Personailty Personailty

DisordersDisorders

Personality DisordersPersonality Disorders

Personality:Personality: An enduring pattern of thinking, feeling An enduring pattern of thinking, feeling and and

behaving that persists across time and circumstances. behaving that persists across time and circumstances.

For some people, elements of their personality (traits) For some people, elements of their personality (traits) can can

manifest in intense emotional difficulties & unhelpful manifest in intense emotional difficulties & unhelpful behaviours impacting negatively on life roles, behaviours impacting negatively on life roles,

occupations &occupations &relationshipsrelationships

Personality Disorder TypesPersonality Disorder Types

Odd/ Eccentric – Cluster AOdd/ Eccentric – Cluster A ParanoidParanoid SchizotypalSchizotypal SchizoidSchizoid

Dramatic/ Erratic - Cluster BDramatic/ Erratic - Cluster B BorderlineBorderline NarcissisticNarcissistic AntisocialAntisocial HistrionicHistrionic

Anxious/ Avoidant – Cluster CAnxious/ Avoidant – Cluster C DependantDependant Obsessive-CompulsiveObsessive-Compulsive AvoidantAvoidant

Parking Lot of the Personality Parking Lot of the Personality

DisorderedDisordered 1. Paranoid: cornered again!2. Narcissist: Largest car, Prominent

hood ornament3. Dependent: Needs other cars to

feel sheltered4. Passive-Aggressive: Angles car to

take two spaces5. Borderline: Rams into car of ex-

lover6. Anti-social: obstructs other cars7. Histrionic: Parks in centre of lot for

dramatic effect8. Obsessive: Perfect alignment in

parking spot9. Avoidant: Hides in corner10.Schizoid: can’t tolerate closeness to

other cars11. Schizotypal: intergalactic parking

Dramatic / Erratic - Dramatic / Erratic - PresentationPresentation

Difficulty controlling/ regulating emotional Difficulty controlling/ regulating emotional reactionsreactions

Difficulty identifying & expressing emotionsDifficulty identifying & expressing emotions Expression of emotions via aggressive outbursts Expression of emotions via aggressive outbursts

or impulsive behaviouror impulsive behaviour Regular situational crisesRegular situational crises Regular interpersonal conflictsRegular interpersonal conflicts Ongoing suicidal feelings or feeling unsafeOngoing suicidal feelings or feeling unsafe Engaging in self destructive behaviourEngaging in self destructive behaviour Difficulty maintaining healthy boundaries in Difficulty maintaining healthy boundaries in

personal & professional relationshipspersonal & professional relationships Behaviour results in others feeling manipulatedBehaviour results in others feeling manipulated Test the limits of relationshipsTest the limits of relationships

Dramatic / Erratic - StrategiesDramatic / Erratic - Strategies Acknowledge emotions but set limits on behaviourAcknowledge emotions but set limits on behaviour Provide choices on how to respond/ deal with the Provide choices on how to respond/ deal with the

situationsituation Do not assume responsibility for the person’s Do not assume responsibility for the person’s

problems – assist them to solve their own problemsproblems – assist them to solve their own problems Reinforce use of distraction strategies to cope with Reinforce use of distraction strategies to cope with

distressdistress Ensure personal/ professional boundaries & Ensure personal/ professional boundaries &

expectations are clear from the startexpectations are clear from the start If boundaries are overstepped address in a timely & If boundaries are overstepped address in a timely &

non-judgemental mannernon-judgemental manner Set firm limits by calmly reinforcing your expectations Set firm limits by calmly reinforcing your expectations

and potential consequences of the unhelpful behaviourand potential consequences of the unhelpful behaviour Positively reinforce benefits of taking responsibility & Positively reinforce benefits of taking responsibility &

any steps taken in this directionany steps taken in this direction

Treatment of personality Treatment of personality disordersdisorders

Requires the person to recognise that they Requires the person to recognise that they have a problem and to want to do something have a problem and to want to do something about it – at least part of the time.about it – at least part of the time.

Involuntary treatment is rarely used. It may Involuntary treatment is rarely used. It may be used for short periods to manage crises be used for short periods to manage crises or if a major mental illness develops. or if a major mental illness develops.

Treat symptoms including substance abuse, Treat symptoms including substance abuse, eating disorder etc. eating disorder etc.

Long term venture, needs patience, Long term venture, needs patience, consistency and skill. consistency and skill.

MHS capacity to engage with MHS capacity to engage with Individuals with PDIndividuals with PD

Will Do:Will Do: Management PlansManagement Plans

Consistency, containment, limit the number of clinicians Consistency, containment, limit the number of clinicians involved, work out what does and doesn’t work for each involved, work out what does and doesn’t work for each individual, problem solve triggerindividual, problem solve trigger

Symptom Management / TreatmentSymptom Management / Treatment If the client is interested in remediating their skills deficit, If the client is interested in remediating their skills deficit,

then we can assist with that (DBT, CBT etc)then we can assist with that (DBT, CBT etc) Motivational Interviewing / Commitment strategiesMotivational Interviewing / Commitment strategies

Will not do:Will not do: Force treatmentForce treatment Taxi serviceTaxi service Take abuseTake abuse Rescue people from the consequences of their own Rescue people from the consequences of their own

actions.actions.

Common AssumptionsCommon Assumptions

MANIPULATIVEMANIPULATIVE

- Definition: Able to handle skillfully; control cleverly or - Definition: Able to handle skillfully; control cleverly or deviously (Collins)deviously (Collins)

- Reality: Borderlines are more often direct, forceful and - Reality: Borderlines are more often direct, forceful and careless.careless.

ATTENTION-SEEKING, SPLITTING, LYING: ATTENTION-SEEKING, SPLITTING, LYING:

- Emotional pain - Emotional pain self-harm or suicide self-harm or suicide invalidated and invalidated and misunderstood misunderstood new ways to seek help. new ways to seek help.

- Not intentional.- Not intentional.- Effective treatment requires therapists to conceptualize - Effective treatment requires therapists to conceptualize

Borderline Personality Disorder in a more empathic and Borderline Personality Disorder in a more empathic and adaptive way. adaptive way.

Borderline Personality Borderline Personality DisorderDisorder(diagnostic criteria)(diagnostic criteria)A pervasive pattern of instability of interpersonal relationships, A pervasive pattern of instability of interpersonal relationships,

self-self-image, and affects, and a marked impulsivity beginning by image, and affects, and a marked impulsivity beginning by

early early adulthood and present in a variety of contexts, as indicated by adulthood and present in a variety of contexts, as indicated by

five (or five (or more) of the following:more) of the following:

(1)(1) Frantic efforts to avoid real or imagined abandonmentFrantic efforts to avoid real or imagined abandonment

(2)(2) A pattern of unstable and intense interpersonal A pattern of unstable and intense interpersonal relationships characterised by alternating between relationships characterised by alternating between extremes of idealisation and devaluationextremes of idealisation and devaluation

(3)(3) Identity disturbance: markedly and persistently unstable Identity disturbance: markedly and persistently unstable self-image or sense of selfself-image or sense of self

(4)(4) Impulsivity in at least two areas that are potentially self-Impulsivity in at least two areas that are potentially self-damaging (eg. Spending, sex, substance abuse, reckless damaging (eg. Spending, sex, substance abuse, reckless driving, binge eatingdriving, binge eating

Borderline Personality Borderline Personality DisorderDisorder

(diagnostic criteria cont’d)(diagnostic criteria cont’d)(5)(5) Recurrent suicidal behaviour, gestures, or Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviourthreats, or self-mutilating behaviour

(6)(6) Affective instability due to a marked reactivity Affective instability due to a marked reactivity of mood (ag. Intabse episodic dysphoria, of mood (ag. Intabse episodic dysphoria, irritability, or anxiety usually lasting a few hours irritability, or anxiety usually lasting a few hours and only rarely more than a few days)and only rarely more than a few days)

(7)(7) Chronic feelings of emptinessChronic feelings of emptiness

(8)(8) Inappropriate intense anger or difficulty Inappropriate intense anger or difficulty controlling anger (eg. Frequent displays of controlling anger (eg. Frequent displays of temper, constant anger, recurrent physical temper, constant anger, recurrent physical fights)fights)

(9)(9) Transient, stress related paranoid ideation or Transient, stress related paranoid ideation or severe dissociative symptomssevere dissociative symptoms

Remember…Remember…

…… A person suffering with this A person suffering with this illness has almost always been illness has almost always been abused at an early ageabused at an early age

…… Borderline Personality Disorder Borderline Personality Disorder is an is an illnessillness

…… The individuals perception often The individuals perception often distorted distorted

Borderline Personality DisorderBorderline Personality Disorder

Borderline Personality Disorder is difficult to treat and to Borderline Personality Disorder is difficult to treat and to date has been a drain on mental health services.date has been a drain on mental health services.

Usual treatment:Usual treatment: ReactiveReactive Crisis ManagementCrisis Management Attempts at problem solvingAttempts at problem solving Attempts at behavioral changeAttempts at behavioral change Inability to take a preventative approachInability to take a preventative approach

Effects of BPD on:

• MENTAL HEALTH SERVICE• Financial Burden – Emergency services - Admissions• Ongoing suicide risk• No-one wants to work with them

• INDIVIDUAL CLINICIANS• Crisis Management• Inadequate, overwhelmed, anxious• Negative responses• Don’t want to work with them

• CLIENTS• History of abuse or neglect• Dysfunctional “patterns”• Maladaptive & high risk coping strategies• Ongoing struggle• All they know

Behavioural ReinforcementBehavioural Reinforcement It is the nature of people to seek pleasure and to avoid It is the nature of people to seek pleasure and to avoid

pain. This means that people as a general rule will seek pain. This means that people as a general rule will seek that which is easiest.that which is easiest.

Hospital is generally easiest because:Hospital is generally easiest because: The person is removed from the situation which has triggered The person is removed from the situation which has triggered

the distressthe distress The person has another person take responsibility for meeting The person has another person take responsibility for meeting

their daily life needs eg food, housing, clothingtheir daily life needs eg food, housing, clothing The person effectively “takes a holiday” from life and the The person effectively “takes a holiday” from life and the

stressors that go with it.stressors that go with it. The person can give in to their impulses because the social The person can give in to their impulses because the social

consequences are lower.consequences are lower. The person can get instant relief through medicationThe person can get instant relief through medication

Hospital is ineffective because:Hospital is ineffective because: It reinforces behaviour that we don’t want eg DSH, regression, It reinforces behaviour that we don’t want eg DSH, regression,

admission / medication seekingadmission / medication seeking It doesn’t teach the skills necessary to make hospital It doesn’t teach the skills necessary to make hospital

unnecessary.unnecessary.

Treatment- HHOT/MHS RoleTreatment- HHOT/MHS Role

Will DoWill DoManagement PlansManagement PlansSymptom Management / TreatmentSymptom Management / Treatment

Will not doWill not doForce treatmentForce treatmentTaxi serviceTaxi serviceTake abuseTake abuseRescue people from the consequences Rescue people from the consequences

of their own actions.of their own actions.

Treatment- Management Treatment- Management PlansPlans

Management Plans co-ordinate treatment Management Plans co-ordinate treatment and response to individuals with PD providing and response to individuals with PD providing them with consistency and containment. them with consistency and containment.

Facilitate interagency collaboration Facilitate interagency collaboration maintaining consistency in response across maintaining consistency in response across organisations.organisations.

Include a treatment planInclude a treatment plan Provide a plan for Crisis Response Provide a plan for Crisis Response Involve the individual in their treatment and Involve the individual in their treatment and

encourage responsibility and autonomyencourage responsibility and autonomy Risk management toolRisk management tool

Rescuer Vs PunisherRescuer Vs Punisher

RescuerRescuer – Understandable as these clients are often easy – Understandable as these clients are often easy to sympathise with. They often have appalling histories to sympathise with. They often have appalling histories and their distress is tangible. Unfortunately, removing the and their distress is tangible. Unfortunately, removing the consequences of their own behaviour or doing things for consequences of their own behaviour or doing things for them, rather than helping them to learn those skills, does them, rather than helping them to learn those skills, does help them to remedy the skills deficit.help them to remedy the skills deficit.

PunisherPunisher – Understandable as these clients create chaos – Understandable as these clients create chaos unnecessarily, over –react to the same life stressors that we unnecessarily, over –react to the same life stressors that we often have deal with, demand more of your energy than often have deal with, demand more of your energy than you have to spare. Unfortunately refusing to assist at all, you have to spare. Unfortunately refusing to assist at all, whilst successfully avoiding reinforcing certain behaviours, whilst successfully avoiding reinforcing certain behaviours, also doesn’t remedy the skills deficits.also doesn’t remedy the skills deficits.

Middle GroundMiddle Ground – Decline certain requests whilst validating – Decline certain requests whilst validating their distress, explaining why your declining and suggesting their distress, explaining why your declining and suggesting / offering alternative distress tolerance techniques./ offering alternative distress tolerance techniques.

Treatment- Your RoleTreatment- Your Role

Ensure from the start that Ensure from the start that personal/professional boundaries are clear personal/professional boundaries are clear (this is what I can do for you, & this is (this is what I can do for you, & this is what I can’t do)what I can’t do)

Never to offer or promise something you Never to offer or promise something you cannot deliver (they have been let down cannot deliver (they have been let down too many times before)too many times before)

If you make an appointment with them If you make an appointment with them KEEP IT! KEEP IT! Cancelling reinforces Cancelling reinforces expectation of abandonment. Also expectation of abandonment. Also appointments are often seen as something appointments are often seen as something to look forward toto look forward to

Treatment- Your RoleTreatment- Your Role

Be familiar with the individuals management Be familiar with the individuals management plan and utilise its recommendationsplan and utilise its recommendations

Always remain calm, in the face of anxiety, Always remain calm, in the face of anxiety, rage or manipulationrage or manipulation

Encourage adaptive coping strategies Encourage adaptive coping strategies (breathing, imagery, problem solving, (breathing, imagery, problem solving, activity etc.)activity etc.)

Try not to react emotionally to outbursts, Try not to react emotionally to outbursts, remain calm in tone and manner – reinforce remain calm in tone and manner – reinforce you view/position on the situationyou view/position on the situation

Treatment- Your RoleTreatment- Your Role• Acknowledge the person’s current emotions, Acknowledge the person’s current emotions,

but set limits on behaviourbut set limits on behaviour• Monitor cues indicating escalating emotions Monitor cues indicating escalating emotions

(ie. Tension, raised voice) and if appropriate (ie. Tension, raised voice) and if appropriate gently point these out in a non-judgemental gently point these out in a non-judgemental manner manner

• Set firm limits by calmly reinforcing your Set firm limits by calmly reinforcing your expectations and potential consequence of a expectations and potential consequence of a specific behaviourspecific behaviour

• Check and validate information before Check and validate information before reacting to itreacting to it

Treatment- Your RoleTreatment- Your Role

• Suicidal/self-harming behaviour is a Suicidal/self-harming behaviour is a cry for help, often the person has no cry for help, often the person has no other way of expressing their distress/ other way of expressing their distress/ emotionsemotions

• Do not assume responsibility for the Do not assume responsibility for the person’s problem, assist them to solve person’s problem, assist them to solve their own problemstheir own problems

• Reinforce the use of Reinforce the use of diversion/distraction strategies to copediversion/distraction strategies to cope

What is DBTWhat is DBT Dialectical Behaviour Therapy is an evidence based Dialectical Behaviour Therapy is an evidence based

intervention for the treatment of Borderline intervention for the treatment of Borderline Personality DisorderPersonality Disorder

DBT is a structured, time-limited, cognitive-DBT is a structured, time-limited, cognitive-behavioural treatment designed specifically for behavioural treatment designed specifically for Borderline Personality Disorder. Borderline Personality Disorder.

Developed by Marsha Linehan in the absence of an Developed by Marsha Linehan in the absence of an existing structured and effective treatment for existing structured and effective treatment for Borderline Personality Disorder.Borderline Personality Disorder.

Specifically focuses on suicidal and “parasuicidal” Specifically focuses on suicidal and “parasuicidal” behaviour (referring to suicide attempts and self-behaviour (referring to suicide attempts and self-harm).harm).

DBT is the first psychotherapy shown to be DBT is the first psychotherapy shown to be effective for BPD, evidenced by randomised effective for BPD, evidenced by randomised controlled trials.controlled trials.

DBT is based on a dialectical world viewDBT is based on a dialectical world view Dialectics is a system of argument in which synthesis is Dialectics is a system of argument in which synthesis is

sought between to opposing forces or extremes (thesis sought between to opposing forces or extremes (thesis and antithesis).and antithesis).

Synthesis discovers what is valuable in bothSynthesis discovers what is valuable in bothAndAnd

Seeks to resolve contradictions between the twoSeeks to resolve contradictions between the two 3.3. Examples of Dialectical Tension:Examples of Dialectical Tension:

Acceptance versus changeAcceptance versus change Nurturing versus challengeNurturing versus challenge Focus on capabilities versus focus on deficitsFocus on capabilities versus focus on deficits Willfulness versus WillingnessWillfulness versus Willingness

Biosocial Theory of BPDBiosocial Theory of BPD Borderline Personality Disorder is primarily a dysfunction of Borderline Personality Disorder is primarily a dysfunction of

the “emotion regulation” system resulting from an the “emotion regulation” system resulting from an interaction between biological and social factors.interaction between biological and social factors.

Biological = emotionally vulnerable individual. An Biological = emotionally vulnerable individual. An emotionally vulnerable person is one whose autonomic emotionally vulnerable person is one whose autonomic nervous system reacts excessively to relatively low levels nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to baseline of stress and takes longer than normal to return to baseline once the stress is removed. once the stress is removed.

Social = invalidating environment. An invalidating Social = invalidating environment. An invalidating environment refers to a situation where the child’s environment refers to a situation where the child’s communication of personal experiences are disqualified or communication of personal experiences are disqualified or met by erratic, inappropriate and extreme responses from met by erratic, inappropriate and extreme responses from significant others.significant others.

Invalidating EnvironmentInvalidating Environment

Examples:Examples: Constant not occasional invalidationConstant not occasional invalidation Abuse is invalidationAbuse is invalidation Indiscriminately rejects communication of private Indiscriminately rejects communication of private

experiences and/or self-generated behaviorsexperiences and/or self-generated behaviors Punishes emotional displays and intermittently reinforces Punishes emotional displays and intermittently reinforces

emotional escalationemotional escalation Over-simplifies ease of problem solving and meeting Over-simplifies ease of problem solving and meeting

goalsgoals

DBT Assumptions re: clientsDBT Assumptions re: clients They are doing the best they can.They are doing the best they can. They want to improve.They want to improve. They must learn new behaviors in all relevant contexts.They must learn new behaviors in all relevant contexts. They cannot fail in DBT.They cannot fail in DBT. They may not have caused all of their own problems, but They may not have caused all of their own problems, but

they have to solve them anyway.they have to solve them anyway. They need to do better, try harder, and/or be more They need to do better, try harder, and/or be more

motivated to change.motivated to change. The lives of suicidal, borderline individuals are unbearable The lives of suicidal, borderline individuals are unbearable

as they are currently being lived.as they are currently being lived.

Stages and Targets of Stages and Targets of TreatmentTreatment

Pre-commitment StagePre-commitment Stage – Commitment Targets: – Commitment Targets:

Stage I TargetsStage I Targets: (stage I = 1year): (stage I = 1year)• Decreasing suicidal & parasuicidal behavioursDecreasing suicidal & parasuicidal behaviours• Decreasing therapy interfering behavioursDecreasing therapy interfering behaviours• Decreasing quality-of-life interfering behavioursDecreasing quality-of-life interfering behaviours

Stage II TargetsStage II Targets::• Decreasing posttraumatic stressDecreasing posttraumatic stress

Stage III TargetsStage III Targets::• Increasing respect for selfIncreasing respect for self• Achieving individual goalsAchieving individual goals

Pre-commitment

• Pre-commitment Stage • Commitment Strategies:

• Pros and Cons• Devil’s Advocate• Foot in the Door / Door in the Face• Connecting Present Commitments to Past Commitments• Highlighting Freedom to Choose and Absence of Alternatives

• Orientation to treatment• Agreement on DBT goals

Stage 1: Active Therapy (12 Stage 1: Active Therapy (12 month DBT program)month DBT program)

Individual TherapyIndividual Therapy Group Skills TrainingGroup Skills Training Phone CoachingPhone Coaching Consult GroupConsult Group

Modes and Functions of Therapy

MODEMODE FUNCTIONFUNCTION

Individual PsychotherapyIndividual Psychotherapy Improve motivationImprove motivation

Group Skills TrainingGroup Skills Training Enhance CapabilitiesEnhance Capabilities

Phone CoachingPhone Coaching Generalisation of capabilities Generalisation of capabilities to all relevant contextsto all relevant contexts

Consult GroupConsult Group Capabilities and motivation of Capabilities and motivation of therapisttherapist

Stage I: Targets and StrategiesStage I: Targets and Strategies

1.1. Decreasing suicidal & parasuicidal behavioursDecreasing suicidal & parasuicidal behaviours2.2. Decreasing therapy interfering behavioursDecreasing therapy interfering behaviours

Behaviour that interferes with client receiving or Behaviour that interferes with client receiving or benefiting from therapy or behaviours that burn-out benefiting from therapy or behaviours that burn-out the therapistthe therapist

3.3. Decreasing quality-of-life interfering behavioursDecreasing quality-of-life interfering behaviours Substance abuse, Financial difficulties, Criminal Substance abuse, Financial difficulties, Criminal

behaviours, High risk sexual behaviours, Serious behaviours, High risk sexual behaviours, Serious dysfunctional interpersonal behaviours/employment dysfunctional interpersonal behaviours/employment behavioursbehaviours

Increasing behavioural skillsIncreasing behavioural skills Core mindfulness skillsCore mindfulness skills Interpersonal effectivenessInterpersonal effectiveness Emotion regulationEmotion regulation Distress toleranceDistress tolerance Self-managementSelf-management

Stages and Targets Cont/d…

Emotion DysregulationEmotion Dysregulation Emotion Regulation – primary and secondary Emotion Regulation – primary and secondary emotions, vulnerability emotions, vulnerability factorsfactors

Behavioural DysregulationBehavioural Dysregulation Distress Tolerance skills – tolerating negative Distress Tolerance skills – tolerating negative emotions without engaging in impulsive, emotions without engaging in impulsive, desperate behaviours eg DSH, substance abuse, desperate behaviours eg DSH, substance abuse, aggressionaggression

Interpersonal Interpersonal DysregulationDysregulation

Interpersonal Effectiveness – balancing priorities Interpersonal Effectiveness – balancing priorities eg objective relationship, self-respect eg objective relationship, self-respect effectiveness and choosing and implementing the effectiveness and choosing and implementing the appropriate skill.appropriate skill.

Self DysregulationSelf Dysregulation MindfulnessMindfulness

Cognitive DysregulationCognitive Dysregulation MindfulnessMindfulness

Individual Psychotherapy

• Individual therapist is the primary therapist. All other therapists that the client is involved with outside of DBT are to be withdrawn.

• All other modes of therapy revolve around individual therapy.

• Helps the client inhibit maladaptive, borderline behaviours and replacethem with adaptive skillful responses.

• Close attention is paid to motivational issues, including personal and environmental factors.

• Sessions are usually once weekly for one hour but can vary according to level of crisis.

• Client expected to keep a diary card which is reviewed in session.

• Chain analysis of events leading to particular incident ie self-harm.• Solution analysis to identify more adaptive & skilful responses.

Group Skills TrainingGroup Skills Training

Distress Tolerance SkillsDistress Tolerance Skills Observing you Breath, Half-smiling, Acceptance Strategies, Observing you Breath, Half-smiling, Acceptance Strategies,

Wilful Vs WillingWilful Vs Willing Emotion RegulationEmotion Regulation

Identifying Emotions, Identifying the function of Emotions, Identifying Emotions, Identifying the function of Emotions, PLEASE Factors, Build Positive Experiences, Opposite to PLEASE Factors, Build Positive Experiences, Opposite to Emotion Action,Emotion Action,

Interpersonal EffectivenessInterpersonal Effectiveness Identifying Priorities eg Objective Vs Relationship Vs Self Identifying Priorities eg Objective Vs Relationship Vs Self

RespectRespect Identifying factors which reduce effectiveness eg skill deficit, Identifying factors which reduce effectiveness eg skill deficit,

worry thoughts, emotions, indecisionworry thoughts, emotions, indecision Indentifying intensity of asking / saying noIndentifying intensity of asking / saying no DEAR MAN, GIVE, FASTDEAR MAN, GIVE, FAST

Core MindfulnessCore Mindfulness Sates of MindSates of Mind What and How SkillsWhat and How Skills

Phone Coaching

• Phone contact with individual therapist - working hours.

• After hours, clients call PEC

• DBT information folders kept with PEC, Acute Care Team, and Wards G, H, and I. Folders contain information on:

• active clients• acute presentation plans• procedure for phone coaching• overview of skills taught

Phone Coaching cont/d…

Purpose of Telephone Coaching

• Decrease suicide crisis behaviours – opportunity to intervene prior to self-harm

• Increase generalisation of DBT behavioural skills to outside environment

• Decrease sense of conflict, alienation, distance with the therapist

• Increase client’s ability to ask for help effectively

NOTE: Phone coaching not available for 24 hours if self-harm has occurred

Crisis Survival SkillsCrisis Survival Skills

MindfulnessMindfulnessDistract with Wise Mind ACCEPTSDistract with Wise Mind ACCEPTSSelf SootheSelf Soothe Improve the MomentImprove the MomentPros and ConsPros and Cons

Mindfulness

“WHAT” SKILLS• Observing - noticing the experience without reacting.

- stay in control and remain alert.- watch your thoughts coming and going.- notice what comes through your senses.

• Describing - use words to describe your experiences.• Participating - become involved in the moment.

- actively practice the skills.“HOW” SKILLS

• Non-judgmentally - do not evaluate. - acceptance of the moment.• One-mindfully - one thing at a time.

- let go of distractions.• Effectively - focus on what works.

Distract with Wise Mind Distract with Wise Mind ACCEPTSACCEPTS

ActivitiesActivities Go for a walk, talk to someone, watch a videoGo for a walk, talk to someone, watch a video

ComparisonsComparisons To someone less fortunate, to when they were doing To someone less fortunate, to when they were doing

betterbetterContributionContribution

Make someone a cup of tea, volunteer workMake someone a cup of tea, volunteer workEmotionsEmotions

Do something that will create a different emotion – Do something that will create a different emotion – watch a funny videowatch a funny video

Pushing AwayPushing Away Decide not to think about that now, mindfulnessDecide not to think about that now, mindfulness

ThoughtsThoughts Imagery techniquesImagery techniques

SensationsSensations Squeeze Ice, run cold water over the back of your Squeeze Ice, run cold water over the back of your

neck / headneck / head

Self SootheSelf Soothe

- the Five Senses:- the Five Senses:Sight – Look at beautiful soothing things eg Sight – Look at beautiful soothing things eg

paintings in a museum, the trees / flowers paintings in a museum, the trees / flowers outside, make your environment prettyoutside, make your environment pretty

Hearing – Listen to soothing things eg Hearing – Listen to soothing things eg music, birds, watermusic, birds, water

Taste – make yourself a treat, have your Taste – make yourself a treat, have your favourite lollies on hand, cup of decaf teafavourite lollies on hand, cup of decaf tea

Smell – burn incense or scented oil, bake Smell – burn incense or scented oil, bake bread, try a perfume testerbread, try a perfume tester

Touch – play with a pet, get a cuddle from a Touch – play with a pet, get a cuddle from a safe person, snuggle in a blanket, try on fur safe person, snuggle in a blanket, try on fur coats in a clothes shopcoats in a clothes shop

IMPROVE the MomentIMPROVE the Moment

ImageryImageryMeaningMeaning

Lemonade out of LemonsLemonade out of LemonsPrayerPrayerRelaxationRelaxation

Breathing, progressive muscleBreathing, progressive muscleOne thing at a timeOne thing at a time

MindfulnessMindfulnessVacationVacation

Stay in bed, ask someone to make you a cup of tea, Stay in bed, ask someone to make you a cup of tea, clean up later (remember other people, reciprocity)clean up later (remember other people, reciprocity)

EncouragementEncouragement CheerleadingCheerleading

Pros and ConsPros and Cons

Pros of doing something (eg DSH, drinking, violence)Pros of doing something (eg DSH, drinking, violence)Cons of doing thatCons of doing thatPros of not doing thatPros of not doing thatCons of not doing thatCons of not doing thatCan only do this activity in “Wise Mind”Can only do this activity in “Wise Mind”Once completed, it can be used as a wallet prompt in Once completed, it can be used as a wallet prompt in

time where they can’t find Wise Mind.time where they can’t find Wise Mind.

Referral Process• All referrals are internal (within INBMHS)• Referrals are made directly to DBT Coordinator• Steps to referral:

* Read referral guidelines* Discuss referral with the client* Discuss referral with DBT Coordinator* Complete generic referral form, specify DBT

• Client will then be assessed for suitability• If suitable, individual therapist assigned• Pre-commitment commenced (approx. 4 sessions)• Referring party remains principal contact until client has entered active treatment (Group skills training)