Dialectical behavior therapy (2)

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  • Impulsive behavior directly elicited by emotions or they function to reduce them
  • Impulsive behavior directly elicited by emotions or they function to reduce them
  • Dialectical behavior therapy (2)

    1. 1. Prof. Amany Haroun El Rasheed Ain Shams Univ., Cairo, Egypt M.N.P., D.P.P., M.D. Master in Mental Hygiene (Johns Hopkins Univ.)Fellowship in Substance Abuse Treatment & Prevention (Johns Hopkins Univ.) APA Membership FRC Psych WPA Fellowship ISAM Membership
    2. 2. BPD Can Be Fatal Among SUICIDES 40-65% have PD Among PD’s BPD is most associated with suicidal behavior Among BPD 8-10% commit suicide Up to 75% attempt suicide 60-80% self-mutilate
    3. 3. Before You Start ~~~ Decide What Treatment Your Patients Will Need
    4. 4. Treatments for BPD- DBT- Transference-focused Therapy- Mentalization-based Therapy (MBT)- Good Psychiatric Management (GPM)- Pharmacotherapy
    5. 5. One Year Health Care Costs Per Patient DBT TAUIndividual Psychotherapy $3,885 $2,915Group Psychotherapy $1,514 $ 147Day Treatment $ 10 $ 876Emergency Room Visits $ 226 $ 569Psychiatric Inpatient Day $2,612 $12,079Medical Inpatient Days $ 360 $1,096Total $8,607 $17,682
    6. 6. Theory of BorderlinePersonality Disorder in DBT
    7. 7. Biosocial Theory of BPD Biological Dysfunction in the Emotion Regulation System Invalidating EnvironmentPervasive Emotion Dysregulation
    8. 8. Biosocial Therapy of BPDA. Biological Vulnerability Patients born with greater emotional sensitivity.B. Environmental Vulnerability Patients grow up in families that fail to validate private experience.
    9. 9. Biosocial Therapy of BPDC. Biology interacts with Environment and produces dysfunction Emotional dysregulation Cognitive dysregulation Behavioral dysregulation Interpersonal dysregulation Identity dysregulation
    10. 10. Development of BPD Linehan’s Biosocial TheoryBPD individuals grow up in invalidating environments their emotions and struggles get trivialized, disregarded, ignored, or punished (even when normal) non-extreme efforts to get help get ignored only extreme communications/behaviors taken seriously sexual abuseWhy? parents are cruel (invalidated or abused as children) low empathy and skill: don’t understand child’s struggle
    11. 11. Development of BPD Linehan’s Biosocial Theory BPD individuals learn to invalidate themselves  intolerant of their own emotions and struggles (punish, suppress, and judge their emotions, even when normal) They easily “feel invalidated” by others They still influence others via extreme behaviors  self-injury/suicidality to get help  aggression, self-injury, and suicidality to get others to back off
    12. 12. Theory of BPD Core Problem: Emotion Dysregulation• pervasive problem with emotions• high sensitivity/reactivity (i.e., easily triggered)• high emotional intensity• slow recovery (return to baseline)• inability to change emotions
    13. 13. Theory of BPD Core Problem: Emotion Dysregulation• inability to tolerate emotions (emotion phobia) – vicious circle (upward spiral) – desperate attempts to escape emotions – inhibited grieving – history of invalidation for emotions – self-invalidation and shame• inability to control behaviors (when emotional)
    14. 14. Theory of BPD Core Problem: Avoidance Denial of problems (avoiding feedback) Non-assertiveness and social avoidance Drug and alcohol abuse Self-injury, suicide attempts , and suicide Self-punishment, self-criticism (block emotions) Dissociation and emotional numbing Anger to block other (more painful) emotions Anger to divert away from sensitive interactions Hospitalization to escape stressful circumstances
    15. 15. A little about DBT . . . DBT is a combination of Cognitive Behavior Therapy and Eastern meditative practices. Seven well-controlled randomized clinical trials with varying research teams have established DBT as a valid and effective treatment for Borderline Personality Disorder.
    16. 16. A little about DBT . . . Several studies have been launched to substantiate this use of DBT in non-borderline groups. For instance, DBT has had several controlled studies and been found effective in treating eating disorders, and substance abuse disorders. The concept of mindfulness is one of the primary Eastern meditative aspects of DBT and has become quite popular in many realms, not just as a psychotherapy treatment modality.
    17. 17. A Definition of Dialectics“…debate intended to resolve a conflict between two contradictory or apparently contradictory ideas or elements logically, establishing truths on both sides rather than disproving one argument.”Encarta World Dictionary, 1993-2003
    18. 18. “Dialect” Many meanings Accept patient where they are while also accepting the need for change Help patients move from rigid to more flexible thinking
    19. 19. Dialectics as PersuasionA method of logic or argumentationby disclosing the contradictions(antithesis) in an opponent’sargument (thesis) and overcomingthem (synthesis).
    20. 20. The Central Dialectic Acceptance and Change BPD clients often feel invalidated when:  others focus on change (they feel blamed), but also insist that their pain ends NOW  others try to get them to tolerate and accept BPD clients need to  build a better life and accept life as it is  feel better and tolerate emotions better Only striving for change is doomed to fail  blocking emotions perpetuates suffering  disappointed when change is too slow
    21. 21. DBT Balances:Standard behavior therapy techniques to induce change vs. Acceptance strategies to promote the therapeutic alliance and keep patients in treatment
    22. 22. DBT Balances: Skills Acquisition: teaching new behaviors vs. Validating and Reinforcing existing adaptive behaviors
    23. 23. Radical Acceptance Acceptance of reality as is. Acceptance is complete and comes from deep within Emotional/physical pain + nonacceptance = suffering Let go and stop fighting reality Letting go transforms unbearable suffering into more ordinary pain, which is part of life Turning the Mind implies that acceptance is an active choice and requires an inner commitment
    24. 24. Balance Core StrategiesVALIDATION Dialectics
    25. 25. Dialectical Behavior Therapy An Overview
    26. 26. How is DBT different than CognitiveBehavioral Therapy? Focus on the dialectical processes Focus on acceptance and validation Emphasis on treating therapy interfering behaviors Emphasis on the therapeutic relationship as essential to treatment
    27. 27. DBT Philosophy Individuals with BPD are so sensitive to negative feedback that their ability to change is drastically reduced. Balance acceptance strategies with change strategies:  “You’re great the way you are” and  “You can do better”
    28. 28. DBT Assumptions1. Difficult behaviors represent maladaptive solutions, not the problem.2. Engaging reluctant patients is a therapeutic task, not a pre-requisite for enrollment.3. Patients are doing the best they can.4. Patients need to do better and try harder to change.5. Patients want to have lives worth living
    29. 29. DBT Assumptions6. When patients say their lives are unbearable, this is a valid statement.7. Patients may not have caused their problems, but they need to solve them.8. Patients need to demonstrate adaptive behaviors in all relevant contexts.
    30. 30. DBT Assumptions9. Safety and security in therapy is not necessarily valued, in so far as it does not reflect the real world.10. Patients cannot fail in treatment.11. Therapists who conduct DBT need consultation.
    31. 31. Targets for DBT Treatment1. Stop suicidal and parasuicidal behaviors2. Address therapy-interfering behaviors3. Address quality-of-life interfering behaviors: stop drug use
    32. 32. Treatment Program DBT Skills Training Group Individual therapy Phone coaching/consultation Emphasis on ongoing assessment and data collection- Diary Cards Clear and precise treatment goals Collaborative working relationship between therapist and patient.
    33. 33. Structure of DBT Treatment: Modes1. Group Skills Training: typically 2 hr. group per week2. Individual Therapy: typically 1-2 sessions per week3. Phone consultation for crisis management, skills coaching4. Team consultation for therapists, typically 2 hrs/week
    34. 34. DBT Skills Training Group Group meets weekly Structured like taking a class: one hour devoted to reviewing homework one hour focused on learning a new skill Groups are no larger than 10 people
    35. 35. DBT: Modes of TherapyGroup skills training  Acceptance skills  Mindfulness  Distress tolerance  Change skills  Interpersonal effectiveness  Emotion regulation
    36. 36. DBT: Modes of TherapyIndividual psychotherapy  Orient to therapy  Agree on treatment goals  Target life threatening behaviors  Attend to therapy interfering behaviors  Address problems that affect quality of life  Generalize skills to daily life
    37. 37. DBT: Modes of TherapyTelephone consultation  In between individual sessions  Coaching  Difficulty asking for help  Relationship enhancement and problem solving  Reduces crises and increases skill generalization  Equalize power in relationship
    38. 38. DBT: Modes of TherapyConsultation for Therapists  Patient reinforces therapist for doing ineffective treatment and punishes therapist for doing effective things  Need peer consultation  Prevent burnout  Support use of DBT skills and techniques  From 2-6 therapists  Apply validation and change strategies to therapist
    39. 39. Getting Started in DBT Treatment1. Identify patient goals2. Identify problems that currently interfere with goals3. Define problems behaviorally4. Patient and therapist make a list of target behaviors5. Patient and therapist agree to work on targets for limited time (one year)
    40. 40. Patient-Therapist Agreements1. Time-limited renewable contract for therapy2. Miss 4 sessions in a row = termination3. Agree to attend therapy, skills groups, and complete homework4. Agree to work on self-destructive behaviors and therapy-interfering behaviors
    41. 41. Patient-Therapist Agreements5. Take meds as prescribed6. Therapist will strive to be competent, ethical, respectful and accessible7. Therapist will maintain confidentiality8. Therapist will seek consultation when needed
    42. 42. Four Skills Modules Mindfulness Distress Tolerance  surviving crises  accepting reality Emotion Regulation  reduce vulnerability  reduce emotion episodes Interpersonal Effectiveness  assertiveness
    43. 43. Taking Hold of Your Mind In DBT there are three states of mind: - Wise Mind - Emotional Mind - Reasonable Mind
    44. 44. States of Mind DiagramReasonable Mind Wise Mind Emotional Mind
    45. 45. Reasonable Mind This is the logical part of you brain. The part that thinks, plans and evaluates what is happening around you. Sometimes our emotions can get in the way of how well we do things. Whether we are in physical pain or emotional pain or any other kind of pain, it makes it harder to plan and think and organize every day activities we take for granted.  Getting ready in the morning: drinking a cup of coffee, morning routine, taking kids to school etc.  Building a house  Following instructions  Planning a vacation  Doing math
    46. 46. Emotional Mind This is when your present emotional state controls most of your thinking and behavior.  Anger-can spur an argument  Love- you might sacrifice yourself for your children  Anxiety-you might rush or be unable to concentrate When we as people are ina state of emotional reactivity our minds are often spinning with so many thoughts it is hard to find the off switch. Whether we are reacting to emotional pain, physical pain, physical or mental over load or any other emotionally heightened situation we are more prone to stress.
    47. 47. Wise Mind This part of our mind is a little more difficult to grasp. It is the integration of the reasonable mind and the emotional mind-this does not mean the ability to flip back and forth between the two or see both sides of coin. Additionally, you usually cannot evoke emotions through reason, and you usually cannot overcome emotions with reason.
    48. 48. Wise Mind It is the part of the mind that gives you peace, and knows and experiences truth. Some people consider this to be the intuitive part of the brain. It integrates all ways of knowing including all of the senses-hearing, seeing, smelling etc. You will not always be in the wise mind, this doesn’t mean it is not there!  Consider: when you have a hard decision to make, and after your choice your whole body feels confident, sure and relaxed, that you took the right course of action. (even if there might be consequences.)
    49. 49. Mindfulness Mindfulness is developed through meditative practice.  Meditation can be achieved in many ways, it is not just part of Eastern religious practices. Mindfulness happens any time you are completely focused on one thing, in that moment, without judgment.  It is the repetitive act of directing your attention to one thing at one moment.
    50. 50. Examples Driving a manual car for the first time you are aware of each movement, later you can drive on automatic pilot, but at first you must be mindful. Eating dessert and noticing every flavor instead of attending to the conversation, or looking around, or eating too fast. Walking in the park and being present. Notice the trees, the children; what it feels like as your feet hit the ground etc, not being distracted by your thoughts and thus not noticing anything.
    51. 51. Mindful? It is rare in our society for a person to be mindful. We are a society of multi-taskers.  Typing and talking  Eating and working  Plotting out your day as you drive to work We are also often preoccupied with the future or the past  Worried about what’s for dinner or what to wear, what our boss thinks, or how much money is in the bank  Did I say the right thing, I should have …, I can’t believe I . . . , If only . . . Etc.
    52. 52. Why Mindfulness? Whatever your attention is on, that’s what life is for you at any given moment. (C. Sanderson) If you take a coffee break, or go exercise to unwind, but all the while you are thinking and worrying about something- Are you really taking a break?
    53. 53. Why Mindfulness? Mindfulness allows you to pay attention to what you choose instead of letting your mind take you captive. We allow our minds to keep us prisoner and we are unable to fully experience each moment because we are lost in some other moment. Mindlessness:  hinders how we relate to our clients, our co- workers, our families, our friends etc.  hinders us enjoying hobbies, vacations, leisure time, etc.  affects how we feel about ourselves, what we have confidence to do and how we treat others.
    54. 54. Mindfulness Of course it is not always feasible or possible to be mindful at every moment in the day. However, without practice it is difficult to choose to be mindful because our inner dialogue has a way of taking us over.
    55. 55. Practicing MindfullyThe skills include:  Observing  Describing  Participating  Being non-judgmental  Being one mindful  Being effective
    56. 56. Mindfulness: Taking hold of your mind“What” Skills “How” Skills Observe Non-judgmentally Describe One mindfully Participate Effectively
    57. 57. Observe The goal of observingto watch is events, emotions, etc without trying to rid yourself of pain or prolonging a certain feeling. When you observe you simply notice what is-without judging it as good or bad. This skill focuses on being aware in the present moment.
    58. 58. Observe Observing and doing are different.(Just because you do something does not mean you are being aware.) Walking doing Noticing how fast you walk, how your feet feel hitting the ground, the sound your shoes make, how your muscles feel  observing Breathing Doing Feeling your chest rise & fall, how deep you breath, the sound of an exhale, the muscles moving, the feel of your breath on your skin observing
    59. 59. Describe Describing is just the facts. NO judgments. Describing is more interested in the process than the conclusion or end result.
    60. 60. Describe Sometimes people make an assumption- “They don’t like me.” The description of this might look like- they don’t invite me to lunch, they don’t make a response when I try to join their conversation, they avoid me, they always have little secret jokes etc. The description does not warrant the conclusion there could be many different reasons people at work have cliques that have less to do with someone outside the clique than with some other factor.
    61. 61. Describe Automatically,judging why a behavior is occurring can prolong the behavior or create conflict or tension. When we allow this to happen we allow our feelings to determine the reality, and we may not even be aware of the descriptors- we automatically see the conclusion.
    62. 62. Participate This means entering fully into an activity- staying in each moment without separating yourself from the events. True participation means getting rid of self-consciousness and letting go of your worries or fears. (not planning what you are going to say or worrying someone is judging what you are saying etc.) Full participation is the ultimate goal in mindfulness.
    63. 63. Participation Have you ever had a conversation and found yourself nodding and giving facial cues?- your body is on automatic pilot while your mind is somewhere else. How often do you drive home without noticing and then suddenly you are home. Participation requires letting your mind and your body participate together in whatever you are doing. Every part of you is involved in what you are doing. No compartmentalizing.
    64. 64. Non-Judgmentally This is means you do things without evaluating them. Avoid judging something as good or bad; valuable or worthless etc.-It just is. It does not mean going from a negative judgment to a positive judgment. (it is not optimism.)
    65. 65. Non-Judgmentally In DBT, there an emphasis on is consequences of behavior and events, but that does not necessarily label it as good or bad. Change is initiated to create more desirable outcomes. (this reduces shame based feelings that can perpetuate behavior with negative outcomes).
    66. 66. Non-JudgmentallyAn extreme scenario You get drunk, attempt to drive home and hit a tree- Instead of focusing on how bad a person you are and how you are so dumb and why can’t you do anything right, what were you thinking, you know better etc. (probably driving yourself back to drinking or something else to avoid the bad feelings you now have about yourself)  Non-judgmentally you can say- I need my car, I don’t like how I feel about myself when I get too drunk and loose control of my thinking, What could I do to get a better end result.
    67. 67. One-Mindfully This means learning to focus the mind and awareness on the current moment. Focusing completely on one activity at a time. Avoid reactions based on mood, negative thoughts, assumptions, expectations, worries etc. One- mindfully is how you participate.
    68. 68. One-MindfullySo back to your conversation with the friend, so you are no longer worrying about the future stuck in auto pilot, you are listening, but as she is talking you are preparing you response- oops this is not keeping your awareness on the present moment.
    69. 69. One-MindfullyThis skill relies on being aware of your thoughts, feelings etc and observing them so you can be careful not to react based on an assumption or a mood. When you observe your thoughts before you speak, you can react without creating conflict. You can enter your wise mind.
    70. 70. One-Mindfully This skill could be practiced when you are baking a cake, you put all your effort into that activity. You keep your mind all your thoughts fully on what you are doing with the cake. You focus on the measuring the textures the sounds, the smells, etc. When you are at home, you focus on home and stop thinking about that family at work that you are worried about, frustrated with etc.  Do give yourself time to One-Mindfully process your feelings regarding that family. A time to fully participate with yourself (sit with an emotion) and acknowledge the whole of what you are feeling and what you want to do. THEN LET IT GO.
    71. 71. Effectively This means do what works. The goal of this skill is to reduce a person’s tendency to be more concerned with being right, feeling good, or being justified instead of doing what is needed or asked in a particular situation. This skills means learning to give in and compromise when it leads to an effective or productive end result.
    72. 72. Effectively Examples:  You really want your significant other to do something special or ordinary for you and you think, he/she should know me well enough to do this. You are hoping it will happen. (this is not effective. If you want something you may need to ask for it or resolve not to be disappointed when your significant other doesn’t read your mind.)
    73. 73. Distress ToleranceThe emphasis is on skills for tolerating painful events and emotions when you cannot make things better right away.
    74. 74. Distress Tolerance Skills Goals Crisis survival strategies Guidelines for accepting reality So as to reduce: Impulsive behaviors Suicide threats Self harm
    75. 75. Distress ToleranceGetting through the moment without making it worse by using:1. Distraction2. Self-soothing3. Improve the moment4. Weigh the Pros and cons
    76. 76. Distress Tolerance: DistractionVisionScentHearingTasteSight
    77. 77. Emotion Vulnerability High sensitivity - Immediate reactions - Low threshold for emotional reaction High reactivity - Extreme reactions - High arousal dysregulates cognitive processing Slow return to baseline - Long lasting reactions - Contributes to high sensitivity to next emotional stimulus
    78. 78. Emotion Regulation Skills Goals Understand emotions you experience Reduce emotional vulnerability Decrease emotional suffering
    79. 79. Emotion Regulation What good are emotions ? Reduce vulnerabilities to negative emotions (proper sleep habits, proper management of physical illness, avoid mood altering drugs, physical exercise) Build positive emotions. Pleasant things
    80. 80. THE PROBLEMe.g., AVOIDANCE OR ESCAPEinterpersonalconflict(abandon, PROBLEM BEHAVIORinvalidation) EMOTION Alcohol & Drugs DYSREGULATION Self-injury CUE Aggression TEMPORARY RELIEF e.g., others back off Reinforcement strengthens this whole process
    81. 81. DBT INTERVENESTeach howto prevent AVOIDANCE OR ESCAPEtriggers X PROBLEM BEHAVIOR EMOTION Teach DYSREGULATION alternative CUE X ways to avoid or Teach how to stop this Regulate or behavior distract tolerate distress X Reduce power TEMPORARY RELIEF of triggers and emotion X vulnerabillity Stop problem Without escape, behavior or emotion dysregulation reinforcement should improve
    82. 82. Focus on Emotion Regulation Reduce emotional reactivity/sensitivity  exercise, and balanced eating and sleep  exposure therapy Reduce intensity of emotion episodes  heavy focus on distraction early on, which is a less destructive form of avoidance
    83. 83. Focus on Emotion Regulation Increase emotional tolerance  Mindfulness  Observe your emotion  Experience your emotions as a wave coming and going  block avoidance Act effectively despite emotional arousal  Remember you are not your emotion: DO not necessarily ACT on emotion.  Opposite action
    84. 84. Skills for Reducing Emotions Distraction  activities with focused attention  self-soothing Intense exercise Relaxation  progressive muscle relaxation  slow diaphragmatic breathing  Biofeedback Temperature  ice cubes in hands  face in ice water (whole body dunk)
    85. 85. Relaxation Training Progressive Muscle Relaxation Slow breathing  breathe from the diaphragm  5-6 breaths per minute (4 sec in, 6 sec out)  exhale longer than inhale
    86. 86. Skills Training for Anger Work on anger collaboratively  motivational interviewing style (no labels)  frame the choice as “right versus effective”  validate what is valid Problem solving  act on anger when it helps reduce a threat Skills training Cognitive restructuring (be careful!) Exposure
    87. 87. Skills Training for Anger Gently avoid (time out)  postpone for a specified amount of time  distraction  pros and cons Relaxation Assertive communication. Empathy and explicit validation (no “should”) Get help for a “reality check”  Ask a friend: “Am I over-reacting?”  What am I failing to understand about other person?  Is it worth the battle/loss (even if I am right)?
    88. 88. Cognitive Restructuring for Anger Empathic interpretations of others  notice “shoulds”  external attributions (current causes)  benefit of the doubt  times client’s intent has been misunderstood  historical causes Ask rather than assume Humor Acceptance and forgiveness
    89. 89. Exposure for Anger Thoroughly assess triggers In vivo exposure  role-play  verbal barbs  homework Imaginal exposure  client can write a script in advance
    90. 90. Responding to Anger in Session Discourage simple venting/catharsis Link behavior to clients goals Refuse to talk about anger-inducing situations when not productive Validate/apologize/repair to the extent that therapist made a mistake. Do not avoid the issues that prompt the anger if they are reasonable to deal with
    91. 91. Acknowledging what is sane, true and valid about a patient’s point of view. Validation must be authentic andgenuine. Validation is not synonymouswith approval, agreement, or sympathy.
    92. 92. Invalidating Environment Pervasively negates or dismisses behavior independent of the actual validity of the behavior
    93. 93. DBT says watch out for Invalidating EnvironmentCommunication that penetrates or reflects to theindividual, that his or her emotional displaysand communication of privateexperience, are incorrect, inaccurate, faultyinappropriate or otherwise invalid.This experience alone is painful and dismisses theperson’s individual interpretations….teaches the personthat others know better NOT you. November 2010
    94. 94. The attitude communicated:“You can pull yourself up by your bootstraps”Belief:Any individual who tries hard enough can make it!“Talking about problems just makes problems worse.”“A child cries on the playground . . . Adult says, “I’ll give you a real reason to 19cry” 02/2003 . November 2010
    95. 95. The DBT Model suggests to focus on skillstraining and behavior change, as well as on the validation of the individual’s current capabilities and behaviors. 02 /20 03 19 November 2010
    96. 96. Validation Validation is:  Finding the kernel of truth or wisdom in the client’s behavior (no matter how bad it is)  Seeing the world from the client’s point of view, and saying so! (Without knowing where our clients are coming from we fail to understand them and therefore fail in providing the best treatment possible.)
    97. 97. Validation Validation does not mean you have to:  Agree with the client  Approve of the client’s behavior, or  Convey warmth
    98. 98. Levels of Validation Listen and pay attention Show you understand  paraphrase what the client said  articulate the non-obvious (mind-reading) Describe how their behaviors/emotions…  make sense given their past experiences  make sense given their thoughts/beliefs/biology  are normal or make sense now Communicate that the client is capable/valid  actively “cheerlead”  don’t treat them like they’re “fragile” or a mental patient
    99. 99. ValidationWhat (“yes, that’s true” “of course”) Emotional pain “makes sense” Task difficulty “It IS hard” Ultimate goals of the client Sense of out-of-control (not choice)How Verbal (explicit) validation Implicit validation  acting as if the client makes sense  responsiveness (taking the client seriously)
    100. 100. Validation Staying Awake: Unbiased listening and observing-Just be quiet and stay focused on the client. Accurate Reflection-saying back to them what they told you, but in different words and without judgment. Verbalizing the unspoken emotions, thoughts or behavior patterns- before you do this you must have a solid relationship with the client.
    101. 101. Validation Validation in terms of past learning or biological dysfunction-what the client has been previously taught or in the context of their mental illness, learning disorders, etc Validation in terms of present context or normative functioning-Understand where they are coming from in terms of what they are going through right now or their stage in life and development Radical Genuineness-Being kind and real at the same time
    102. 102. Functions of Validation Increases client willingness to change Strengthens therapeutic relationship Reinforces staying in therapy Reinforces clinical progress Provides feedback to shape behavior Increases self-validation by modeling validation Increases positive expectancies (believing in client)
    103. 103. Self-ValidationGet the patient to say:“It makes perfect sense that I … because…”  it is normal or make sense now  of my past experiences  of the brain I was born with  of my thoughts/beliefsGet the patient to act as if she makes sense:  non-ashamed, non-angry nonverbal behavior  confident tone of voice
    104. 104. Problem Solving Functional analysis (chain analysis) Solution analysis  accept, tolerate, mindfulness  change, regulate  self vs. environment Anticipate and solve obstacles Skills acquisition (model) Rehearse – “dragging out new behavior” Commitment
    105. 105. Problem SolvingFiguring out what to focus on: Self-injury Therapy-interfering behavior Emotion regulation and skillful behavior  shame and self-invalidation (judgment)  anger and hostility (judgment)  dissociation and avoidance In-session behavior
    106. 106. Understand the ProblemDo detailed behavioral analyses to discover:  environmental trigger  key problem emotions (and thoughts)  what happened right before the start of the urge?  what problem did the behavior solve?and conceptualize the problem (i.e., identify factors that interfere with solving the problem)
    107. 107. Chain Analysis Vulnerability Problem behaviorPrompting event Links Consequences
    108. 108. Chain Analysis Analysis is of chain of events moment to moment over time Examine vulnerabilities, antecedents and consequences of problem behavior Allow for determination of patterns of behaviors Examine options for getting on a different path away from problems behaviors
    109. 109. Chain Analysis1. Pre-existing vulnerabilities: what conditions make client more likely to engage in problem behavior?2. Precipitating event: what external event triggered the problem behavior? Where was the point of no return?3. Links in the chain leading to problem behavior: include bodily sensations, thoughts, feelings, behaviors, eve nts in the environment
    110. 110. Chain Analysis4. Problem behavior occurs: be sure problem is defined in specific behavioral terms5. Consequences: what happened next? Helps to identify reinforcers for problem behavior.
    111. 111. Diary Cards Daily monitor of target symptoms and skills usage Target symptoms include: - self harm urge and action - substance use - suicidal ideation - level of misery Allows individual therapist to target most urgent target symptoms for a session
    112. 112. Understand the ProblemIdentify factors that Interfere with solving the problem Lack of ability for effective behavior Effective behavior is not strong enough Thoughts, emotions, or other stronger behaviors interfere with effective behavior
    113. 113. Behavioral Formulation1. Summarize the story2. Add any insights you have3. Identify which links in the chain are dysfunctional4. Identify reinforcers: what keeps this problem behavior going?5. Identify function: how does this target behavior serve the patient?
    114. 114. Skills for Reducing Behavior Pros/Cons of new behavior Mindfulness of current emotion/urge Postpone behavior for a specific small amount of time (fully commit)  Distract, relax, or self-soothe  Postpone behavior again Do the behavior in slow motion Do the behavior in a very different way Add a negative consequence for behavior
    115. 115. Skills for Increasing BehaviorTo get opposite action: Pros/Cons of new behavior Mindfulness of current emotion/urge Break overwhelming tasks into small pieces and do first step  something always better than nothing Problem solve; Build mastery
    116. 116. Skills Training Procedures Skills acquisition Skills strengthening Skills generalization
    117. 117. Solution Analysis: new alternativebehaviors to replace dysfunctional links1. Brainstorm all possible solutions:2. Remember 4 Solutions to Any Problem: 1. Solve the problem 2. Feel better about the problem 3. Tolerate the problem 4. Be miserable3. Pick a solution to work on
    118. 118. Solution Analysis: new alternativebehaviors to replace dysfunctional links4. Make a commitment to try the solution5. Strengthen the commitment using commitment strategies6. Troubleshoot the solution7. Rehearse the solution
    119. 119. Contingency Management: Requiresno co-operation from the patient 1. Reinforce desired behaviors (surprising how we forget this) 2. Fail to reinforce maladaptive behaviors: extinction 3. Punish maladaptive behaviors: will only suppress behavior
    120. 120. Response to Unacceptable Behaviors1. Describe the problem behavior to the patient2. Patient performs chain analysis on the problem behavior3. Patient reviews chain analysis with therapist for behavioral formulation4. Patient presents chain analysis to community, gets feedback
    121. 121. Response to Unacceptable Behaviors5. Patient and therapist identify damage done by problem behavior6. Correction: make amends for damage done by returning the situation back to baseline7. Overcorrection: the amend actually improves the situation (“makes is better than it was to start with”)8. Correction-overcorrection procedure is strengthened by therapist withholding some goody (warmth) until patient successfully completes the overcorrection (then warmth is restored)
    122. 122. Extinction Procedures1. Orient the patient: explain the procedure and the rationale2. Withdraw reinforcement for the maladaptive behavior3. Validate, soothe, cheerlead
    123. 123. Extinction Procedures4. Remind patient of rationale and his/her prior commitments.5. Find an alternative behavior to reinforce6. DO NOT give in halfway through the extinction procedure: intermittent reinforcement will make the problem behavior very durable
    124. 124. Ultimate Aversive Sanction: Vacation from Therapy1. Describe the problem behavior to the patient2. State that failure to stop this behavior is leading to vacation3. Give patient a chance to escape the vacation (by solving the problem)
    125. 125. Ultimate Aversive Sanction: Vacation from Therapy4. Place patient on vacation.Patient may resume therapy when problem is solved.5. Give appropriate referrals for continuity of care6. Maintain non-demand contact with patient (“pining for his/her return”)
    126. 126. Interpersonal Effectiveness The emphasis is on learning and practicing skills that make relationships with others work better.
    127. 127. Interpersonal Effectiveness Strategies Including the following:  Assertiveness skills  Communication skills  Refusal skills  Conflict resolution skills
    128. 128. Interpersonal Effectiveness “DEAR MAN” Describe: Describe the situation - Stick to the facts Express: Express your feelings about the situation Assert: Assert yourself by asking clearly Reinforce: Reinforce or reward the person ahead of time by explaining consequences
    129. 129. DEAR MAN Mindful: Maintain your focus on your objectives, ignore if other person attacks, threatens or tires to change subject. Appear Confident: Be effective and competent, good eye contact, confident voice Negotiate: Be willing to give to get, offer and ask alternative solutions. Turn the table to other person. “What do you think we should do ?”
    130. 130. Therapy Interfering Behaviors (TIB) arrives late leaves early passive or helpless not do diary card excessively talks (hard for therapist to talk) complains but does not work in session excessively angry excessively judgmental/critical of therapist
    131. 131. DBT Treatment OutcomesDBT has better outcomes than TAU on:• suicidal behavior (self-injury)• psychiatric admissions and ER• treatment retention• angry behavior• global functioningAll treatments show improvement on:• suicide ideation• depressed mood• trait anger
    132. 132. DBT: Outcome Data Controlled clinical trial Levels of self-injury were half that of control group Levels of re-hospitalizations were half that of control group Makes DBT very appealing to medical community and financial supporters
    133. 133. Final WisdomThe world is full of suffering,it is also full of overcoming it. Helen Keller
    134. 134. THANK YOU

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