Linehan, et al., 2001 Dialectical Behavior Therapy: Clinical Outcomes and Essential Characteristics Marsha M. Linehan University of Washington.

Linehan, et al., 2001Linehan, et al., 2001Linehan, et al., 2001Linehan, et al., 2001

Dialectical Behavior Therapy:Dialectical Behavior Therapy:Clinical Outcomes Clinical Outcomes and Essential Characteristics and Essential Characteristics

Marsha M. LinehanMarsha M. LinehanUniversity of WashingtonUniversity of Washington

Dialectical Behavior Therapy:Dialectical Behavior Therapy:Clinical Outcomes Clinical Outcomes and Essential Characteristics and Essential Characteristics

Marsha M. LinehanMarsha M. LinehanUniversity of WashingtonUniversity of Washington

DBT is a DBT is a cognitive-behavioral therapycognitive-behavioral therapydesigned for the designed for the severe and severe and

chronic multi-diagnosticchronic multi-diagnostic, difficult-, difficult-to-treat patientto-treat patient

with both Axis I with both Axis I and Axis IIand Axis II disorders disorders

DBT is a DBT is a cognitive-behavioral therapycognitive-behavioral therapydesigned for the designed for the severe and severe and

chronic multi-diagnosticchronic multi-diagnostic, difficult-, difficult-to-treat patientto-treat patient

with both Axis I with both Axis I and Axis IIand Axis II disorders disorders

Borderline Personality DisorderDisorder (Re-organized)

Borderline Personality DisorderDisorder (Re-organized)

Emotion Dysregulation Affective lability & Problems with angerInterpersonal Dysregulation Chaotic relationships & Fears of abandonmentSelf Dysregulation Identity disturbance/confused sense of self Sense of emptinessBehavioral Dysregulation Parasuicidal behavior & Impulsive behaviorCognitive Dysregulation Dissociative responses &/or paranoid ideation

Emotion Dysregulation Affective lability & Problems with angerInterpersonal Dysregulation Chaotic relationships & Fears of abandonmentSelf Dysregulation Identity disturbance/confused sense of self Sense of emptinessBehavioral Dysregulation Parasuicidal behavior & Impulsive behaviorCognitive Dysregulation Dissociative responses &/or paranoid ideation

Randomized Clinical Trials (Randomized Clinical Trials (6 with BPD)6 with BPD)Randomized Clinical Trials (Randomized Clinical Trials (6 with BPD)6 with BPD)

DBT Superior to Comparison TreatmentsDBT Superior to Comparison Treatments

Reducing:Reducing:• Suicide attemptsSuicide attempts and self-injury and self-injury• Premature Premature drop-outdrop-out• InpatientInpatient/ER admissions and days/ER admissions and days• Drug abuseDrug abuse• Depression, hopelessnessDepression, hopelessness, anger, anger• ImpulsivenessImpulsiveness

Increasing:Increasing:• Global adjustmentGlobal adjustment• Social adjustmentSocial adjustment

(See Lieb, K., Zanarini, M., Linehan, M.M. (See Lieb, K., Zanarini, M., Linehan, M.M. and Bohus, M. Seminar Section: and Bohus, M. Seminar Section: Borderline Personality Disorder. The Borderline Personality Disorder. The Lancet 2004;364:453-61.) Lancet 2004;364:453-61.)

DBT grew out of DBT grew out of an iterative attempt (1971- ) an iterative attempt (1971- )

to apply behavioral principles andto apply behavioral principles andstandard cognitive behavior therapy standard cognitive behavior therapy

to to highly suicidal patients with highly suicidal patients with

Borderline Personality DisorderBorderline Personality Disorder

DBT grew out of DBT grew out of an iterative attempt (1971- ) an iterative attempt (1971- )

to apply behavioral principles andto apply behavioral principles andstandard cognitive behavior therapy standard cognitive behavior therapy

to to highly suicidal patients with highly suicidal patients with

Borderline Personality DisorderBorderline Personality Disorder

Workshop goalsWorkshop goalsWorkshop goalsWorkshop goals

• Learn the essential characteristics Learn the essential characteristics of DBTof DBT

• Assess whether DBT (in whole or Assess whether DBT (in whole or in part) may be useful in your in part) may be useful in your practicepractice

• Decide if you are interested in Decide if you are interested in further training in DBTfurther training in DBT

• Learn the essential characteristics Learn the essential characteristics of DBTof DBT

• Assess whether DBT (in whole or Assess whether DBT (in whole or in part) may be useful in your in part) may be useful in your practicepractice

• Decide if you are interested in Decide if you are interested in further training in DBTfurther training in DBT

Problem 1

Impaired Cognitive ProcessingImpaired Cognitive Processing ++

Intense Effort to ControlIntense Effort to Control

FOCUS ON CHANGEFOCUS ON CHANGE

!!AROUSAL!!!!AROUSAL!!SENSE OF SENSE OF

OUT-OF-CONTROLOUT-OF-CONTROL

The ClientThe ClientThe ClientThe Client

Shut Down, Withdrew, QuitShut Down, Withdrew, Quitoror

Shut Down, Withdrew, QuitShut Down, Withdrew, Quitoror

INVALIDATIONINVALIDATION

OF OF SUFFERINGSUFFERING

The ProblemFurther

FOCUS ON FOCUS ON ACCEPTANCEACCEPTANCE !!AROUSAL!!!!AROUSAL!!

SENSE OFSENSE OF OUT-OF-CONTROLOUT-OF-CONTROL

Solution Was to Apply Solution Was to Apply A Dialectical Approach A Dialectical Approach

BalancingBalancing

Solution Was to Apply Solution Was to Apply A Dialectical Approach A Dialectical Approach

BalancingBalancing

AcceptanceAcceptanceStrategiesStrategies

ChangeChangeStrategies Strategies

Problem 2:Problem 2:Problem 2:Problem 2:

ProblemBehavior 1Problem

Behavior 1ProblemBehavior

2

ProblemBehavior

2ProblemBehavior

i

ProblemBehavior

i

Percent Axis I Diagnoses: BPD Chronically Suicidal PatientsBPD Chronically Suicidal Patients Diagnosis Lifetime Current

Major depression 96.7% 75.0%Dysthymic disorder N/A 14.3%Substance abuse 15.2% 5.4%Substance dependence 56.5% 26.1%PTSD 56.5% 51.1%Social phobia 21.7% 16.3%Panic disorder 52.2% 40.2%OCD 23.9% 19.8%Eating disorder 41.3% 23.9%

Linehan et al., 2004 APA presentationLinehan et al., 2004 APA presentation

Problem 2:Problem 2:Problem 2:Problem 2:

ProblemBehavior 1Problem

Behavior 1ProblemBehavior

2

ProblemBehavior

2ProblemBehavior

i

ProblemBehavior

i

LOW Distress LOW Distress ToleranceTolerance

ProblemBehavior 2Problem

Behavior 2

Problem

Behavior 2

Problem

Behavior 2

Problem Behaviors

4,5….

Correlation between a measure of distress Correlation between a measure of distress tolerance (PASAT) and BPD (BSL)tolerance (PASAT) and BPD (BSL)

Correlation between a measure of distress Correlation between a measure of distress tolerance (PASAT) and BPD (BSL)tolerance (PASAT) and BPD (BSL)

0

60

120

180

240

300

360

420

0 0.5 1 1.5 2 2.5 3

BSL Total Score

PA

SA

T D

ura

tio

n (

se

co

nd

s)

< ½ SD below BPD patient mean

Lejuez, Daughters, Wolf, Kosson, & Lynch.(under review).

Female Inner City Residential Treatment

Seeking Drug Users

Solution Was to Teach Solution Was to Teach Two Sets of New Behaviors Two Sets of New Behaviors

Solution Was to Teach Solution Was to Teach Two Sets of New Behaviors Two Sets of New Behaviors

AcceptanceAcceptanceSkillsSkills

ChangeChangeSkills Skills

Solution Was to Apply Solution Was to Apply A Dialectical Approach A Dialectical Approach

BalancingBalancing

Solution Was to Apply Solution Was to Apply A Dialectical Approach A Dialectical Approach

BalancingBalancing

Acceptance Acceptance ValidationValidation

Change Change Problem SolvingProblem Solving

DialecticsDialectics

Definition of Dialectics:Definition of Dialectics:Definition of Dialectics:Definition of Dialectics:

1““worldview…worldview…

2““debate…establishing truths on both debate…establishing truths on both sides rather than disproving one sides rather than disproving one argument”argument”

Encarta World, English Dictionary, North American EditionEncarta World, English Dictionary, North American Edition

1““worldview…worldview…

2““debate…establishing truths on both debate…establishing truths on both sides rather than disproving one sides rather than disproving one argument”argument”

Encarta World, English Dictionary, North American EditionEncarta World, English Dictionary, North American Edition

Dialectical World ViewDialectical World View Dialectical World ViewDialectical World View

–Holistic, connected, and in relationshipHolistic, connected, and in relationship

–Complex, oppositional, and in polarityComplex, oppositional, and in polarity

–Change is continualChange is continual

–Change is transactionalChange is transactional

–Identity is relational and in continuous Identity is relational and in continuous changechange

–Holistic, connected, and in relationshipHolistic, connected, and in relationship

–Complex, oppositional, and in polarityComplex, oppositional, and in polarity

–Change is continualChange is continual

–Change is transactionalChange is transactional

–Identity is relational and in continuous Identity is relational and in continuous changechange

BPD is a Systemic Emotion BPD is a Systemic Emotion Regulation Disorder Regulation Disorder

BPD is a Systemic Emotion BPD is a Systemic Emotion Regulation Disorder Regulation Disorder

BPD criterion behaviors function to BPD criterion behaviors function to regulate emotions orregulate emotions or

are a natural consequence of are a natural consequence of emotion dysregulationemotion dysregulation

BPD criterion behaviors function to BPD criterion behaviors function to regulate emotions orregulate emotions or

are a natural consequence of are a natural consequence of emotion dysregulationemotion dysregulation

Emotion DysregulationEmotion DysregulationEmotion DysregulationEmotion Dysregulation

Emotional VulnerabilityEmotional Vulnerability

Inability to Modulate EmotionsInability to Modulate Emotions

Emotional VulnerabilityEmotional Vulnerability

Inability to Modulate EmotionsInability to Modulate Emotions

BPD results from BPD results from transactiontransaction of of biological vulnerability with invalidation biological vulnerability with invalidation

over timeover time

BPD results from BPD results from transactiontransaction of of biological vulnerability with invalidation biological vulnerability with invalidation

over timeover time

A1A1 B1B1

A2A2 B2B2

AAii

A1A1 B1B1

A2A2 B2B2

AAii BPDBPD

Invalidating EnvironmentInvalidating EnvironmentInvalidating EnvironmentInvalidating Environment

Invalidates (punishes, ignores) Invalidates (punishes, ignores)

behavior independent of the behavior independent of the

actual validity of the behavioractual validity of the behavior

Invalidates (punishes, ignores) Invalidates (punishes, ignores)

behavior independent of the behavior independent of the

actual validity of the behavioractual validity of the behavior

Characteristics ofCharacteristics ofan Invalidating Environmentan Invalidating Environment

Characteristics ofCharacteristics ofan Invalidating Environmentan Invalidating Environment

1.1. INDISCRIMINATELY REJECTS INDISCRIMINATELY REJECTS communication of private experiences and communication of private experiences and self-generated behaviors self-generated behaviors

2.2. PUNISHES PUNISHES emotional displaysemotional displays andand INTERMITTENTLY REINFORCES INTERMITTENTLY REINFORCES emotional emotional escalationescalation

3.3. OVER-SIMPLIFIES OVER-SIMPLIFIES ease of problem solving ease of problem solving and meeting goalsand meeting goals

1.1. INDISCRIMINATELY REJECTS INDISCRIMINATELY REJECTS communication of private experiences and communication of private experiences and self-generated behaviors self-generated behaviors

2.2. PUNISHES PUNISHES emotional displaysemotional displays andand INTERMITTENTLY REINFORCES INTERMITTENTLY REINFORCES emotional emotional escalationescalation

3.3. OVER-SIMPLIFIES OVER-SIMPLIFIES ease of problem solving ease of problem solving and meeting goalsand meeting goals

STANDARD DBT isSTANDARD DBT is....STANDARD DBT isSTANDARD DBT is....

FLEXIBLEFLEXIBLE

COMPREHENSIVECOMPREHENSIVE

PRINCIPLE-DRIVENPRINCIPLE-DRIVEN

FLEXIBLEFLEXIBLE

COMPREHENSIVECOMPREHENSIVE

PRINCIPLE-DRIVENPRINCIPLE-DRIVEN

Standard DBT ModesStandard DBT ModesStandard DBT ModesStandard DBT Modes

• Outpatient Individual PsychotherapyOutpatient Individual Psychotherapy

• Outpatient Group Skills TrainingOutpatient Group Skills Training

• Telephone ConsultationTelephone Consultation

• Therapists’ Consultation MeetingTherapists’ Consultation Meeting

• Uncontrolled Ancillary TreatmentsUncontrolled Ancillary Treatments

– PharmacotherapyPharmacotherapy

– Acute-InpatientAcute-Inpatient PsychiatricPsychiatric

• Outpatient Individual PsychotherapyOutpatient Individual Psychotherapy

• Outpatient Group Skills TrainingOutpatient Group Skills Training

• Telephone ConsultationTelephone Consultation

• Therapists’ Consultation MeetingTherapists’ Consultation Meeting

• Uncontrolled Ancillary TreatmentsUncontrolled Ancillary Treatments

– PharmacotherapyPharmacotherapy

– Acute-InpatientAcute-Inpatient PsychiatricPsychiatric

5 Functions of All5 Functions of AllComprehensive TreatmentsComprehensive Treatments

5 Functions of All5 Functions of AllComprehensive TreatmentsComprehensive Treatments

1.1. Enhance capabilities Enhance capabilities

2.2. Improve motivationalImprove motivationalfactorsfactors

3.3. Assure generalization to natural Assure generalization to natural environmentenvironment

4.4. Structure the environment Structure the environment

5.5. Enhance therapist capabilities and Enhance therapist capabilities and motivation to treat effectively motivation to treat effectively

1.1. Enhance capabilities Enhance capabilities

2.2. Improve motivationalImprove motivationalfactorsfactors

3.3. Assure generalization to natural Assure generalization to natural environmentenvironment

4.4. Structure the environment Structure the environment

5.5. Enhance therapist capabilities and Enhance therapist capabilities and motivation to treat effectively motivation to treat effectively

Stages of TreatmentStages of TreatmentStages of TreatmentStages of Treatment

Pre-Treatment:Pre-Treatment:

Stage 1: Severe Behavioral DyscontrolStage 1: Severe Behavioral Dyscontrol Behavioral ControlBehavioral Control

Stage 2: Quiet DesperationStage 2: Quiet Desperation Emotional ExperiencingEmotional Experiencing

Stage 3: Problems in LivingStage 3: Problems in Living

Ordinary Happiness /UnhappinessOrdinary Happiness /Unhappiness

Stage 4: IncompletenessStage 4: Incompleteness Capacity for Joy and FreedomCapacity for Joy and Freedom

Pre-Treatment:Pre-Treatment:

Stage 1: Severe Behavioral DyscontrolStage 1: Severe Behavioral Dyscontrol Behavioral ControlBehavioral Control

Stage 2: Quiet DesperationStage 2: Quiet Desperation Emotional ExperiencingEmotional Experiencing

Stage 3: Problems in LivingStage 3: Problems in Living

Ordinary Happiness /UnhappinessOrdinary Happiness /Unhappiness

Stage 4: IncompletenessStage 4: Incompleteness Capacity for Joy and FreedomCapacity for Joy and Freedom

Commitment and Commitment and AgreementAgreement

Commitment and Commitment and AgreementAgreement

• DecreaseDecrease–Life-threatening behaviorsLife-threatening behaviors–Therapy-interfering behaviorsTherapy-interfering behaviors–Quality-of-life interfering behaviorsQuality-of-life interfering behaviors

• IncreaseIncrease behavioral skillsbehavioral skills

MindfulnessMindfulness Distress ToleranceDistress Tolerance Interpersonal EffectivenessInterpersonal Effectiveness EmotionEmotion RegulationRegulation

• DecreaseDecrease–Life-threatening behaviorsLife-threatening behaviors–Therapy-interfering behaviorsTherapy-interfering behaviors–Quality-of-life interfering behaviorsQuality-of-life interfering behaviors

• IncreaseIncrease behavioral skillsbehavioral skills

MindfulnessMindfulness Distress ToleranceDistress Tolerance Interpersonal EffectivenessInterpersonal Effectiveness EmotionEmotion RegulationRegulation

Stage 1 Primary TargetsStage 1 Primary TargetsDialectical SynthesisDialectical Synthesis

Stage 1 Primary TargetsStage 1 Primary TargetsDialectical SynthesisDialectical Synthesis

Pre-Treatment:Pre-Treatment: Commitment & Commitment & AgreementAgreement

Commitment & Commitment & AgreementAgreement

Dialectical SynthesisDialectical Synthesis- the “middle path” -- the “middle path” -

Dialectical SynthesisDialectical Synthesis- the “middle path” -- the “middle path” -

Dialectical AnalysesDialectical Analyses

Truth is sought through efforts to discover what Truth is sought through efforts to discover what is left out of current ways of ordering eventsis left out of current ways of ordering events

Dialectical Lifestyle:Dialectical Lifestyle:Balanced Behavior PatternsBalanced Behavior Patterns

Balanced actionsBalanced actions

Balanced emotionsBalanced emotions Balanced cognitionBalanced cognition

Dialectical AnalysesDialectical Analyses

Truth is sought through efforts to discover what Truth is sought through efforts to discover what is left out of current ways of ordering eventsis left out of current ways of ordering events

Dialectical Lifestyle:Dialectical Lifestyle:Balanced Behavior PatternsBalanced Behavior Patterns

Balanced actionsBalanced actions

Balanced emotionsBalanced emotions Balanced cognitionBalanced cognition

DBT Targets for Skills TrainingDBT Targets for Skills TrainingDBT Targets for Skills TrainingDBT Targets for Skills Training

• Decrease behaviors likely to destroy Decrease behaviors likely to destroy therapytherapy

• IncreaseIncrease skill acquisition/ skill acquisition/ strengthen skillsstrengthen skills

• Decrease treatment interfering Decrease treatment interfering behaviorsbehaviors

• Decrease behaviors likely to destroy Decrease behaviors likely to destroy therapytherapy

• IncreaseIncrease skill acquisition/ skill acquisition/ strengthen skillsstrengthen skills

• Decrease treatment interfering Decrease treatment interfering behaviorsbehaviors

DBT Targets for Phone CallsDBT Targets for Phone CallsDBT Targets for Phone CallsDBT Targets for Phone Calls

• For the Individual TherapistFor the Individual Therapist–DECREASE DECREASE suicide crises behaviorssuicide crises behaviors

– INCREASE INCREASE generalization of DBT generalization of DBT behavioral skillsbehavioral skills

–DECREASE DECREASE sense of conflict, sense of conflict, alienation, distance with therapistalienation, distance with therapist

• For the Individual TherapistFor the Individual Therapist–DECREASE DECREASE suicide crises behaviorssuicide crises behaviors

– INCREASE INCREASE generalization of DBT generalization of DBT behavioral skillsbehavioral skills

–DECREASE DECREASE sense of conflict, sense of conflict, alienation, distance with therapistalienation, distance with therapist

DBT Therapists OBSERVE DBT Therapists OBSERVE Their Own LimitsTheir Own Limits

DBT Therapists OBSERVE DBT Therapists OBSERVE Their Own LimitsTheir Own Limits

Basic Behavioral ParadigmBasic Behavioral ParadigmBasic Behavioral ParadigmBasic Behavioral Paradigm

CueCue

Problem BehaviorProblem Behavior

Consequences

Consequences

Basic DBT ParadigmBasic DBT ParadigmBasic DBT ParadigmBasic DBT Paradigm

CueCue

Emotion Dysregulation

Emotion Dysregulation

Problem BehaviorProblem Behavior

Consequences

Consequences

DBT Problem SolvingDBT Problem SolvingDBT Problem SolvingDBT Problem SolvingBehavioral AnalysisBehavioral Analysis

InsightInsightSolution AnalysisSolution Analysis

DidacticDidacticOrientingOrienting

CommitmentCommitment

Behavioral AnalysisBehavioral AnalysisInsightInsight

Solution AnalysisSolution Analysis

DidacticDidacticOrientingOrienting

CommitmentCommitment

SKILLS TRAININGSKILLS TRAINING

CONTINGENCIESCONTINGENCIES

EXPOSUREEXPOSURE

COGNITIVE MODIFICATIONCOGNITIVE MODIFICATION

SS

TT

AA

NN

DD

AA

RR

DD

CC

BB

TT

11stst Figure out the problem: Figure out the problem:

Conduct a Conduct a Behavioral AnalysisBehavioral Analysis

11stst Figure out the problem: Figure out the problem:

Conduct a Conduct a Behavioral AnalysisBehavioral Analysis

Analyze the chain of events Analyze the chain of events moment-to-moment overtimemoment-to-moment overtimeAnalyze the chain of events Analyze the chain of events moment-to-moment overtimemoment-to-moment overtime

PROMPTINGEVENT

VULNERABILITY PROBLEMBEHAVIOR

CONSEQUENCES

LINKS

22ndnd

Figure out what to do:Figure out what to do:

Generate solutions and Generate solutions and new behaviorsnew behaviors

22ndnd

Figure out what to do:Figure out what to do:

Generate solutions and Generate solutions and new behaviorsnew behaviors

Possible SolutionsPossible SolutionsPossible SolutionsPossible Solutions

1.1. Solve the problemSolve the problem

2.2. Change emotional reaction to the problemChange emotional reaction to the problem

3.3. Radically Accept and Tolerate the Radically Accept and Tolerate the problemproblem

4.4. Stay miserableStay miserable

1.1. Solve the problemSolve the problem

2.2. Change emotional reaction to the problemChange emotional reaction to the problem

3.3. Radically Accept and Tolerate the Radically Accept and Tolerate the problemproblem

4.4. Stay miserableStay miserable

33rdrd Address factors getting in the Address factors getting in the

way of new behaviors:way of new behaviors:

33rdrd Address factors getting in the Address factors getting in the

way of new behaviors:way of new behaviors:

1.1. Apply ContingenciesApply Contingencies

2.2. Teach New Skills Teach New Skills

3.3. Break Maladaptive AssociationsBreak Maladaptive Associations

4.4. Modify Cognitions Modify Cognitions

Consequence Consequence

-Add Reinforcer-Add Reinforcer

-Remove Aversive -Remove Aversive

-Withhold Reinforcer-Withhold Reinforcer

-Maintain Aversive-Maintain Aversive

-Add Aversive-Add Aversive-Remove Positive-Remove Positive

Consequence Consequence

-Add Reinforcer-Add Reinforcer

-Remove Aversive -Remove Aversive

-Withhold Reinforcer-Withhold Reinforcer

-Maintain Aversive-Maintain Aversive

-Add Aversive-Add Aversive-Remove Positive-Remove Positive

Goal Goal

StrengthenStrengthenBehaviorBehavior

WeakenWeakenBehaviorBehavior

SuppressSuppressBehaviorBehavior

Goal Goal

StrengthenStrengthenBehaviorBehavior

WeakenWeakenBehaviorBehavior

SuppressSuppressBehaviorBehavior

Contingency ManagementContingency Management

Contingency Management Contingency Management Changes the Hierarchy of BehaviorChanges the Hierarchy of Behavior

Contingency Management Contingency Management Changes the Hierarchy of BehaviorChanges the Hierarchy of Behavior

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

00.10.20.30.40.50.60.70.80.9

1 highhigh

lowlow

STRENGTH OF BEHAVIORSTRENGTH OF BEHAVIORSTRENGTH OF BEHAVIORSTRENGTH OF BEHAVIOR

Adaptive BehaviorAdaptive Behavior

Maladaptive Behavior

REINFORCE

Punish/Punish/ExtinguishExtinguishPunish/Punish/ExtinguishExtinguish

SKILLS TRAININGSKILLS TRAINING

Mindfulness Mindfulness

Distress Tolerance Interpersonal Distress Tolerance Interpersonal Effectiveness Effectiveness

Emotion RegulationEmotion Regulation

SKILLS TRAININGSKILLS TRAINING

Mindfulness Mindfulness

Distress Tolerance Interpersonal Distress Tolerance Interpersonal Effectiveness Effectiveness

Emotion RegulationEmotion Regulation

44thth

Give needed information:Give needed information:

Do PsychoeducationDo Psychoeducation(DBT Didactic Strategies)(DBT Didactic Strategies)

44thth

Give needed information:Give needed information:

Do PsychoeducationDo Psychoeducation(DBT Didactic Strategies)(DBT Didactic Strategies)

55thth

Explain the rationale: Explain the rationale: Orienting to TreatmentOrienting to Treatment

55thth

Explain the rationale: Explain the rationale: Orienting to TreatmentOrienting to Treatment

• Describe the general taskDescribe the general task

• Link to C’s goals (rationale)Link to C’s goals (rationale)

• Link to specific expectations and Link to specific expectations and

behaviorsbehaviors

• Rehearse new expectationsRehearse new expectations

• Describe the general taskDescribe the general task

• Link to C’s goals (rationale)Link to C’s goals (rationale)

• Link to specific expectations and Link to specific expectations and

behaviorsbehaviors

• Rehearse new expectationsRehearse new expectations

66thth

Get a commitment: Get a commitment:

Strengthen it, get it again, strengthen it, Strengthen it, get it again, strengthen it,

get it again….get it again….

66thth

Get a commitment: Get a commitment:

Strengthen it, get it again, strengthen it, Strengthen it, get it again, strengthen it,

get it again….get it again….

Core StrategyCore StrategyCore StrategyCore Strategy

Validation DefinedValidation Defined"The action of validating or making valid…a

strengthening, reinforcement, confirming; an establishing or ratifying" as valid

SynonymsTo Confirm

To Authenticate

To Corroborate

To Substantiate

To Verify

"The action of validating or making valid…a strengthening, reinforcement, confirming;

an establishing or ratifying" as valid

SynonymsTo Confirm

To Authenticate

To Corroborate

To Substantiate

To Verify

Levels of ValidationLevels of ValidationLevels of ValidationLevels of Validation

1.1. Staying Awake: UnbiasedStaying Awake: Unbiasedlistening and observinglistening and observing

2.2. Accurate reflectionAccurate reflection

3.3. Articulating the unverbalized emotions, Articulating the unverbalized emotions, thoughts, or behavior patternsthoughts, or behavior patterns

4.4. Validation in terms of pastValidation in terms of pastlearning or biological dysfunctionlearning or biological dysfunction

5.5. Validation in terms of present context or Validation in terms of present context or normative functioningnormative functioning

6.6. Radical GenuinenessRadical Genuineness

1.1. Staying Awake: UnbiasedStaying Awake: Unbiasedlistening and observinglistening and observing

2.2. Accurate reflectionAccurate reflection

3.3. Articulating the unverbalized emotions, Articulating the unverbalized emotions, thoughts, or behavior patternsthoughts, or behavior patterns

4.4. Validation in terms of pastValidation in terms of pastlearning or biological dysfunctionlearning or biological dysfunction

5.5. Validation in terms of present context or Validation in terms of present context or normative functioningnormative functioning

6.6. Radical GenuinenessRadical Genuineness

Core StrategyCore StrategyCore StrategyCore Strategy

Acceptance Acceptance

ValidationValidation

Dialectics: Step by StepDialectics: Step by StepDialectics: Step by StepDialectics: Step by Step

Step 1:Step 1: Adopt and model a dialectical Adopt and model a dialectical world view world view

Step 2:Step 2: Balance treatment strategies and Balance treatment strategies and therapeutic positions. therapeutic positions.

Step 3:Step 3: When polarization occurs, work When polarization occurs, work for a synthesis. for a synthesis.

Step 4:Step 4: When one dialectical strategy When one dialectical strategy doesn’t work, try anotherdoesn’t work, try another

Step 1:Step 1: Adopt and model a dialectical Adopt and model a dialectical world view world view

Step 2:Step 2: Balance treatment strategies and Balance treatment strategies and therapeutic positions. therapeutic positions.

Step 3:Step 3: When polarization occurs, work When polarization occurs, work for a synthesis. for a synthesis.

Step 4:Step 4: When one dialectical strategy When one dialectical strategy doesn’t work, try anotherdoesn’t work, try another

1. Model a 1. Model a Dialectical World ViewDialectical World View1. Model a 1. Model a Dialectical World ViewDialectical World View

• Teach biosocial theory of etiology.Teach biosocial theory of etiology.– Development and maintenance of Development and maintenance of

disorder is transactional.disorder is transactional.– Disorder is systemic.Disorder is systemic.

• Search for “what is left out.”Search for “what is left out.”– Disorder occurs when focus is on Disorder occurs when focus is on

part without reference to wholepart without reference to whole..

• Allow natural change.Allow natural change.

• Teach biosocial theory of etiology.Teach biosocial theory of etiology.– Development and maintenance of Development and maintenance of

disorder is transactional.disorder is transactional.– Disorder is systemic.Disorder is systemic.

• Search for “what is left out.”Search for “what is left out.”– Disorder occurs when focus is on Disorder occurs when focus is on

part without reference to wholepart without reference to whole..

• Allow natural change.Allow natural change.

Change AcceptanceChange Acceptance

CoreCore

Problem Solving

Problem Solving

IrreverenceIrreverence

ValidationValidation

Team Consultation

Team Consultation

ReciprocityReciprocity

Environmental Intervention

Environmental Intervention

Consultation-to-the-PatientConsultation-to-the-Patient

2. Balance Treatment Strategies2. Balance Treatment Strategies2. Balance Treatment Strategies2. Balance Treatment Strategies

3. When Polarization Occurs3. When Polarization Occurs3. When Polarization Occurs3. When Polarization Occurs

Search for The SynthesisSearch for The SynthesisSearch for The SynthesisSearch for The Synthesis

Invoke “WISE MIND”Invoke “WISE MIND”

4. When one dialectical strategy 4. When one dialectical strategy doesn’t work, try anotherdoesn’t work, try another

4. When one dialectical strategy 4. When one dialectical strategy doesn’t work, try anotherdoesn’t work, try another

• Magnify the tension between oppositesMagnify the tension between opposites–Devil’s AdvocateDevil’s Advocate

–ExtendingExtending

• Enter the paradoxEnter the paradox–And versus ButAnd versus But

–Making Lemonade out of lemonsMaking Lemonade out of lemons

• Develop MetaphorsDevelop Metaphors–StoriesStories

–AnalogiesAnalogies

• Magnify the tension between oppositesMagnify the tension between opposites–Devil’s AdvocateDevil’s Advocate

–ExtendingExtending

• Enter the paradoxEnter the paradox–And versus ButAnd versus But

–Making Lemonade out of lemonsMaking Lemonade out of lemons

• Develop MetaphorsDevelop Metaphors–StoriesStories

–AnalogiesAnalogies

50.20

In DBT, The Therapist Acting from In DBT, The Therapist Acting from Wise Mind...Wise Mind...In DBT, The Therapist Acting from In DBT, The Therapist Acting from Wise Mind...Wise Mind...

practicespractices• Observing (Observing (Just NoticesJust Notices))

– Describing (Describing (Puts Words OnPuts Words On))

– Participating (Participating (Acts Intuitively from Wise MindActs Intuitively from Wise Mind))

and isand is

– Non-Judgmental (Non-Judgmental (Neither Good nor BadNeither Good nor Bad))– One-Mindful (One-Mindful (In-the-MomentIn-the-Moment))– Effective (Effective (Focus on What WorksFocus on What Works))

practicespractices• Observing (Observing (Just NoticesJust Notices))

– Describing (Describing (Puts Words OnPuts Words On))

– Participating (Participating (Acts Intuitively from Wise MindActs Intuitively from Wise Mind))

and isand is

– Non-Judgmental (Non-Judgmental (Neither Good nor BadNeither Good nor Bad))– One-Mindful (One-Mindful (In-the-MomentIn-the-Moment))– Effective (Effective (Focus on What WorksFocus on What Works))

You canYou can

do do

this!this!

You canYou can

do do

this!this!