DBT/PE Journeys
Program
Shani Ofrat, B.A.
Helen Valenstein-Mah, M.S.
Emily Scheiderer, Ph.D.
Disclosures
– We have no financial relationships to disclose.
– We will not discuss off label drug use and/or
investigational drug use in this presentation.
Acknowledgements
• Thank you to Drs. Ethan McCallum, Laura
Meyers, and Paul Thuras for their
contributions to the information being
presented today.
Overview
• Background
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What is Dialectical Behavioral Therapy?
What is Prolonged Exposure?
How can they be combined?
Research review
• Program Structure
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Components of treatment
Referrals
Screening and patient selection
Clinical considerations
• Outcomes
– Treatment engagement/dropout
– PTSD symptoms
– Service utilization
Dialectical Behavior Therapy
• Dialectical Behavior Therapy (DBT) is an evidence-based
treatment for Borderline Personality Disorder (BPD) (Linehan,
1993; The Cochrane Library, 2012)
• BPD is a disorder of pervasive dysregulation (emotional, behavioral,
cognitive, self, interpersonal)
– Traditional behavior therapy or supportive therapy unsuccessful
with BPD patients
– DBT uses dialectics (honoring the core, essence of opposites) to
further growth
» Primary dialectic: ACCEPTANCE and CHANGE
» Example: We are all doing the best we can AND we can do
better
Dialectical Behavior Therapy
• Standard DBT – Four Modes:
• Individual Therapy (1 hour/week)
• Skills group training (2 hours/week, rotating modules)
– Mindfulness, distress tolerance, emotion regulation,
interpersonal effectiveness)
• Phone coaching (24/7, as needed)
• Therapy consultation (weekly)
• DBT is effective in reducing problems associated with BPD
(suicide attempts, non suicidal self injury, impulsiveness,
anger) (Lieb et al., 2004)
Dialectical Behavior Therapy
But there is a problem…
• High rate of co-occurring BPD and posttraumatic stress
disorder (PTSD) (56%) in clinical samples (Zanarini et al., 1998)
• Up to 76% of combat veterans with BPD also meet criteria
for PTSD (Southwick et al., 1993)
• PTSD reduces likelihood of achieving remission from BPD,
increases risk of suicide and self-injury (Harned & Valenstein, 2013;
Harned, Rizvi, & Linehan, 2010)
• PTSD not adequately treated by DBT alone (Harned et al., 2008)
Prolonged Exposure
Good news: there are effective treatments for PTSD!
• Prolonged Exposure (PE) is a manualized cognitive
behavioral treatment for PTSD (Foa, Hembree, & Rothbaum, 2007)
• Strong empirical support, VA rolled out naturally
• Three main components: psychoeducation, imaginal exposure, in vivo
exposure
• Based on emotional processing theory (Foa & Kozak, 1985)
– Activate fear associations through exposure learn feared stimuli are not
actually dangerous in current context and habituate, shift other emotions
(e.g., guilt, shame)
– Example: Patient raped by police officer (exposure to memory of rape,
actual VA and community police officers)
DBT + PE
• DBT PE created to more effectively treat PTSD in individuals with
BPD(Harned, Korslund, Foa, & Linehan, 2012)
• Stage-based treatment
• Stage 1 targets behavioral dyscontrol (DBT)
• Stage 2 targets PTSD (PE + ongoing DBT)
• Stage 3 addresses remaining problems (DBT)
• Significant reductions in PTSD, trauma-related guilt cognitions,
shame, anxiety, depression (Harned et al., 2012)
• Improvements found for suicidal ideation, no evidence that DBT PE
led to exacerbations in self-injury urges or behavior (Harned et al., 2012)
• Treat what you target: PTSD and BPD severity lower in stages 2 and
3 of DBT PE v. DBT only (Harned, Gallop, & Valenstein-Mah, 2016)
Rationale for DBT PE program in VA
• There is a need for DBT PE in the VA
• Veterans with PTSD and significant BPD traits (e.g., suicidality, selfharm, dissociation) often don’t have other treatment options
• DBT is effective treatment for BPD but not sufficient to treat cooccurring PTSD
• DBT PE integrates evidenced-based PTSD treatment into DBT in a
stage-based approach
• Effective in reducing PTSD and BPD symptoms
• Does not exacerbate suicidality, exposure therapy can be done safely
in this context
What is Journeys?
• 12-week intensive outpatient DBT and PE
program
• Began 10/12
• Developed for Veterans with PTSD unable to
complete PE or CPT due to BPD sxs
– suicidality, self-harm, dissociation, high emotions,
interpersonal chaos
• Intensive outpatient care
– Uses Building 10 unsupervised lodging
Active Components
DBT
PE
Community
Outings
Journeys Program Structure
DBT
Weeks
Pre
1
2
3
4
5
PE
Assess
Outing
7
8
9
10
11
12
Post
Individual: 2 session in first 2 weeks, 1 session following 10 weeks
Group: Skills group 3x/week
Other
6
Repeat skills group
Start – 2 sessions per week
PCL
DASS
Etc
IPDE
PSSI
MMPI
PCL
DASS
Etc
PCL and DASS every other week
Two outings per week- Enjoying life and In-vivo outing
Clear Minds
Lovingkindess
Clear Minds
Lovingkindess
Resources/infrastructure
• Providers:
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Mainly psychologists, social workers, nurses, trainees.
MSA/administrative support
Psychiatrist meets once
ER for emergent issues
24 hr phone coaching shared with outpatient DBT, staffed by psych
• Training:
– Trained in PE or DBT, preferably both.
– Follow DBT philosophy
• Infrastructure:
– Lodging, unsupervised
• Funding for outings:
– The American Legion Riders
– MN Vikings
– Other smaller organizations
Referrals
• Only program of its kind
• Referrals accepted nationally (2/3 out of VISN) due to
lack of access to DBT at home VAs
• Within VISN patients get priority
• Providers submit application
• Pts are screened to verify
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PTSD sx
BPD sx
Likely to benefit from PE
Need level of care
Motivated to engage in treatment
Criteria for Admission
Inclusion Criteria
• Co-morbid PTSD and BPD, or
traits of BPD, that interfere
with outpatient PE or CPT
– Self-harm
– Suicide ideation/attempts
– Interpersonal chaos
– Dissociation
– High emotions
Exclusion Criteria
• Must be appropriate for
outpatient-level care
– No suicide attempts or
inpatient hospitalizations
for 3 months
– No significant substance
abuse issues for 3 months
– No Antisocial PD
– Must be able to live alone
and care for self
Case example:
• Not admitted:
– Pt with factitious disorder, unclear about veracity of
traumatic events
– Pt who has not attempted outpatient PE/CPT, does
not come to appointments regularly
– Pt with primary SUD, recent relapses that interfere
with engagement in care
• Deferred:
– Recent suicide attempt/inpatient stay but otherwise a
good fit
– Milieu interfering behavior that can be shaped
Unique treatment features: Outings
• Enjoying life outing:
– Funding from donation to Journeys program
– Goal is to enjoy an activity as a group, be present, re-engage with life
– Ex:
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Twins game
Aveda salon
Salt caves
Movie
• Facing life:
– Ex:
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Riding the light rail
Going to a crowded/loud mall
Going to target
Social skills party
– Opportunity to practice exposure, with coaching from providers, in the
real world
– Trouble shoot, if no habituation is occurring
Special Considerations
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Monitoring self-harm, suicide risk
Dissociation
Shame in-vivos
Community re-integration and generalizing
treatment gains
Managing self-harm/Suicide
• Inclusion criteria
• PE starts in week 3 of program
• Pts start with distress tolerance TIPP skills to help tolerate PE
• Coaching is available 24 hrs
• Urges to self-harm are monitored in DBT
• If pt self-harms, PE stops (contingency)
• DBT provider creates a post-exposure skills plan for after
PE
Dissociation
• Interferes with willingness or ability to
tolerate trauma work
• “Contingencies create capabilities”
• Can’t do trauma work if this is occurring
• Use grounding techniques:
– Ice packs
– Walking around
– Eyes open
– Eye contact
Case example: Dissociation
• 40, female, AA
• Pt had very long history of childhood sexual and physical abuse from
multiple sources;
• In session, change in facial expression and voice (more neutral to angry),
and would not respond to her name
• Strategies:
– Imaginals conducted with eyes open at first
– She stated that she would “come back” if her name was called, a technique
her adoptive mom used with her
– Once called her mom in session to assist
– Held sessions outside in the fall in MN…brr!
– Offered balance board or standing, though she declined
– Tried ice, didn’t seem to help
– Name and outdoors most effective
• PE was completed, pt successfully graduated
Shame In-Vivo Exposures
• Shame is a very prevalent emotional response in
BPD/PTSD
– Although in-vivo exposure work typically focuses on
fear provoking stimuli in outpatient PE, can be used
with shame
• Assign exposures to unjustified shame
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Asking for help
Saying no
Looking in a mirror
Returning items
Buying things for oneself
Case example:
• Example 1:
– 40s AA man with CSA
– Although fear was present, shame was prevalent
emotion
– Invited male therapist to be in the room during PE, to
act opposite to shame
• Example 2:
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Never bought “women’s clothing”
Never tried things on in a store
Went with “battle buddy” to pick out a dress
Took photos and wore dress to graduation
Community Re-integration and
Generalizing Treatment Gains
• Re-engage with values and community activities
– Assigned on in-vivo hierarchy
• Volunteering
• Contacting estranged friends or family
• Develop hobbies and join groups
• Communication with home supports/providers
– Planning ahead for reintegration
– Discussing treatment plan with family
– Discussing therapy interfering behaviors with home
providers
Case example:
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In-vivos started with spending time in mall
Attended meetup.com events
Volunteered for Habitat for Humanity
Following Journeys, started own meetup
group, now with 150 members
• Coaches a sport locally
Journeys Program Outcomes
 Dropout rate
 Self-reported outcomes (pre, post, 3 mo., 12 mo.)

PTSD symptoms (PCL-4/5)
 Service Utilization (via remote data)
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Psychiatric Hospitalizations
Outpatient MH visits
Intensive Outpatient Programs/Partial Hospitalization
Programs
ED visits
Primary care visits
Drop-Out
 Veterans accepted previously dropped out of
trauma-focused treatment (TFT), did not fully
engage, or did not begin due to provider
concerns re BPD symptoms
 Drop-out rate for Journeys (over 4 years): 23.4%
– Outpatient dropout for PE/CPT: 32% to 44% reported
in clinic-based studies (Tuerk et al 2011; Jeffreys et al., 2014)
– 30% to 38% in randomized trials (Schnurr et al., 2007; Forbes
et al., 2012; Suris et al., 2013)
40
30
Journeys
20
RCT
Outpatient
10
0
Drop-out %
Follow-Up Response Rates
 44% response rate to 3-mo. follow-up
 33% response rate to 12-mo. follow-up
 Expected non-incentivized rate: ~20%
 No significant difference between responders,
non-responders at 3-, 12-month surveys on
baseline PCL scores
– (mean baseline PCL score of ~69 for all groups)
PTSD Sx Outcomes
 Clinically Significant Improvement: reduction of 10+
on PCL from pre to post.
 79.2% of Journeys pts demonstrated.
 This rate of improvement > rate reported nationally
for PE/CPT.
– E.g., < two thirds (62.4%) of veterans in Eftekhari et
al. (2013) study showed CSI in PTSD sxs.
PTSD Outcomes cont’d
 Journeys: 94% screened positive for PTSD at
pre-treatment vs 42% at post-treatment.
 Compared to…. Nat’l PE/CPT roll-out sample:
88% screened positive for PTSD at pretreatment vs 46% at post-treatment.
100
80
60
40
Journeys
Roll-out
20
0
Clinically
Pre-tx Positive Post-tx Positive
sigificant
PTSD screen (%)PTSD screen (%)
improvement
(%)
PTSD Outcomes cont’d
 69.6% continue to report clinically significant
improvement in PTSD symptoms at 3-month
compared to pre-tx.
 58.8% at 12-month compared to pre-tx.
100
80
60
Post-treatment
3 mo. Follow-up
40
12 mo. Follow-up
20
0
Clinically significant
improvement (%)
Service Utilization: Psychiatric
Hospitalizations
 Depends on how we look at it…
– NOT statistically significant reduction in total number
of hospitalizations (p = .063).
• 24 in the yr prior, 15 in the yr following.
– BUT significant reduction in number of individuals
w/ any hospitalizations prior to vs following (p = .05).
• 39%: at least one psych hospitalization in yr prior to.
• 24%: at least one in yr following Journeys graduation.
Psychiatric Hospitalizations - cont’d
 Average length of psych hospitalization:
– Graduation from Journeys was associated w/ a
statistically significant reduction in average length of
stay (p = .028).
• Mean length of stay prior: 11.51 (SD = 16.1) days.
• Mean length of stay following: 5.89 (SD = 14.1) days.
50
40
30
Pre
20
Post
10
0
Percentage Hospitalized
P = .05
30
20
20
Pre
Pre
10
Post
10
0
Post
0
Total Hospitalizations
P = .063
Length of stay (days)
P = .028
Service Utilization - cont’d
 Graduation from Journeys: not associated w/
statistically significant reductions in…
– Outpatient MH visits
– Emergency Dept visits
– Primary Care visits
 Was associated w/ statistically significant
reduction in: Use of PPH/IOP (Z = -2.62, p = .009):
• Mean number of admissions prior to: 14.25 (SD = 36.1).
• Mean number of admissions following: 3.15 (SD = 36.1).
OUTCOMES SUMMARY
• Journeys dropout rates: lower than reported in PE/CPT lit.
• Reduction in self-reported PTSD symptoms.
– Maintained at 3- and 12-mo. follow up.
– Consistent w/ or better than comparable published studies of
outpatient PE/CPT
• Fewer graduates psychiatrically hospitalized.
– Length of stays significantly reduced.
– Drop in overall psychiatric hospitalizations: not significant.
• No significant drop in use of outpatient MH services,
primary care visits, or ED visits.
• Significant reductions in utilization of PPH and IOP.
Questions?
PTSD Outcomes
Variable
n
Pre-
Follow up
M (SD)
M (SD)
t
df
p
d
PCL 5 Total
Pre/Post
39
62 (11.7) 42 (21.6)
7.79
38
< .001
1.25
Pre/3 mo.
14
59 (13.2) 45 (20.98)
6.01
13
.003
.89
Pre/12 mo.
5
48 (14.1) 35 (16.26)
3.72
4
.020
1.66
n
Pre-
Follow up
t
df
p
d
M (SD)
M (SD)
48 (17.7)
10.16 47
< .001
1.47
Variable
PCL 4 Total
Pre/Post
48
69 (9.7)
Pre/3 mo.
23
69 (10.2) 54 (13.0)
7.54
22
< .001
1.57
Pre/12 mo.
17
69 (9.9)
3.92
16
.001
0.95
55 (18.3)
Service Utilization - cont’d
 Outpatient Mental health visits:
– Graduation from Journeys: not associated w/ statistically
significant reduction in outpt MH visits (Z = -0.399, p = .69).
• Mean number of visits prior to: 81.4 (SD = 75.2).
• Mean number of visits following: 74.24 (SD = 76.6).
 Partial Hospitalization Programs/Intensive
Outpatient Programs:
– Graduation from Journeys: was associated w/ statistically
significant reduction in use of PPH/IOP (Z = -2.62, p = .009).
• Mean number of admissions prior to: 14.25 (SD = 36.1).
• Mean number of admissions following: 3.15 (SD = 36.1).
Service Utilization cont’d
 Emergency Department visits:
– Graduation from Journeys: not associated w/ a statistically
significant reduction in ED visits
(Z = -0.152, p = .88).
• Mean number of visits prior to: 1.72 (SD = 2.7).
• Mean number of visits following: 2.05 (SD = 3.8).
 Primary Care visits:
– Graduation from Journeys: not associated w/ a statistically
significant reduction in use of PC.
(Z = -1.36, p = .18).
• Mean number of visits prior to: 7.2 (SD = 6.3).
• Mean number of visits following: 7.9 (SD = 5.5).