DOCUMENT 1
FOI 23/24-0023
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Research – Dialectical Behavioural Therapy
The AAB have requested further information Dialectical Behavioural Therapy
(DBT).
The Applicant is a 23yo female with Asperger’s Syndrome, ASD and/or
Dissociative Identity Disorder.
In preparation for hearing of the matter, the AAB have requested a high level
review of DBT, in particular in application and effectiveness. They would also like
information to assist in determining whether DBT constitutes a treatment for
mental health and who would be responsible for funding treatment under
APTOS.
Further to above, please provide information on the treatment DBT, e.g. :
• What is DBT?
Brief
• What is the evidence base for DBT?
• What is the effectiveness of DBT?
• What is the general application of DBT?
• What conditions is DBT recommended for? (Particularly interested
in any application/ evidence for Asperger’s Syndrome, ASD and/or
Dissociative Identity Disorder)
• Is DBT a recommended for mental health conditions?
• What funding options are available for treatment of DBT? E.g.
under Health or Mental Health services
• Please provide a list of possible experts in DBT in Australia.
Date
23/06/21
Requester(s)
s47F - personal privacy - Senior Technical Advisor (TAB/AAT)
Researcher
s47F - personal privacy - Research Team Leader (TAB)
Cleared
Please note:
The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These
are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on
access or planning matters they are to call the TAPS line for advice.
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Research – Dialectical Behavioural Therapy
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The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of
these matters.
The contents of this document are OFFICIAL
1 Contents
2
Summary ......................................................................................................................................... 2
3
What is dialectical behavioural therapy? ........................................................................................ 3
4
Evidence base and effectiveness of dialectical behaviour therapy ................................................ 3
4.1
Other conditions where evidence of effectiveness exists ...................................................... 4
4.2
Dialectical behaviour therapy for the treatment of dissociative identity disorder ................ 4
4.3
Dialectical behaviour therapy for the treatment of autism spectrum disorder ..................... 5
5
What is the general application of DBT? ........................................................................................ 5
6
Available funding options ............................................................................................................... 7
6.1
Public services ......................................................................................................................... 7
6.2
Private services ....................................................................................................................... 7
7
Please provide a list of possible experts in DBT in Australia........................................................... 7
8
References ...................................................................................................................................... 9
2 Summary
• Dialectical Behaviour Therapy (DBT) is the gold standard psychological treatment for
borderline personality disorder (BPD).
• The use of DBT has been suggested as an effective treatment option for the
treatment of Dissociative Identity Disorder (DID). Although no randomised controlled
trials exist, expert consensus and empirical research have found that DBT can be
adapted without significant changes to treat DID given the many similarities to BPD
such as self-harm, suicidal behaviour, emotion dysregulation, identity disturbance,
and dissociation.
• There are no studies to suggest DBT is useful for autism spectrum disorders.
• DBT can be funded through public and private mental health clinics.
• Treatment consists of one on one sessions, group skills training and telephone
coaching sessions.
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3 What is dialectical behavioural therapy?
DBT is a type of psychotherapy/talk therapy and a form of cognitive behavioural therapy
(CBT). It was originally designed to treat the problems of chronically suicidal individuals with
BPD. People with this BPD feel intense, uncontrollable emotions, have
troubled relationships and have a disturbed sense of self.
The approach is called "dialectical" because it involves the interaction of two conflicting
ideas, which are that improving the symptoms of BPD involves both acceptance and change
[1].
It is designed to help people change unhelpful ways of thinking and behaving while also
accepting who they are. It helps patients learn to manage emotions by letting them
recognise, experience and accept themselves. DBT can also help patients understand why
they might harm themselves, so they are more likely to change their harmful behaviour.
DBT usually includes [2]:
• individual sessions with a therapist
• skills training in groups
• telephone coaching sessions with a therapist if you are experiencing a crisis
DBT therapists often work in teams and help each other, so they can provide the best
treatment possible.
A typical course of DBT involves weekly individual therapy sessions (approximately 1 hour),
a weekly group skills training session (approximately 1.5–2.5 hours), and a therapist
consultation team meeting (approximately 1–2 hours) [2].
4 Evidence base and effectiveness of dialectical
behaviour therapy
DBT is currently the gold standard treatment for borderline personality disorder (BPD) and
an effective treatment for associated problems such as repeated self-harming, attempting
suicide, alcohol or drug problems, eat disorders, unstable relationships, depression, feelings
of hopelessness and post-traumatic stress disorder in this population [3]. It has been shown
to reduce the need for medical care and medications by as much as 90% [1].
A Cochrane Review which assessed the beneficial and harmful effects of psychological
therapies for people with BPD was conducted in 2020 [4]. Twenty-four randomised
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controlled trials (RCTs) were included that investigated DBT or modified DBT related
treatments.
Compared to treatment as usual (TAU), which includes various forms of psychotherapy,
DBT:
• Reduced BPD symptom severity, self-harm, anger, impulsivity, dissociation and
psychotic‐like symptom and improved psychosocial functioning at end of treatment.
o These treatment effects are small to moderate in size, however, the evidence
was graded as low which means there is some uncertainty around the results.
• Did not reduce suicide related outcomes, affective instability, interpersonal
problems, depression or chronic feelings of emptiness compared to TAU.
No adverse effects were found.
Earlier systematic reviews and meta-analyses have come to similar conclusions in relation to
DBT for stabilising self-destructive behaviour, reducing suicide attempts and self-injurious
behaviours in people diagnosed with BPD [5-7].
4.1
Other conditions where evidence of effectiveness exists
• Post-traumatic stress disorder (PTSD) [8, 9]
• Substance abuse and addiction disorders [10, 11]
• Depression [12, 13]
• Eating disorders [14]
4.2
Dialectical behaviour therapy for the treatment of dissociative identity
disorder
Dissociative identity disorder (DID) is a complex post-traumatic disorder which is highly
comorbid with BPD. About two-thirds of people with BPD meet the criteria for a dissociative
disorder, and display features of BPD such as a high degree of suicidality [15-17].
There are no published randomized controlled trials investigating treatments for DID [15].
Empirical data and expert consensus developed by the International Society for the Study of
Trauma and Dissociation suggests that carefully staged trauma-focused psychotherapy can
result in a significant reduction in DID symptomology [18-20].
It has been argued by Foote and Van Orden [15] that DBT can be usefully adapted without
significant changes to treat DID given the many similarities to BPD such as self-harm, suicidal
behaviour, emotion dysregulation, identity disturbance, and dissociation [15].
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4.3
Dialectical behaviour therapy for the treatment of autism spectrum
disorder
Simular to DID, autism spectrum disorder (ASD) has overlapping traits with BPD such as
emotional dysregulation, self-harm and social difficulties [21].
Adapting DBT for the treatment of ASD has been suggested by various authors [22, 23].
However, only one non-randomised trial could be located that investigates DBT for ASD
[24]. This included delivering radically open dialectical behaviour therapy (RO DBT) which
has been developed as an adapted form of DBT to directly target over control. The study
showed the intervention was effective, with a medium effect size of 0.53 for improvement
in global distress. Participants with a diagnosis of ASD who completed the therapy had
significantly better outcomes than completing participants without an ASD diagnosis.
A study into the effect of DBT in ASD patients with suicidality and/ or self-destructive
behaviour is currently underway, however, no results have been published [25].
As of 2013,
Asperger’s is now considered part of the autism spectrum and is no longer
diagnosed as a separate condition [26].
5 What is the general application of DBT?
DBT is composed of four elements that the individual and therapist usually work on over a
year or more [1, 27]:
• Individual DBT therapy, which uses techniques like cognitive restructure and
exposure to change behaviour and improve quality of life.
• Group therapy, which uses skills training to teach patients how to respond well to
difficult problems or situations.
• Phone calls, which focus on applying learned skills to life outside of therapy.
• Weekly consultation meetings among the DBT therapists, which offer a means of
support for the therapists and to ensure they are following the DBT treatment
model.
Some of the strategies and techniques that are used in DBT include:
Core Mindfulness
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One important benefit of DBT is the development of mindfulness skills [28]. Mindfulness
helps to focus on the present or “live in the moment.” Mindfulness skills help you slow
down and focus on using healthy coping skills when you are in the midst of emotional pain.
The strategy can also help you stay calm and avoid engaging in automatic negative thought
patterns and impulsive behaviour [27, 28].
Distress Tolerance
Distress tolerance skills help patients to accept oneself and their current situation. There are
four techniques for handling a crisis [27]:
• Distraction
• Improving the moment
• Self-soothing
• Thinking of the pros and cons of not tolerating distress
Distress tolerance techniques help prepare patients for intense emotions and empower
them to cope with a more positive long-term outlook [1].
Interpersonal Effectiveness
Interpersonal effectiveness, at its most basic, refers to the ability to interact with others
[27]. It helps patients to become more assertive in a relationship (for example, expressing
your needs and be able to say "no") while still keeping a relationship positive and healthy.
Principles include learning to listen and communicate more effectively, deal with
challenging people, and respect yourself and others [27, 29].
Emotion Regulation
Emotion regulation lets an individual navigate powerful feelings in a more effective way. The
skills learnt will help to identify, name, and change emotions [30].
When an individual is able to recognize and cope with intense negative emotions (for
example, anger), it reduces emotional vulnerability and helps to enable more positive
emotional experiences.
Over the course of treatment, individuals will learn [1, 27]:
•
Acceptance and change: Learn strategies to accept and tolerate life circumstances,
emotions, and yourself. Develop skills that can help you make positive changes in
your behaviours and interactions with others.
•
Behavioural: Learn to analyse problems or destructive behaviour patterns and
replace them with more healthy and effective ones.
•
Cognitive: Focus on changing thoughts, beliefs, behaviours, and actions that are not
effective or helpful.
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•
Collaboration: Learn to communicate effectively and work together as a team
(therapist, group therapist, and psychiatrist).
•
Skill sets: Learn new skills to enhance your capabilities.
•
Support: Be encouraged to recognize your positive strengths and attributes and
develop and use them.
6 Available funding options
In most Australian states, DBT programs can be accessed through both the public and
private mental health system [31, 32].
6.1 Public services
Public DBT programs are free to people living in the catchment area of a hospital that offers
a program. A case manager, mental health professional or GP can assist with referral
options.
Depending on the hospital, there may be a waiting time to access the program. Some DBT
programs run continuously across the year, while others operate on a more specific
schedule.
6.2 Private services
Private DBT programs require payment. Prices will vary depending on the specific service
chosen. If you have private health insurance, check that it covers psychiatric admissions.
To join a private DBT program, a psychiatrist from the specific hospital or clinic can provide a
referral.
7 Please provide a list of possible experts in DBT in
Australia
Dr Amanda Johnson (Clinical Psychologist)
Dr Johnson have been trained at Monash University and in the United States at the
University of Denver. Her doctoral thesis evaluated a standard DBT program in a community
health setting over a three year period. She has been involved in the development of several
DBT programs in the public and private sectors in Victoria and providing specialist DBT
supervision, consultation and training.
Email xxxx@xxxxxxxxxxxxxxxxxx.xxx.xx
Ph 03 9530 9777
Dr. Julie King (Clinical Psychologist)
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Dr Julie King is a clinical psychologist who offers a range of psychological services. Her
doctorate examined the experience of intellectual giftedness as asynchrony. She has worked
with the development of youth and antidepressant protocols in general practice. With a
passion for increasing resiliency and coping, Julie is intensively trained in DBT for Borderline
Personality Disorder.
Mob: 0414 432 623
Email: xxxxxxxxxx@xxxxx.xxx
Dr. Lillian Nejad (Clinical Psychologist)
Lillian Nejad, PhD, is a registered and endorsed clinical psychologist with over 20 years of
experience in the assessment and treatment of adults with mild to severe psychological
issues and disorders. She has applied her extensive knowledge and experience in a variety of
settings as a Monash University Lecturer and Clinical Supervisor, as a Senior Psychologist in
public mental health settings, in private practice, and within community and corporate
organisations.
Contact can be made through her website. https://www.drlilliannejad.com/letstalk
Dr. Peter King (Mental Health Nurse; Individual Psychotherapist)
Peter provides education and program development in specialty areas that include
Borderline Personality Disorder, Dialectical Behaviour Therapy, Crisis Intervention,
Psychiatric Emergencies, Somatic Trauma Therapy and Mindfulness-based approaches in
mental health care. Peter has specialist training in CBT, DBT, Somatic Trauma Therapy,
Mindfulness and his Ph.D. explores treatments for individuals with Borderline Personality
Disorder and clinicians’ training needs
xxxxx@xxxx.xxx
Australian DBT Institute: 07 56473438
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