue try to recall a specific event, i.e. something that happened at a parGcular place and Gme and lasted less than a day.
Overdose paGents
Cue Response
Happy Being with John
Sorry Sorry if I’ve hurt anyone, any
time
Arguments
Safe Being in my flat
Angry A lot of the time
A lot of people make me angry
21/08/17
9
Control subjects
Cue Response
Happy When I went to see my daughter in
her new house
Sorry When I went to see my sister after
her husband had a heart attack
Safe After reaching home after driving a
long way (from Hull)
Angry I was very angry after I found that
my older son had been misbehaving
Williams & Broadbent, 1986
Psychological Factors
Interpersonal problem solving
Deficits in problem solving in those with suicidal behaviour
Suicidal paGents provide fewer than half as many ways of solving problems as non-‐suicidal (but equally depressed) (MEPS).
Give more passive, less versaGle and less relevant types of soluGons.
Plac et al., 1987; Schoce and Clum, 1987; Howat & Davidson, 2002 (older
adults)
MEPS: EffecGve Problem Solving
First thing is to introduce herself to the immediate neighbours,
explaining that she had just moved in, possibly inviting the
people for a coffee anytime, and also if they seem interested
in her, if they invite her, making it clear that she intends to take
it up anytime. Chatting to people in the local shops, joining
clubs, offering to be helpful in some ways, e.g. baby-sitting,
gardening for old people. One tactic would be to get a dog
and take it for walks – that’s easy to get in contact. Similarly if
she has children, it’s easy to get in contact. Inviting people
round for dinner or drinks (rated 7 – extremely effective)
Psychological Factors
Future directed thinking (MacLeod)
Suicidal patients
High levels of hopelessness at the time of an attempt
predict future harm at 6 months and greater risk of
suicide at 10 years (Beck et al., 1989)
Less able to think of future positive events but do not
differ from controls in being able to anticipate negative
events.
MacLeod et al., 1993
Macleod et al., 1998
Conaghan & Davidson, 2002 (older adults)
Over-generality - a maladaptive mode of
processing self-relevant material
• Overgeneral memory is a particular feature of those individuals who habitually use rumination and avoidance strategies to deal with negative situations, thoughts or emotions (Hermans et al, 2005; Raes et al., 2005).
Reducing deliberate self-harm
Main strategies § Increase understanding of self-harm through formulation
of problems - relationship between core beliefs and self-harm behaviours
§ Decrease hopelessness
§ Explore consequences of self-harm, both short and long term
§ Attend to self-nurturing behaviours (eating, sleeping, activity etc.)
§ Shift focus to increasing awareness of more adaptive coping responses (practical & interpersonal) & positive future events
§ Attend to when the patients manages not to self-harm.
Kate Davidson PD workshop 2017 54
21/08/17
10
Central problems in BPD
CogniGve regulaGon/ Interpersonal
Behavioural regulaGon
EmoGonal regulaGon
Kate Davidson PD workshop 2017 55
When upset, how do you calm yourself?
Please think of 3 ways from
your repertoire?
Kate Davidson PD workshop 2017 56
Central problems in BPD
Behavioural regulaGon
EmoGonal regulaGon
Cogni>ve
regula>on/
Interpersonal
Kate Davidson PD workshop 2017 57
Cognitive behaviour therapy
working on different levels of cognition
Structural level
Automatic thoughts
Assumptions
Core beliefs
Treatment technique
Thought records
Behavioural experiments
Continuum
Historical test of schema
Notebook to strengthen more adaptive beliefs
Kate Davidson PD workshop 2017 58
Continuum for core beliefs
New belief
I am able cope on my own
0% x 100%
Kate Davidson PD workshop 2017 59
Historical test of belief (5 to 10 years)
Old belief: I am not worthy of love
New belief: Others may like me & I can be loved
Evidence for the old belief
• My mother criticised me a
lot
• I was bullied at school
• The teachers never said I
was good at anything
Evidence for my new belief
§ My aunt cuddled me
§ My mother was unhappy because my father was often drunk, not because of me
§ Susie liked me
Kate Davidson PD workshop 2017 60
21/08/17
11
Behavioral Experiments
• Relationship very important - based in trust
• Induce sprit of curiosity & willingness to experiment
• Guided discovery & Socratic questions
• Also a number of other skills: e.g. encouragement, coaxing, modelling, coaching, creativity, use of humour, think on your feet.
Kate Davidson PD workshop 2017 61
Types of Experiment
• Active Experiments
1. Real situations
2. Simulated (e.g. role-plays)
• Observational Experiments
1. Direct observation
2. Surveys
3. Data gathering from other sources (e.g. internet)
Kate Davidson PD workshop 2017 62
Core beliefs and behaviour
Develop new core belief
Increase under-developed behaviours
ENVIRONMENT
Stages & process of change in therapy
Engagement
Develop understanding of self
NarraGve formulaGon to help client understand problems in non-‐blaming way
Developing skills and understanding of relaGonships Increase ability and skill to recognise & manage thoughts & feelings & how these relate to self & relaGonship
Increase self resilience
RelaGonships improved through enhanced interpersonal skills, self-‐resilience & robustness
Stages of therapy From the formulaGon – what would you do next?
Change beliefs about
self and others
Change behaviour
Regulate emoGons
Central problems in BPD
EmoGonal regulaGon
CogniGve regulaGon/ Interpersonal
Behavioural regulaGon
21/08/17
12
Reducing deliberate self-harm
Main strategies § Increase understanding of self-harm through formulation
of problems - relationship between core beliefs and self-harm behaviours
§ Explore consequences of self-harm, both short and long term
§ Attend to self-nurturing behaviours (eating, sleeping, activity etc.)
§ Shift focus to increasing awareness of more adaptive coping responses
§ Attend to when the patients manages not to self-harm.
Behavioral Experiments
• RelaGonship very important -‐ based in trust • Induce sprit of curiosity & willingness to experiment
• Guided discovery & SocraGc quesGons • Also a number of other skills: e.g. encouragement, coaxing, modelling, coaching, creaGvity, use of humour, think on your feet.
Behavioral Experiments
I. Behavioral experiments are:
• Usually planned (occasionally spontaneous) • ExperienGal acGviGes • Undertaken by parGcipants in or between sessions
• Based on experimentaGon or observaGon
Types of Experiment
• Active Experiments
1. Real situations
2. Simulated (e.g. role-plays)
• Observational Experiments
1. Direct observation
2. Surveys
3. Data gathering from other sources (e.g. internet)
Planning the experiment
Be specific Be clear Elicit what is being predicted? How will expt be carried out? When Where With whom?
Worst case scenario/ ways of coping ReporGng what happened
Angela and self harm
Role play
§ Acend to when Angela has not self harmed (when would have in the past in response to a similar situaGon) § Clarify what she did that was different from self harming § How did she cope with emoGons? § What happened aPer not self harming?
Define the strategy used clearly. Ask her to imagine this is a strategy she could use again. Envisage using the strategy again DifficulGes vs Advantages
21/08/17
13
Role play
In pairs Swap over paGent / therapist roles
Central problems in BPD
CogniGve regulaGon/ Interpersonal
Behavioural regulaGon
EmoGonal regulaGon
Emotional sensitivity
• Emotional sensitivity may have a
hereditable component.
• Infants may be hypersensitive
• May lead to disorganised attachment
• Cohen (separation may be deliberate and
wilful)(interpretation of separations
important)
DifficulGes in EmoGonal RegulaGon Scale: some examples.
Kaufman, Xia, Fosco, et al 2015
ALMOST NEVER (0-‐10%) SOMETIMES (11-‐35%) ABOUT HALF THE TIME (36-‐65%) MOST OF THE TIME (66-‐90%) ALMOST ALWAYS (91-‐100%) I pay a?en@on to how I feel
I have no idea how I am feeling
I have difficulty making sense of my feelings
I am confused about how I feel
When I’m upset, I become embarrassed for feeling that way
When I’m upset, I feel out of control
When I’m upset, I have difficulty concentra@ng
When I’m upset, I lose control over my behaviour
When I’m upset, I believe there is nothing I can do to make myself feel be?er • 18 items short form (DERS-‐SF)
When upset, how do you calm yourself?
Please think of 3 ways from
your repertoire?
Your clients & emoGonal regulaGon exercise
Think of a client with difficulty controlling their emoGonal reacGons to situaGons. e.g. they may become highly distressed, they may self–harm,
they may shout at people, they may throw things, they may take
drugs or alcohol, etc.
What techniques might you suggest to help them to re-‐gain control of their emoGons?
21/08/17
14
Techniques
CogniGve techniques Recognising that a core belief is acGvated AcenGonal shiP Changing the scene Physical distracGon Seeking out posiGve relaGonships CatharGc wriGng DistracGng with opposite emoGons
Central problems in BPD
Behavioural regulaGon
EmoGonal regulaGon
Cogni>ve
regula>on/
Interpersonal
EmoGon-‐related cogniGve processing in BPD
MaladapGve cogniGve processes SelecGve acenGon and memory: – Habitually acend to negaGve sGmuli, – DisproporGonate access to negaGve memories – Endorse negaGve beliefs about self and others – Make negaGvely biased interpretaGons of neutral or ambiguous sGmuli
– Distorted beliefs and interpretaGons CogniGve processing characterised by ruminaGon & thought suppression -‐ associated with more severe symptoms Baer et al 2012, Clinical Psychology Review, 32, 359-‐369
RuminaGon
• RuminaGon is a form of repeGGve thought (Watkins, 2008)
• Habit. Many believe ruminaGon necessary to gain insight and solve problems.
• Depressive ruminaGon intensifies negaGve mood, impairs concentraGon and memory and problem solving, reduces moGvaGon for acGon, works to maintain SH, post trauma stress, disordered eaGng and substance abuse (Nolen-‐Hoeksema et al 2008, Watkins, 2008)
RuminaGve processing style
BPD abstract ruminaGve thinking focused oPen on anger and interpersonal concerns. “Why does this always happen to me?”
“Why is my life a mess?”
“Why does everyone leave me?”
“Why does everyone hate me?”
“Why am I such a loser?”
“It’s all my fault”
“I always get the blame”
“People are out to get me”
ShiP style from abstract to more concrete
• Train client to ask how quesGons rather than why quesGons? This is more adapGve to situaGons that cause distress.
• What happened? Focus on concrete details. How did it begin? Details described. The sequence that lead up to the event. What can s/he do next?
• FuncGonal analysis • Use imagery • Detailed prompts and quesGons from therapist.
21/08/17
15
Thought suppression in BPD
• Deliberate acempt to push unpleasant thoughts out of awareness. Almost never successful and associated with increased negaGve affect when thoughts recur (Najmi et al 2009)
• Strong tendency to avoid negaGve emoGons and stress (Chapman et al., 2005; Wegner & Zanakos, 1994).
Thought suppression
• People with BPD afraid of their own negaGve emoGons and may turn to thought suppression of emoGon inducing thoughts in a misguided acempt to manage their emoGonal states. (Baer et al., 2012)
Needs further exploraGon in BPD as only few observaGonal studies and none focused on treatment.
working at different levels of thinking
Structural level
AutomaGc thoughts AssumpGons &
Core beliefs
Treatment technique Thought records Behavioural experiments ConGnuum Historical test of schema Notebook to strengthen more adapGve beliefs
Continuum for core beliefs
New belief
I am able cope on my own 0% x 100%
Historical test of belief (5 to 10 years)
Old belief: I am not worthy of love
New belief: Others may like me & I can be loved
Evidence for the old belief
my mother cri@cised me a
lot
I was bullied at school
The teachers never said I
was good at anything
Evidence for my new belief my aunt cuddled me
my mother was unhappy because my father was
oKen drunk, not because of
me
Susie liked me
Ending
&
the final phase of CBTpd
Kate Davidson PD workshop 2017 90
21/08/17
16
Review of progress and new
learning
• Discuss progress with problems
• Note pattern of problems. ( For example, stress/ alcohol use etc and how this has an effect on self-harm, relationships etc)
• Discuss how the patient’s response (behaviour) has changed over time of therapy. What more adaptive strategies have been acquired? How did they developed these new strategies?
• Discuss how old and new core beliefs influence behaviour
Kate Davidson PD workshop 2017 91
Deal with separation issues
• Be clear that therapy is structured, has finite number of sessions.
• Increase frequency of sessions to weekly at end (if
necessary).
• Discuss how the patient will cope without therapy and
what supports and new ways of behaving are available
to them.
• Acknowledge the quality and meaning of the
relationship.
Kate Davidson PD workshop 2017 92
What if there is a crisis?
Try to deal with crisis within time
frame outlined to patient.
Review patient’s new ways of coping (from previous
sessions)
Discuss patient’s anxieties about end
of therapy.
Kate Davidson PD workshop 2017 93
Helping families / staff groups work with PD
Professor Kate Davidson CBTpd January 2016
AssumpGons that may help
Marsha Linehan
It may be hard to understand this but… • They are doing the best they can
Professor Kate Davidson CBTpd 2016
PotenGal Trap
Professor Kate Davidson CBTpd 2016
21/08/17
17
Tips for families and staff
① If you need to set a limit, then prepare to do so. ② Be clear about the aim of sekng limit. ③ Why limit would be useful/ a good thing to do for the
individual concerned and for you. ④ What are the benefits and costs. ⑤ Seek consensus for carrying it out ⑥ Keep the benefits of the limits in mind when the going gets
hard ⑦ Prepare mentally. Don’t be stuck -‐ explore fears. Be ready
and anGcipate. ⑧ Reinforce the right behaviours (Adapted from Randi Kreger: Stop walking on Eggshells)
Professor Kate Davidson CBTpd August 2017
hcp://www.ucl.ac.uk/clinical-‐psychology/competency-‐maps/pd-‐map.html
Generic therapeuGc competences
Assessment &
formulaGon
General clinical care
Specific
Ψ
therapies
Meta-‐competences
Conclusions • PD a complex disorder originaGng in childhood • EmoGonal hypersensiGvity & social dysfuncGon may be
central problem in BPD
• Psychological therapies help – emphasis on validaGon, helpful trusGng relaGonship & coping skills
• CBTpd for BPD – least intensive of all therapies for BPD: effecGve, gains maintained at follow up of 6 years, cost efficient
• CBTpd for ASPD – only RCT to date, promising, used in community & forensic sekngs
Kate Davidson PD workshop 2017 99
References
Davidson KM (2007) (2nd EdiGon) Cogni@ve therapy for personality disorders: a guide for
clinicians. Routledge, Hove.
Thank you
Professor Kate Davidson [email protected]