DBT RESIDENCIAL PROGRAM IN VINAGO-ITALY- -Fabio Rancati-

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1 DBT RESIDENCIAL PROGRAM IN VINAGO-ITALY- -Fabio Rancati- Crest (Center for the Study and Treatment of Personality Disorders ) was established in 1984 by two psychiatrists ( Roberto Bertolli, Furio Ravera). They had worked, up to then, in a crisis unit in a psychiatric clinic. After the initial stage of being freed physically from drugs, the patients then needed to be sent to a suitable center to help them stay free from drugs. Consequently the first therapeutic community was founded in Cuveglio. The community was able to host up to thirty patients. During this period of time a particular personality structure was observed in some patients which would not allow them to benefit from a behavioral therapy program once they were physically free from drugs. Therefore, we began to think about establishing a second T.C. in which we could treat these different pathologies. Requests for admission for being freed from drugs decreased and admissions for different psychiatric illnesses increased, such as anxiety disorders, eating disorders, acute psychotic attacks and personality disorders, especially those of cluster B.This new community was inaugurated in March 1995 in an old villa near Lake Maggiore in the little town of Vinago. It can host twenty-two patients. The purpose of this community is to plan a personalized program for each patient. Each program integrates the instruments of cognitive-behavioral therapy ( DBT ) in a social rehabilitation model using psychoanylitical support in the observation and treatment of the patients. The members of the staff (psychologists, psychiatrists, nurses, educators, psychotherapists) come from heterogeneous backgrounds that necessitated the use of a common language (jargon) during our weekly staff meetings for supervision. Marsha Linehan's Dialectical Cognitive-Behavioral Therapy enabled us to speak a common language and use concepts that were understandable for everyone.the first contact a patient has with Crest is on admission to our crisis unit in "Le Betulle", a private psychiatric clinic. Here the patient is treated anywhere from fifteen days to one month. During this period the patient is freed physically from drugs if this is necessary. Also a pharmacological therapy is initiated and evaluated along with an early attempt at diagnosis.in addition, this is when a commitment is made with the patient and his family to enter our community for at least three months for further observation. In this stage psychiatrists work with the patient to motivate him to enter our community and try to explain his pathology using the terms of the Biosocial theory of Borderline Personality Disorders. Once the patient has entered the community we begin to work on obtaining a commitment from him to begin actual therapy. During this stage the staff (3 psychiatrists, 3 educators, 2 nurses, 2 psychologists and 1 psychotherapist) work with the patient to obtain a commitment from him and to identify maladaptive behavior patterns to target in the treatment plan. Finally, they arrange for the patient's entrance in the Skills Training sessions as well as the individual sessions with his primary therapist, in accordance with the principles of D. B.T. In addition, during the morning meeting, the patient's diary card is evaluated along with those of the others.to date we have Three skills training groups in session: - one weekly session for an hour and a half on emotion regulation for 4-8 patients.

2 - one weekly session for an hour an a half on mindfulness for 4-8 patients. - one weekly session for an hour an a half on distress tolerance for 4-8 patients. The relation effectiveness modul is going to be ready soon. Once the patients have finished a module they join a follow up group that reinforces what has been learned so far until a skills training group for another module is ready to begin.initially the groups were open. However, due to our high turnover we decided to form closed groups. Our patients work on generalizing skills learned in these skills training sessions with the help and support of a DBT primary therapist. Some patients are assisted by psychotherapists, who have a psychodynamic orientation, outside our structure. All patients participate in weekly emotion groups to identify and understand emotions according to the DBT schema using handouts 2 and 3 of the module on emotions in Marsha Linehan's manual. We also set up a problem solving group in which, the more advanced patients who have already learned the basic skills of the skills training sessions, will participate. The members of the staff (psychologists, psychiatrists, nurses, educators, psychotherapists) come from heterogeneous backgrounds that necessitated the use of a common language (jargon) during our weekly staff meetings for supervision. Marsha Linehan's Dialectical Cognitive-Behavioral Therapy enabled us to speak a common language and use concepts that were understandable for everyone.our staff has daily meetings to discuss necessary interventions concerning the patterns of each single patient. Every week there is a supervision session for all the staff, all members of different sectors discuss case management. The operators confront one another to ensure that a dialectical position is always maintained by all team members. In addition, the increase in the use of DBT skills is evaluated along with each team member's motivation. Here, patient treatments records are evalueted.group sessions for the families of the patients and individual therapy sessions for patients in the last stages of treatment -- when they are no longer residents in our community -- are held in the Out-Patient structure in Milan. We have tried and are still trying to integrate the different styles of the team members who work in different sectors of our institution. To reach this goal we have begun training sessions for the operators and are attempting to gradually pass to a therapy that is based completely on DBT principles.right from the beginning, the DBT model becomes a reference point for every patient. Differences between American and Italian patients should be considered. In fact, our case load has very few patients who are a high risk for suicide, although we have many who are selfdestructive. Furthermore, in our experience we have seen many more suicide threats than actual suicide attempts. Also, trauma relative to incest seems to be much less frequent. However, very often we have observed dependent interpersonal relationships within the family as well as a difficult and late departure of the young adults from the family of origin. This is why it is so important to include the whole family in making a commitment to therapy. The fact that our institution is private is another important factor to take into consideration when contemplating its differences as well as the difficulties in coordinating the whole program. In the majority of cases the fee for therapy is paid by the patient's family. Therefore the patient is not the only one involved in commitment but the family as well. We have to give continual

3 progress reports to the family concerning the patient all through the program and to make contracts step by step. However, when the team, for one reason or another, believes it is impossible to proceed effectively in the patient's treatment, during Case Management, it makes the difficult decision of breaking the contract with the patient or put him in vacation. Criteria for selection. The criteria for selection of patients that are suitable for the type of intervention organized in the therapeutic community is based on the possibility of foreseeing a connection between the patient's clinical picture and the predicted effectiveness, in a therapeutic meaning, of the method applied in the Community. As in all therapeutic communities the first criteria for placement in our T.C. is the impossibility of placing the patient in a non residential program. These patients have been diagnosed (DSM IV) as having a serious personality disorder or a psychosis. We usually try to select patients between the age of 18 and 35 who do not have repeated psychiatric admissions to hospitals or clinics in their past. Weekly structure The therapeutic environment has been arranged in such a manner as to gather information. Therefore, the residents find themselves in a "holding" situation. Here, protecting the quality of life, they find the space to be listened to and to be helped through clinical intervention. The protected residence at Vinago is able to host twenty-two residents. It is a large villa with a garden, on the edge of a little town between Varese and Milan. The residents have a double room with bath. In the house, besides the dining room, there are two spacious rooms used as lounges during free time where one can listen to music as well as play it (there is a piano) and watch television. These rooms are also used for some groups. In addition, there are rooms for workshops, a small gym, the Staff room, a study for individual interviews and an infirmary. Life in the TC alternates between moments when residents have individual sessions to refine their diagnosis and group and individual treatment for support therapy, and moments of leisure, workshops and responsibilities inside the house. During the week the residents wake up around 7:30. They make breakfast and, after putting the house in order, meet with the staff members for the morning meeting. There is then a coffee break after which one of the workshops begins. After lunch the residents clean-up the kitchen (the meals are prepared by a cook) and then have time off until 4:00 p.m. At this time they participate in group therapy, individual therapy or workshops. At 7:00 p.m. the night meeting, during which residents share their experiences and emotions of the day, ends the day. After dinner residents have free time to dedicate to their own personal interests until 11:00 p.m. A medical doctor is always on duty during the night. Residents can organize outings from the community from Friday to Sunday which are planned and discussed in special groups for this purpose. They can use a protected apartment situated in the center of Milan.

4 During these two and a half years, our community has hosted around 81 patients of which 39 were males and 42 were females. The average age was 29 (14 the youngest and 60 the oldest). The average stay was six months. The majority of our patients come from the middle class and have initiated high school, even if some have not completed it. Usually they are living with their parents at the time they enter our community and almost all of them have had previous outpatient treatment. DBT evaluation plan of patient progress During the initial observation phase, the team works on building a therapeutic contract and, with the patient, decides on the targets of the therapeutic plan as well as the task analysis, that is the possible ways of reaching these targets. Then the work team verifies the patient's progress every fifteen days by analyzing the following points: 1. We check the presence or absence of thoughts that can be dangerous for the patient's life. 2. We check the presence, frequency and severity of therapy-interfering behavior. 3. We evaluate the patient's ability to use skills we have taught. It is at this time that the Skill Trainer (the staff member who conducts the skill training group) tells the team the patient's progress, especially concerning number 3 above. The primary therapist (staff member who conducts the cognitive-behavioral individual sessions) explains the patient's progress for what concerns number 1 and 2 above. Our organization has a psychologist responsible for maintaining contact with the patients' families and who also conducts groups with these families. She evaluates their understanding of the patient's pathology and attempts to decrease an invalidating attitude on their part towards the patient. In this way it is also possible to unmask any actions on the part of the family that could sabotage therapy. This is necessary to evaluate the family's ambivalence concerning the treatment that the patient has undertaken. At this point we also seek the psychiatrist's and the psychoanalyst's point of view concerning the information we have obtained from our observation. Since we have a residential structure our goal is to help the patients become capable of continuing their treatment as out-patients. In other words, we try to "school" the patients and give them strategies they can use in moments of crisis. Post-residence Consistent with the personal therapeutic plan which has been developed together with the patient, at the end of "schooling" we consider the possibility of undertaking the out-patient phase which includes, according to the situation, the patient s return to his family or the continuation of his therapy in protected apartments. Conclusion In our brief experience we have had a drop out rate of 47% of our patients, 30.8% of which within the first month of their stay in the community. In 53% of the cases definite improvements have

5 been noted. Presently we are studying the best way to have a portion of our patients, that have shown good results, continue as out-patients for about one year ( a period of time which seems necessary to us) before finishing their therapy.