Dialectical Behavior Therapy Paulette Aasen, Ph.D. Director of Psychology Services West Central Human Service Center Bismarck, ND (701) 328-8888 Badlands.

Dialectical Behavior Therapy

Paulette Aasen, Ph.D.

Director of Psychology ServicesWest Central Human Service Center• Bismarck, ND • (701) 328-8888

Badlands Human Service Center• Dickinson, ND• (701) 227-7500

February 10, 2014

Overview of DBTDeveloped by Marsha Linehan, Ph.D., in

1993 as treatment for clients struggling with severe & persistent emotional, behavioral, & thought difficulties, especially those diagnosed with Borderline Personality Disorder.

Dr. Linehan recently shared that she struggles with Borderline Personality Disorder.

The Goal of DBT: “Create a life worth living.”

Foundations of DBTDBT is a synthesis of three paradigms:

◦ Dialectics◦ Behaviorism◦ Mindfulness

Purpose:◦ Reducing dysfunctional behaviors◦ Increasing skillful behaviors◦ Building a life worth living

Client needs validating environment in which s/he is taught to regulate emotions, deal with interpersonal conflicts, tolerate distress, and find balance.

Swenson, Witterholt, & Bohus, 2007

Linehan Diagnosis forBorderline Personality Disorder

Emotion Dysregulation◦ Affective lability◦ Problems with anger

Interpersonal Dysregulation◦ Chaotic relationships◦ Fears of abandonment

Self Dysregulation◦ Identity disturbance – difficulties with sense of self◦ Sense of emptiness

Behavioral Dysregulation◦ Parasuicidal behavior◦ Impulsive behavior

Cognitive Dysregulation◦ Dissociation / paranoid ideation

(Linehan, 1993)

Bio-Social ModelBiological Sensitivity

AND Invalidating Environment = Dsyregulation Disorder Symptoms

Invalidating

Environment

Biology

Invalidating

Environment

Invalidating

Environment

Biology

Biology

Bio-Social Model (cont.)High SensitivityHigh ReactivitySlow Return to BaselineOften “Transactional” with the

Environment

Slow Return to Baseline

Series1

0

1

2

3

4

5

6

7

8

9

AverageDysregulatedThreshold

Em

oti

on

s

Dialectical ParadigmDialectics is the theory that opposites can co-exist.

• Hegel: “Process of change in which a concept or its realization passes over into and is preserved and fulfilled by its opposite.”

• Bohr: “The Universe is so constructed that the opposite of a true statement is a false statement, but the opposite of a profound truth is usually another profound truth.”

Dialectical Paradigm

From DBT Self Help at http://www.dbtselfhelp.com

Dialectics: A Model for Change

Movement Over Time

Thesis

Synthesis

Antithesis

Primary Dialectic in DBT

Acceptance

Change

Dialectical Dilemmas

Unrelenting Crisis

Social

Biological

Emotional Vulnerabili

ty

Apparent Competen

ce

Active Passivity

Self-Invalidation

Inhibited Experienci

ng

Dialectical StrategiesBalance Treatment

StrategiesEnter the paradoxMetaphorDevil’s AdvocateExtendingWise Mind“Lemonade out of lemons”Allowing natural changeDialectical Assessment

Behaviorism Paradigm

From DBT Self Help at http://www.dbtselfhelp.com

Behavior Therapy BasicsBehavioral Principles necessary to be

effective Behavior Therapy: a non-biological

form of therapy that developed from learning theory. The purpose is to change maladaptive patterns of behavior.

Shaping: Divide a behavior to be learned into a series of steps.

DBT: Harm reduction model so shape clients toward that

DBT Assumptions about ClientsClients are doing the best they

can.Clients want to improve.Clients need to do better, try

harder, and be more motivated to change.

Clients may not have caused all of their own problems, AND they need to solve them anyway.

Assumptions about Clients (cont.)

The lives of suicidal individuals with Borderline Personality Disorder are unbearable as they are currently being lived.

Clients must learn new behaviors in all relevant contexts.

Clients cannot fail in DBT.

Assumptions About TherapyThe most caring thing a therapist

can do is help clients change in ways that bring them closer to their own ultimate goals.

Clarity, precision, and compassion are of utmost importance in conducting DBT.

The therapeutic relationship is a real relationship between equals.

Hierarchy of TargetsIndividual Therapy

1. Life threatening behaviors2. Therapy interfering behaviors3. Quality of life interfering behaviors4. Increasing behavioral skills

Client Agreement

Client and Therapist BOTH sign the agreement to acknowledge what it is they are agreeing to in the therapy relationship.

Session StructureReview Diary CardAttention to Target HierarchyChain Analysis on highest

targeted behaviorWeave in Solution AnalysisContinue to move down hierarchy

until able to discuss skills related to current life situations or session time ends

Commitment StrategiesTherapist discusses PRO’s and CON’s

of commitment to changeUse the DEVIL’S ADVOCATE technique

to strengthen commitment and build sense of control

Highlight PRIOR COMMITMENTS consumer has made

Present consumer with CHOICE stressing the freedom to choose while presenting the consequences of choices clearly and directly

Commitment Strategies (cont.)

Therapist uses principles of SHAPING to elicit commitment

Therapist generates hope by CHEERLEADING

Therapist and client agree on HOMEWORK

Validation of ConsumerStay AwakeAccurate ReflectionArticulating unverbalized emotions,

thoughts, and behavior patternsValidation in terms of past learning

or biological dysfunctionValidation in terms of current

context or normative functioningRadical Genuineness

Self-Verification TheoryValidation = Self-VerificationInvalidation of Self-Construct

leads to AROUSAL!!! (Sense of out-of-control)

HIGH AROUSAL + OUT-OF-CONTROL leads to >>>>

Failure to process New Information =

NO NEW LEARNING!

Relationship StrategiesAccept the relationship as it is in

the current moment, use the relationship as therapy – YOU are the Key

Use problem solving on the relationship

Attend directly to generalization of behaviors learned in the relationship

Be honest about limitsBe consistently firmCombine Soothing, Validating, &

Problem Solving with Observing LimitsWarm Engagement:

◦Limits on Warmth◦Coping with anger/rage at the consumer◦Warm engagement and touch in

psychotherapyGenuineness

DBT Skills GroupScreening session1-year commitmentBoth client and therapist sign

agreementAgreement includes statements

regarding homework completion and attendance

Co-facilitators

Hierarchy of TargetsDBT Skills Group

1. Therapy destroying behavior2. Skills acquisition, strengthening,

and generalization3. Therapy interfering behaviors

Zen PracticeBe Mindful to the current momentSee reality as it is without delusionsAccept reality without judgment Focus on one’s own experiencing as

a means of understanding the worldLet go of attachments that obstruct

seeing and accepting reality as it isUse skillful meansFind the middle way

Mindfulness ParadigmMindfulness is at the core of

◦Emotion Regulation (emotions, thoughts, and behaviors).

◦Distress Tolerance (skills used to help us cope and survive during a crisis, distracting or soothing activities).

◦Interpersonal Effectiveness (skills which help us to attend to relationships, balance priorities versus demands, balance the “wants” and the “shoulds,” and build a sense of mastery and self-respect.

From DBT Self Help at http://www.dbtselfhelp.com

Mindfulness“Paying attention on purpose, in the

present moment, and nonjudgmentally to the unfolding of experiences moment by moment.” (Kabat-Zinn, 2003, p. 145).

Non-JudgmentPatienceBeginner’s Mind or Child’s MindTrustNon-StrivingAcceptanceLetting Go

Kabat-Zinn, 1990

5 Stages of Accomplishment

1. Denial

2. Uncertainty

3. Resistance

4. Panic

I can’t do it!

Maybe I can do

it!

There’s no way I can do it!

AAAARGH!What if I can’t do

it?!

5. Acceptance

CONGRATULATIONS!

ALL RIGHT!I DID IT!

LET’S PARTY!

References DBT Self-Help Website http://www.dbtselfhelp.com

Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Delacorte.

Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford.

Miller, A. L., Rathus, J. H., & Linehan, M. I. (2007). Dialectical Behavior Therapy for Suicidal Adolescents. New York: Guilford.

Swenson, C. R., Witterholt, S., & Bohus, M. (2007). Dialectical behavior therapy on inpatient units. In: L. Dimeff & K. Koerner (eds.). Dialectical Behavior Therapy in Clinical Practice. New York: Guilford.

DBT AssociatesChristine Kvidera, MSW, LICW

7362 University Ave. NE, Suite 101

Fridley, Minnesota 55432Phone & Fax: (763) 503-3981www.dbtassociates.comEmail: [email protected]