Stabilizing outpatient group treatment for DID

1. Stabilizing outpatient group treatment for DID Six years of experiences Erik Baars Mary Byrde Bernard Lievegoed Kliniek

3. Bernard Lievegoed Kliniek

4. Overview of the workshop • Historic development • Current program • Typical cases • Experiences with each part of the program • Treatment trajectories • Theoretical backgrounds • Guidelines: based on experience and theoretical backgrounds • Future: improvement and evaluation Bernard Lievegoed Kliniek

5. 1. Historic development • Why we started • Development of program • Learning from clients • Learning from theory Bernard Lievegoed Kliniek

6. 1a Historic development: Why we started • Many DID-clients • All outpatient clients were treated individually • Two non-verbal therapists were working: • too many clients • a need for clients to share and exchange experiences about daily life functioning • All outpatient clients were treated individually • Start with inexperienced group treatment team Bernard Lievegoed Kliniek

7. 1b Historic development: - development of program - • Content • psycho-education • working on daily life functioning • mindfulness skills (Linehan) • non-verbal activities (observation skills training and distress regulation) • therapeutic eurythmics • psycho-education for partners • exchange sessions with main therapists Bernard Lievegoed Kliniek

8. Program: • weekly sessions for a period of 9 months • 5 theme-blocks of 8 sessions • 9.15 - 15.15 hrs. • structure of the day • course-like • rules and boundaries Bernard Lievegoed Kliniek

9. 1b Historic development: Learning from clients • duration: program too long • group size was too big • triggered by eating together • how to bring clients in the here and now? • how to encourage the client to be responsible for their own share in the therapeutic process? • improvement of ‘time-outs’ • not to work on making safe places in group setting • not to work with movement therapy in group setting • change of rules • becoming more predictable, more explicit about can’s and cannot’s Bernard Lievegoed Kliniek

10. 1b Historic development: Learning from theory • Herman/ Van der Hart et al.: phase-oriented treatment model • Kluft: basic rules • Bloom/ Herman: safety and sanctuary • Linehan/ Steiner: mindfulness skills training • Hubble, Duncan & Miller: the Heart & Soul of change • Baars et al.: review group treatment for chronic childhood abuse and neglect • Baars et al.: review stabilizing treatment goals Bernard Lievegoed Kliniek

11. Aspects of trauma treatment: • Van der Hart/ Steele & Nijenhuis: dissociation theory • Boon & Van der Hart: triggers • Cohen/ Frye: non-verbal therapy • Boekaerts et al.: self-regulation • Nijenhuis: animal defence states • Biographies of DID clients Bernard Lievegoed Kliniek

12. Current program Bernard Lievegoed Kliniek

13. New patients Preparation group Stabilization group • Individual non-verbal therapy blocks for the indications: • Safe places • Internal • communication • - Emotion • regulation Stress reduction group Skills training group Self regulation group

14. Current program: general aspects • Intake • Communication with main therapist: • With every decision • Size of the groups • Evaluation: • Individual talk • Proposal for next group or individual non-verbal session discussed with main therapist Bernard Lievegoed Kliniek

15. House rules • You are expected to be able to travel to the clinic independantly. • You should arrive on time to be able to start the session together. • You will be fetched from the waiting room. • If you are unable to attend phone the reception. • You are not allowed to have contact with any inpatients while in the clinic. • Clients are called by their christian name. • Smoking is not allowed. In the breaks you may smoke outside. Bernard Lievegoed Kliniek

16. You are responsible for being in the "here and now" and following the program. • Time outs are allowed if necessary and agreed to.We expect you to take care of the rooms andmaterials. • Homework will be written down and evaluated. • Telling eachother of traumatic memories or happenings is forbidden. This includes during the program, the breaks and outside the clinic. • Everything that is spoken about in the group sessions will remain within the group. • Any form of aggression towards group members or staff will not be tolerated.

17. If you have a clinical admittance to an inpatient clinic you will stop with the program and have a new intake if you wish rejoin the program • Reasons for dismissal are the following; • more than once absent ( excepting illness or extenuating circumstances). • acts of aggression to others or materials. • not able to follow the program. • During the period of attendance of the stabilisation program you may phone the clinic in the weekends and evenings. A nurse will answer the phone. In an emergency you are expected to phone your GP. • Telephone contact for clients and therapists can be made at the following times: Monday:09.15- 10.00 a.m.: Antonet Ebbenn/ Mary Byrde. Friday: 13.45 - 14.15 p.m.: Erik Baars.

18. Current program • Goals • In- and exclusion criteria • Program • Evaluation • Experiences Bernard Lievegoed Kliniek

19. New patients Preparation group Stabilization group • Individual non-verbal therapy blocks for the indications: • Safe places • Internal • communication • - Emotion • regulation Stress reduction group Skills training group Self regulation group

20. Preparation group 1: goals • Structuring of daily functioning • Introduction of mindfulness skills • Getting acquainted with other DID clients in a group • Getting acquainted with non-verbal therapies • Coping with travelling from and to the clinic

21. Preparation group 2: in- and exclusion criteria • General preconditions: • Main therapist (psychologist, psychiatrist or social worker) who is trained in treating DID: weekly sessions (minimum 30 min.) • Diagnosis DID • Motivated to work on: • Acquiring more insight and control of the own situation • Learning how to make choices, decisions • Planning and working with tasks. • Willing to evaluate the treatment process

22. Preparation group 3: program • 3 periods a year • Six weekly sessions from 10.15 – 12.15 hrs. • 10.15 - 11.00 hrs: • observation exercise • structuring daily life • mindfulness skills • 11.00 – 11.15 hrs: break • 11.15 – 12.00 hrs: non-verbal therapies • 12.00 – 12.15 hrs: closure: looking back on the morning

23. Preparation group: evaluation • First step: individually with each client • Second step: consultation with main therapist • Third step: team decision > advise to client and main therapist

27. Experiences with: the preparation group • Uncertainty about possibilities and needs of clients > possibility to ‘assess’ clients • Some clients have to learn how: • To cope with the stress of travelling to and from the clinic • To be in a group • To handle not being allowed to write or express themselves • To use non-verbal techniques

28. New patients Preparation group Stabilization group • Individual non-verbal therapy blocks for the indications: • Safe places • Internal • communication • - Emotion • regulation Stress reduction group Skills training group Self regulation group

29. Stabilization group 1: goals • Learning to formulate and structure tasks • Working on own realistic tasks • Practising mindfulness skills • Learning to formulate, discuss, ask, question and advise • Learning to use non-verbal therapies in the here and now • Learning about phase-orientated treatment, with specific attention towards stabilizing treatment trajectories

31. Stabilization group 2: in- and exclusion criteria • General preconditions • Main therapist (psychologist, psychiatrist or social worker) who is trained in treating DID: weekly sessions (minimum 30 min.) • Diagnosis DID • Motivated to work on: • Acquiring more insight and control of the own situation • Learning how to make choices, decisions • Planning and working with tasks. • Willing to evaluate the treatment process

32. Stabilization group 3: program • 3 periods a year: 10 weekly sessions (alternating program) • 9.15 hrs: start with a round XXXXXXXXXX • 9.20 hrs: • observation exercise • ‘looking back & forward (weekly tasks)’ • ‘good news’ • 10.00hrs: break • 10.15 hrs: observation drawing • 10.30 hrs: looking back on last week psycho-education

33. 10.50 hrs: break • 11.00 hrs: non verbal therapies • 12.00 hrs: round ....9XXXXXX • 12.10 hrs: closure with a seasonal poem (chosen by a client) • 12.15 hrs: end

34. Stabilization group: evaluation • First step: individually with each client • Second step: consultation with main therapist • Third step: team decision > advise to client and main therapist

42. Experiences with:the stabilization group • Observation: • many clients experience that for the first time they really actively look at something • It helps them to stay in the ‘here and now’ • It enriches life • Weekly tasks: • clients experience that they rush through life • They experience that they think in ‘all or nothing’ terms

43. Weekly tasks: • Learning to accept and work with ‘changing goes by small steps’ • Learning to become more realistic in goal setting • Experience that one can reach an endgoal by planning, small steps, practice and will power • Clients are rarely satisfied about their own results • Clients learn from sharing and advising eachother, strengthened by the fact that groups consist of older as well as newer members.

44. New patients Preparation group Stabilization group • Individual non-verbal therapy blocks for the indications: • Safe places • Internal • communication • - Emotion • regulation Stress reduction group Skills training group Self regulation group

45. Stress reduction group 1: goals • To gain insight in the own ways of handling stress • To gain insight in healthy principles of stress reduction • Sustain: focusing attention/ here and now • Internal communication: Emotion barometer • Learning how to use the instruction form for cyclical ongoing working on topics of stress reduction • Practicing on own sources of stress

46. Stress reduction group 2: in- and exclusion criteria • General preconditions • At least one stabilization group

47. Stress reduction group 3: program • 2 periods a year: 4 weekly sessions followed by 6 fortnightly session • Theory and reflection on own situation (4 sessions) • General practice • Attention • Focusing • Working with scheme • Working on own reachable goals

48. 9.30 – 12.00 hrs • 9.30 hrs: • observation exercise • ‘present condition round’ • ‘good news-highlights round’ • 9.45 hrs: • Psycho-education and discussing the theme (weekly sessions) • Discussing homework (fortnightly sessions) • 11.15 hrs: non verbal stress reduction skills training • 12.00 hrs: closure with ‘how do you leave-round’

50. SPANNINGSREGULATIE - Basisschema – E B C D A