Dialectical Behavioral Therapy: Creating a Life Worth Living Presented by Niki Serravalle
What to expect….• The theory – Quick overview• The skills – Few examples• How it relates to us and what we do Cheese face
What is DBT: Dialectical Behavioral Therapy• Developed by Dr. Linehan, Washington University to treat persons with Borderline Personality Disorders. (1991)• A combination of CBT and Eastern meditative practices.
What is the Dialect in DBT?• The term Dialectics refers to opposing forces that create a whole or a synthesis. DBT focuses on finding a balance in opposing forces.
More on DialectsDBT makes three basic assumptions: – (1) all things are interconnected – (2) change is constant and inevitable and – (3) opposites can be integrated to form a closer approximation of the truth. In DBT, the patient and therapist are working to resolve the contradiction between self-acceptance and change Cha Accep nge tance
The theory Individuals are born with a biological predisposition for emotional dysregulation who are then subjected to an invalidating environment where they learn maladaptive behaviors which are reinforced over time.Treatment that specifically designed for persons with BPD and high suicidal behaviors
Symptoms of a person with BDP•Make frantic efforts to avoid real or imagined abandonment.•Have a pattern of difficult relationships caused by alternating betweenextremes of intense admiration and hatred of others.•Have an unstable self-image or be unsure of his or her own identity.•Act impulsively in ways that are self-damaging•Have recurring suicidal thoughts, make repeated suicide attempts, orcause self-injury through mutilation, such as cutting or burning himself orherself.•Have frequent emotional overreactions or intense mood swings, includingfeeling depressed, irritable, or anxious.•Have long-term feelings of emptiness.•Have inappropriate, fierce anger or problems controlling anger. Theperson may often display temper tantrums or get into physical fights.•Have temporary episodes of feeling suspicious of others without reason(paranoia) or losing a sense of reality.
DBT Goals• The focus of DBT is on helping the individual learn and apply skills that will decrease the effects of emotion dysregulation and unhealthful attempts to cope with strong emotions.• Create a life worth living by improving coping skills, interpersonal effectiveness and problem solving.
The hierarchyDBT targets behaviors in a descending hierarchy:• decreasing high-risk suicidal behaviors• decreasing responses or behaviors (by either therapist or patient) that interfere with therapy• decreasing behaviors that interfere with/reduce quality of life• decreasing and dealing with post-traumatic stress responses• enhancing respect for self• acquisition of the behavioral skills taught in group• additional goals set by patient
How DBT Works…• Individual session that improving the client’s motivation to work toward obtaining a life worth living• DBT focuses on group skills training to enhance Mindfulness, Interpersonal Effectiveness and Distress Tolerance and Emotional Regulation.• Telephone consultation is to ensure generalization of skills and effective problem-solving strategies in daily living• The commitment to therapy is imperative to success in treatment. Individual and therapist commit to goals prior to beginning.• A weekly consultation team meeting is held between DBT therapists for the purpose of enhancing each therapist’s own motivation and capability to effectively treat BPD clients
The Contract States…• To accept a dialectical philosophy (at least 1 year of therapy)• The individual will participate in therapy and follow all given directives. Even when they don’t want to. (Irreverence)• The therapist believes that the individual is doing the best they can at all times, that behavior is a result of their past experiences, and there is a willingness to change. (Dialect) – No one can fail at DBT, the treatment fails.
Therapy Interfering Behaviors (TIB)• arrives late• leaves early• passive or helpless• not do diary card (homework)• excessively talks (hard for therapist to talk)• complains but does not work in session• excessively angry• excessively judgmental/critical of therapist
Assumptions….• Clients are doing the best they can• Clients want to improve• Clients needs to do better, try harder and be motivated to change• Clients have not caused their problems, but they are forced to solve them• Their lives are unbearable (suicidal)• Clients must learn new behaviors• Clients can not fail in therapy• Therapists need support (interdisciplinary: staff meetings a MUST)
Core Concepts (skill models)• Mindfulness: Paying attention on purpose• Distress tolerance: Bear pain skillfully• Emotional regulation: Manage emotions instead of being managed by them• Interpersonal effectiveness: All the skills come together in a synergistic way
State of our Mind• Emotional Mind: thoughts are being controlled by our emotions. Unable to be reasonable.• Reasonable Mind: think logically, be rational about what is occurring. No emotions.• Wise Mind: The balance of emotional mind and reasonable mind. Goal of DBT
States of Mind DiagramReasonable Mind Wise Mind Emotional Mind
Mindfulness• Is paying attention on purpose• Being non-judgmental• In the moment, present, in the here and now• Increases awareness of all senses
Research suggestsMindfulness practice will…. – Reduce stress • Lowers blood pressure • Improves circulation – Elevate mood • Brain and immune function improves • Able to recovery from negative faster – Improve Productivity • Feel better, better work
Mindfulness Skills The “What” Skills The “How” Skills• Observe: attending to • Non-judgmentally:emotions/behavior without experiencing the world aroundtrying to end (increases us without judgments; separateawareness) our thoughts and feelings from• Describe: apply verbal labels whats actually going onto behavioral and • Effectively: Use the skills thatenvironmental events you are learning; do what works.(separates emotion from • One-mindfully: sustainedthought) attention on the present•Participate: action with moment; do one thing at a timeattention, not mindlessparticipation
Emotional RegulationEmotions can frequently be very intense and labile, which means they change often.Emotions often drive behavior (problems to be solved). A lot of the behaviorfocuses around finding ways to get those emotions validated or to get rid of the pain.DBT teaches skills to manage these emotions more effectively. In the past theylearned to not feel emotions because they were taught to (smile and be nice evenwhen you feel angry or upset-invalidating environment). These emotions are asecondary response to a primary emotion (feels ashamed because I was angry).
Emotional Regulation Skills1. Identifying and labeling emotions2. Understanding the function of emotions3. Identifying obstacles to changing emotions4. Reducing vulnerability to “emotion mind”5. Increasing positive emotional events6. Increasing mindfulness to current emotions7. Taking opposite action
Emotional Regulation Skills: Identifying and Labeling Emotions1. Prompting event2. Interpretation3. Phenomenological experience: physical sensation of emotion4. Behavior expressing emotion5. After effects of the emotion on other areas of life Event Interpretation Emotion See bff with bf They are talking about me Anger See my car with flat tire Someone did this to me Anger Getting negative points Staff is out to get me Anger See staff laughing They are making fun of me Sadness
Emotional Regulation SkillsReducing vulnerability to “emotional mind”: PLEASE MASTER PLEASE MASTER Treat PhysicaL Illness Take care of your body, see a doctor when needed Balance Eating Don’t eat too much or too little, stay away from foods that make you feel emotional Avoid mood Altering Drugs Non-prescribed drugs and ALCOHOL Balance Sleep Get the amount that makes you feel good Get Exercise Build up to 20 minutes a day Act MASTERy Do one thing at a time to make yourself feel confident and in control
Distress Tolerance• Acceptance of reality is not equivalent to approval of reality.• DBT assumes pain and distress are a part of life; they cannot be entirely avoided or removed. Therefore one has to learn to tolerate and survive. Accept life as it is in the moment.• DBT teaches how to bear pain skillfully.• Distress Tolerance skills address impulsivity in high risk behaviors.
Distress Tolerance Skills• Distracting• Self-soothing• Improving the moment• Thinking of the pros/cons The most important aspect of these skills is the radical acceptance of the dialect…
Distracting…• WISE mind accepts: Activities Contributing (changes focus from self to others, creates a sense of meaning in life, giving back) Comparisons (changes focus from self to others by examining how others cope) Emotions (replace with positive ones) Pushing away (leave situation causing stress, blocking, only used in ER) Thoughts (fill head with thoughts that provide powerful, positive physical reactions) Sensations (hold ice cubes, snap the bands)
Improving the Moment• IMPROVE: Imagery: Imagine relaxing scenes, things going well, or other things that please you Meaning: Find some purpose or meaning in what you are feeling Prayer: Either pray to whomever you worship, or, if not religious, chant a personal mantra, LET GO Relaxation: practice deep breathing, use self soothing One thing in the moment: stay present Vacation: take a brief break, allow yourself to be taken care of Encouragement: cheerlead yourself
Pros/Cons SkillTo get opposite action: Pros/Cons of new behavior:• Pros/Cons of new •Postpone behavior for a specific behavior small amount of time (fully commit)• Mindfulness of current •Distract, relax, or self-soothe emotion/urge •Postpone behavior again• Break overwhelming tasks into small pieces •Do the behavior in slow motion and do first step •Do the behavior in a very different – something always way better than nothing •Add a negative consequence for• Problem solve; Build behavior mastery
Interpersonal EffectivenessThe interpersonal effectiveness module focuses onsituations where the objective is to change something(e.g., requesting that someone do something) or toresist changes someone else is trying to make (e.g.,saying no). The skills taught are intended to maximizethe chances that a person’s goals in a specific situationwill be met, while at the same time not damagingeither the relationship or the person’s self-respect.
Interpersonal Effectiveness SkillsFocuses on developing skills that address problem solving. Theybalance the dialect between maintaining the relationship andmaintaining self respect. Difficult to do with populations thatvacillate between all or nothing (avoidance of conflict and intenseconfrontation).1.Objectives effectiveness- prioritizing achievable objective goals2.Relationship effectiveness- prioritizing a conflict-free relationship3.Self-respect effectiveness- prioritizing acting within your ownprinciples so that you feel comfortable with how you approachedthe situation
Interpersonal Effectiveness Skills The Skills1.Attending toRelationships2.Balancing the Wants-to-Shoulds ratio in Lifeand Relationships3.Building Mastery andSelf Respect
Interpersonal Effectiveness Skills GIVE Skill for maintaining relationshipsGentle: Use appropriate language, no verbal or physical attacks, no put downs,avoid sarcasm unless you are sure the person is alright with it, and be courteousand non-judgmental.Interested: When the person you are speaking to is talking about something, actinterested in what they are saying. Maintain eye contact, ask questions, etc. Do not use yourcell phone while having a conversation with another person!Validate: Show that you understand a person’s situation and sympathize with them.Validation can be shown through words, body language and/or facial expressions.Easy Manner: Be calm and comfortable during conversation, use humor, smile.
Interpersonal Effectiveness DEARMAN - getting somethingThis acronym is used to aid one in getting what he or she wants when asking.Describe your situation.Express why this is an issue and how you feel about it.Assert yourself by asking clearly for what you want.Reinforce your position by offering a positive consequence if you wereto get what you want.Mindful of the situation by focusing on what you want and ignoredistractions.Appear Confident even if you don’t feel confident.Negotiate with a hesitant person and come to a comfortablecompromise on your request.
Interpersonal EffectivenessBalancing priorities with demands:Priorities are those things you want, are important to youDemands are those things other people want, important to themFAST - keeping self-respectThis is a skill to aid one in maintaining his or her self-respect. It is to be used incombination with the other interpersonal effectiveness skills.Fair: Be fair to both yourself and the other person.Apologies: Don’t apologize more than once for what you have done ineffectively,or apologize for something which was not ineffective.Stick to Your Values: Stay true to what you believe in and stand by it. Don’t allowothers to get you to do things against your values.Truthful: Don’t lie. Lying can only pile up and damage relationships and your self-respect.
Skills applied…Problem solving and change strategies areagain balanced dialectically by the use ofvalidation. It is important at every stage toconvey to the individual that their behavior,including thoughts feelings and actions areunderstandable, even though they may bemaladaptive or unhelpful.
Therapist skills• Radical Acceptance• Validation: communicates validation by listening, reflecting, and highlighting the valid or “kernel of truth” in the client’s phenomenal experience• Reciprocal communication: being responsive, warm, and engaged; using self-disclosure; and being genuine.• Irreverent communications aim to get the patient’s attention, shift the response, and help the patient see a different point of view.
PLEASE MASTER becomes SEEDS Grow Emotion regulation handout 10 Keeping control of your emotions SEEDS GROW Sickness needs to be treated You need to take care of yourself and your body. See your doctor and take your medicine Eat right You need to eat good food. Do not eat too much or too little Exercise Do some exercise every day. Stay in shape every day Drugs are Stay away from drugs and alcohol. They make you out of bad control Sleep Get enough sleep at night so you are not tired during the day GROW Do something you are good at every day and try doing every day something new every day