Top Banner
National Education Alliance for Borderline Personality Disorder www.borderlinepersonalitydisorder.com www.bpdforum.com Special thanks to the National Institute of Mental Health (NIMH) for its conference grant support Dialectical Behavior Therapy Perry D. Hoffman, Ph.D.
163

Perry D. Hoffman, Ph.D. - Borderline Personality Disorder · Marsha Linehan, Ph.D. Developer of Dialectical Behavior Therapy. Marsha Linehan, Ph.D. DBT. 8 Why is DBT So Valued. ...

Jul 18, 2018

ReportDownload

Documents

dinhbao

  • National Education Alliance for Borderline Personality Disorder

    www.borderlinepersonalitydisorder.comwww.bpdforum.com

    Special thanks to the National Institute of Mental Health (NIMH) for its conference grant support

    Dialectical Behavior TherapyPerry D. Hoffman, Ph.D.

    http://www.borderlinepersonalitydisorder.com/

  • Special thanks to Alan E. Fruzzetti, Ph.D. for the contribution of some of his slides.

    Dr. Fruzzetti is the author of The High Conflict Couple

  • What is Dialectical Behavior Therapy

  • 4

    Dialectical Behavior Therapy Dialectical Behavior Therapy (DBT) is a Comprehensive, (DBT) is a Comprehensive,

    MultiMulti--component, component, PrinciplePrinciple--driven Treatmentdriven Treatment

    based on a skills model based on a skills model of treatment.of treatment.

  • Marsha Linehan, Ph.D.

    Developer of Dialectical Behavior Therapy

  • Marsha Linehan, Ph.D.DBT

  • 8

    Why is DBT So ValuedWhy is DBT So Valued

  • DBT: Evidence-Based Treatment

    More than 50 studies More than 14 randomized controlled trials Adults (including elderly) & adolescents Women and men Outpatient, inpatient, day tx., forensics BPD, BPD features, mixed personality disorders Suicide attempts, parasuicidal behaviors Substance abuse, eating disorders, depression,

    dissociation, panic & other anxiety disorders

  • 10

    What Outpatient Studies ShowWhat Outpatient Studies ShowDBT better than comparison treatments:DBT better than comparison treatments: Decreased: Decreased:

    number of selfnumber of self--injuriesinjuries Psychiatric inpatient days, ER visitsPsychiatric inpatient days, ER visits AngerAnger Overall psychological distress & disorders, etc.Overall psychological distress & disorders, etc. Overall costs & efficiencyOverall costs & efficiency

    Increased:Increased: Treatment retention (decreased dropout)Treatment retention (decreased dropout) Social adjustmentSocial adjustment Global adjustmentGlobal adjustment

  • 11

    Cost EfficiencyCost Efficiency More efficient: uses few resourcesMore efficient: uses few resources Clear oneClear one--year cost savingsyear cost savings Several studies suggest DBT costs about Several studies suggest DBT costs about

    50% of treatment as usual50% of treatment as usual Savings comes primarily from lower Savings comes primarily from lower

    inpatient, emergency, and medical inpatient, emergency, and medical utilizationutilization

    Treatment with high Treatment with high utilizersutilizers saves moresaves more Cost savings compounds over timeCost savings compounds over time Has been replicated multiple timesHas been replicated multiple times

  • 12

    Provider Satisfaction!Provider Satisfaction!

    Provider preference: reduced burnout, Provider preference: reduced burnout, more consistent with values more consistent with values

    Therapists report increased satisfaction Therapists report increased satisfaction from prefrom pre-- to postto post--training in DBTtraining in DBT

    Provider satisfaction predicts patient Provider satisfaction predicts patient outcomes, and viceoutcomes, and vice--versaversa

  • 13

    Who Can Benefit from DBT: Who Can Benefit from DBT: Diagnostic IssuesDiagnostic Issues

  • 14

    Emotion Dysregulation DisordersEmotion Dysregulation Disorders

    Borderline Personality DisorderBorderline Personality Disorder Other personality disordersOther personality disorders Many anxiety disordersMany anxiety disorders Many affective disordersMany affective disorders Many substance use, eating disordersMany substance use, eating disorders Multiple other Axis I problemsMultiple other Axis I problems Many interpersonal difficultiesMany interpersonal difficulties

  • Borderline Personality Disorder

  • 16

    BPD is the prototype emotion BPD is the prototype emotion dysregulation disorder.dysregulation disorder.

    Name change considerationName change considerationEmotion Regulation DisorderEmotion Regulation Disorder

  • What do we know about Borderline Personality Disorder?

  • Facts in the General Population ~5 in 100 people

    More common than bipolar disorder

    More common than schizophrenia

    Disproportionately high use of medical resources6% of all medical visits

    10% psychiatric outpatients20% psychiatric inpatient admissions

    High mortality ~ 10% of persons with BPD kill themselvesCongressional Briefing on Borderline Personality Disorder May 8, 2007

  • More Facts

    BPD is linked to biologically- based, emotionally hypersensitive temperament

    Genetic predisposition - it is estimated that 30% to 50% of personality temperament is inherited

    BPD is much more treatable than previously thought

    50% of patients remit by 2 years

  • The Course of Disorder

    Age of onset: adolescence and early adulthood

    Progression of symptoms: ~ 60 to 75% affected show symptom reduction over time, especially with effective treatment

    Prognosis: positive predictors: early detection; effective treatment

    negative predictors: impulsivity (decreases with age); substance abuse; early sustained abuse

    Congressional Briefing on Borderline Personality Disorder May 8, 2007

  • Criteria for BPD

  • DSM-IV Personality Disorders10 in Total

    A. Cluster A (odd/eccentric)1. Paranoid2. Schizoid3. Schizotypal

    B. Cluster B (dramatic/emotional/impulsive)1. Antisocial2. Borderline3. Histrionic4. Narcissistic

    C. Cluster C (anxious/fearful)1. Avoidant2. Dependent3. Obsessive-Compulsive

    D. Personality Disorder Not Otherwise Specified

  • Borderline Personality Disorder (DSM-IV)

    1. Frantic efforts to avoid real or imagined abandonment.

    2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

    3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

    4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).

  • Borderline Personality Disorder (DSM-IV)

    5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

    6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

    7. Chronic feelings of emptiness.

    8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

    9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

  • Acute Symptoms Self-injury, suicide efforts, quasi-psychotic thoughts

    Resolve relatively quickly

    Are the best markers for the disorder

    Are often the main reason for inpatient stays

    Adapted from: Zanarini MC, et al. Am J Psychiatry. 2007;164:929-935.

  • Temperamental Symptoms Angry feelings and acts. distrust and suspiciousness,

    abandonment concerns

    Resolve relatively slowly

    Are not just specific to BPD

    Are associated with ongoing psychosocial impairment

    Adapted from: Zanarini MC, et al. Am J Psychiatry. 2007;164:929-935.

  • In total, there are over 256 ways the disorder can present

  • And, if that is not enough

  • 29

    CoCo--morbidity/Comorbidity/Co--occurring Disordersoccurring Disorders

    DepressionDepression Substance useSubstance use Eating disordersEating disorders Panic disorderPanic disorder PTSDPTSD Social phobiaSocial phobia GADGAD DissociationDissociation Violence & Violence &

    aggressionaggression

    Bipolar disorderBipolar disorder Attention deficit disorderAttention deficit disorder Conduct disorderConduct disorder Oppositional/defiant Oppositional/defiant

    disorderdisorder Other Cluster B disordersOther Cluster B disorders Other Personality Other Personality

    DisordersDisorders

  • ASPDASPD

    AnxietyAnxiety

    BPDBPD

    AVPDAVPDHPDHPD

    NPDNPD

    STPDSTPD

    PTSDPTSDBip-IIMDDMDD

    Borders on Disorders

    Borderline personality disorder rarely stands alone

  • Prevalence of Disorders Commonly Occurring with

    Borderline Personality DisorderIn the General

    Population (1 Yr.) With BPD

    Major Depressive Disorder 10.5% ~ 80%

    Substance use Disorders 6% 64%

    Anxiety/panic Disorders 7% 68%

    PTSD ~ 3% 56%

    Eating Disorders .05% 21-26%

    ADHD 5% 25%

  • Borderline personality disorderis an emotion dysregulation disorder as well

    as having four more dysregulationsfive in total.

  • 33

    Borderline Personality Disorder1. Emotion Dysregulation

    Affective labilityProblems with anger

    2. Interpersonal DysregulationChaotic relationshipsFears of abandonment

    3. Self DysregulationIdentity/difficulties with sense of selfSense of emptiness

    4. Behavioral DysregulationSuicidal and non-suicidal self-injuryImpulsive behavior

    5. Cognitive DysregulationDissociative behavior/transient paranoia

  • 34

    Targets are the Behaviors, Targets are the Behaviors, Skills are the SolutionsSkills are the Solutions

    Emotion Emotion Dysregulation Dysregulation Emotion Regulation SkillsEmotion Regulation Skills

    Behavioral Behavioral Dysregulation Dysregulation Distress Tolerance SkillsDistress Tolerance Skills

    Interpersonal Interpersonal Dysregulation Dysregulation Interpersonal SkillsInterpersonal Skills

    Cognitive & Self Cognitive & Self Dysregulation Dysregulation Mindfulness SkillsMindfulness Skills

  • Genesis of Borderline Personality Disorder

  • 36

    Theory:Theory:BioBio--social or Transactional social or Transactional

    Model for the Model for the DevelopmentDevelopment and and MaintenanceMaintenance of Borderline of Borderline

    Personality (and other Disorders Personality (and other Disorders of Emotion Dysregulation)of Emotion Dysregulation)

  • Biosocial Theory of BPD

    Results in Intense EmotionsResults in Intense Emotions

    Biological Dysfunction in the Biological Dysfunction in the Emotion Regulation SystemEmotion Regulation System

    EnvironmentalEnvironmentalFactorsFactors

  • 38

    Emotion Vulnerability: Emotion Vulnerability: Three Factors:Three Factors:

    1.1. High sensitivityHigh sensitivity High level of discrimination of stimuli with High level of discrimination of stimuli with

    an emotional valencean emotional valence2.2. High reactivityHigh reactivity

    When discriminated, reactions are When discriminated, reactions are extremeextreme

    3.3. Slow return to baselineSlow return to baseline Slow return leaves the individual Slow return leaves the individual

    vulnerable to the next emotional stimulusvulnerable to the next emotional stimulus

  • The Brain

  • Neuroimaging Studies

    Studies consistently show smaller volumes in the amygdala of adult patients with BPD

    Neuroimaging studies revealed dysfunctional brain networks that seem to mediate most of the symptoms of BPD

  • The Environment

  • 43

    Invalidating EnvironmentInvalidating Environment(Invalidating)

    PervasivePervasive communication that validcommunication that validresponses of the individual, responses of the individual, especially private ones (e.g., especially private ones (e.g., emotions, thoughts, wants) are emotions, thoughts, wants) are incorrect, inaccurate, faulty,incorrect, inaccurate, faulty,inappropriate or otherwise invalidinappropriate or otherwise invalid

  • 44

    Invalidating EnvironmentInvalidating Environment

    1. Rejects the thoughts of the person1. Rejects the thoughts of the person2. Punishes emotional displays and 2. Punishes emotional displays and

    intermittently reinforces emotional intermittently reinforces emotional escalationescalation

    3. Oversimplifies ease of problem 3. Oversimplifies ease of problem solving and meeting goalssolving and meeting goals

  • Environmental Influenceon the Maintenance

    of the Disorder

  • 46(Fruzzetti, Shenk, & Hoffman, 2005)

    Low Emotion

    Vulnerability

    Consistent Validating

    Responses

    Modest Heightened Emotional Arousal

    Accurate Expression

    Validating Responses

    Event

    Healthy Transactions and Emotion Regulation

  • 47

    Healthy Emotional Processing Healthy Emotional Processing BumpBump into stimulus into stimulus primary emotional primary emotional

    responseresponse Notice and allow the primary emotionNotice and allow the primary emotion Approach it with interest and selfApproach it with interest and self--validationvalidation Others validate, offer instrumental supportOthers validate, offer instrumental support ProblemProblem--solve the situation, if neededsolve the situation, if needed Arousal goes down (natural course)Arousal goes down (natural course) Go on with life; Go on with life; negativenegative countercounter--

    balanced by balanced by positivepositive BumpBump again, and againagain, and again

  • 48

    What Goes WrongWhat Goes Wrong Too many big negative Too many big negative bumpsbumps (too few +)(too few +)

    Improve job, relationships, living situation, etc.Improve job, relationships, living situation, etc. Avoid situations, ignore reactions (suppress, Avoid situations, ignore reactions (suppress,

    selfself--invalidate)invalidate) Exposure (and response prevention)Exposure (and response prevention)

    Get judgmental about another, or selfGet judgmental about another, or self Jump to secondary emotionJump to secondary emotion Cut off primary emotional arousal processCut off primary emotional arousal process Others invalidate, increase demandsOthers invalidate, increase demands Get stuck in primary or secondary emotionGet stuck in primary or secondary emotion

  • 49(Fruzzetti, Shenk, & Hoffman, 2005)

    Event

    Vulnerability (sensitivity, reactivity,

    etc)

    Pervasive History of Invalidating

    Responses

    Heightened Emotional Arousal*

    Inaccurate Expression

    Invalidating Responses

    Judgments

    Transactional Model for Emotion Dysregulation

  • 50

    Transactional Model: Factors Influence Transactional Model: Factors Influence Each Other (ReciprocalEach Other (Reciprocal))

    Individual Emotion Vulnerability & Dysregulation

    Invalidating Responses

  • 51

    Summary on Severe DistressSummary on Severe Distress

    1.1. Combination of all three:Combination of all three:a)a) SensitivitySensitivityb)b) ReactivityReactivityc)c) Slow return to baseline Slow return to baseline PLUSPLUS

    2.2. Inability to modulate emotions (lack of Inability to modulate emotions (lack of skillful selfskillful self--management)management)PLUSPLUS

    3. Invalidating social/family environment3. Invalidating social/family environment

  • But, there is great hope!

  • 53

    Dialectical Behavior TherapyDialectical Behavior Therapy

  • 54

    Core DialecticCore Dialectic

    Acceptance/ Acceptance/ ValidationValidation

    Change/ Change/ Problem SolvingProblem Solving

    DialecticsDialectics

  • 55

    Comprehensive Treatment:Comprehensive Treatment:Modes and Functions of DBTModes and Functions of DBT

  • Standard DBT Modes

    Individual Psychotherapy

    Group Skills Training

    Telephone Consultation

    Therapists Consultation Meeting

    Ancillary TreatmentsMedicationAcute-inpatient psychiatric admissionFamily psychoeducation

  • 57

    DBT Functions & Modes of Therapy1. INDIVIDUAL THERAPY Improve motivation (Focusing

    on chain analysis of antecedents and consequences of primary targets/solutions).

    2. SKILLS TRAINING (Skills Acquisition) Enhance capabilities

    3. Phone Consultation Assure generalization to natural environment

  • 58

    DBT Functions & Modes of Therapy

    4. CONSULTATION TEAM MEETING Enhance therapist capabilities and motivation to treat effectivelyTherapists, Supervision, Continuing Education, Staff Incentives

    5. STRUCTURE THE ENVIRONMENT to allow progressAdmin. or Treatment Setting, Family & Social Environment

  • Important DBT Tenets

  • Assumptions

  • 61

    Dialectical Assumptions:Dialectical Assumptions:

    There is no one or any absolute truthThere is no one or any absolute truth Everyone is doing the best they canEveryone is doing the best they can Everyone needs to try harderEveryone needs to try harder Interpret things in the most benign way possibleInterpret things in the most benign way possible

  • 62

    Dialectical Assumption: PatientsDialectical Assumption: Patients

    Patients want to improvePatients want to improve Patients must learn and use new behaviors in all Patients must learn and use new behaviors in all

    relevant contextsrelevant contexts Patients cannot fail in DBTPatients cannot fail in DBT Patients may not have caused all of their own Patients may not have caused all of their own

    problems, but they have to solve them anywayproblems, but they have to solve them anyway Patients need to do better, try harder, and/or be Patients need to do better, try harder, and/or be

    more motivated to changemore motivated to change The lives of suicidal, borderline individuals are The lives of suicidal, borderline individuals are

    unbearable as they are currently being livedunbearable as they are currently being lived

  • 63

    Dialectical Assumptions: TherapistDialectical Assumptions: Therapist

    The therapeutic relationship is a real relationship The therapeutic relationship is a real relationship between equal human beingsbetween equal human beings

    Therapists treating borderline patients need supportTherapists treating borderline patients need support DBT therapists can failDBT therapists can fail DBT can fail even when therapists do notDBT can fail even when therapists do not

  • Starting the Treatment

  • 65

    Stages of Treatment,Stages of Treatment,andand

    Treatment Targets by StageTreatment Targets by Stage

  • 66

    Overarching DBT Goals are Not:Overarching DBT Goals are Not:

    Keeping the client aliveKeeping the client alive Keeping the client out of the hospitalKeeping the client out of the hospital Reducing the overall cost of care for the Reducing the overall cost of care for the

    clientclient

  • 67

    Overarching DBT Goal:Overarching DBT Goal:Creating a Life Worth LivingCreating a Life Worth Living

  • 68

    PrePre--Treatment AssessmentTreatment Assessment Inclusion/exclusion criteriaInclusion/exclusion criteria Problem assessment (what stage of treatment: Problem assessment (what stage of treatment:

    primary targets, secondary targetsprimary targets, secondary targets Client expectations, goals and desiresClient expectations, goals and desires Contingencies affecting participationContingencies affecting participation Analysis of problems in previous treatments Analysis of problems in previous treatments

    (failures, dropout, prior therapy(failures, dropout, prior therapy--interfering interfering behaviors, etc.)behaviors, etc.)

    Social/family/work environment factorsSocial/family/work environment factors

  • 69

    Getting Started in PreGetting Started in Pre--TreatmentTreatment

    Do the treatment before starting the treatment Do the treatment before starting the treatment (structure & process)(structure & process)

    Orienting and explicitly committing to:Orienting and explicitly committing to: goalsgoals diary cardsdiary cards treatment target hierarchytreatment target hierarchy

  • Treatment Hierarchies

  • STAGE 1 focuses on suicidal behaviours, therapy intefering behaviors andbehaviors that interfere with the quality of life, together with developing the necessary skills toresolve these problems.

    STAGE 2 deals with post-traumatic stress related problems (PTSD)

    STAGE 3 focuses on self-esteem and individual treatment goals.

    Summary of Stages

  • 72

    Stage 1Stage 1Severe Behavioral Severe Behavioral DyscontrolDyscontrol Behavioral ControlBehavioral Control

    Primary TargetsPrimary Targets Decrease:Decrease:

    LifeLife--threatening behaviors: suicide, selfthreatening behaviors: suicide, self--injury, injury, homicide, aggression/violence, child neglecthomicide, aggression/violence, child neglect

    TherapyTherapy--interfering behaviorsinterfering behaviors QualityQuality--ofof--life interfering behaviorslife interfering behaviors

    Increase Behavioral Skills & SelfIncrease Behavioral Skills & Self--ManagementManagement MindfulnessMindfulness Interpersonal EffectivenessInterpersonal Effectiveness Emotion RegulationEmotion Regulation Distress ToleranceDistress Tolerance

  • 73

    LifeLife--Threatening BehaviorsThreatening Behaviors

    SuicideSuicide--related behaviorsrelated behaviors SelfSelf--injurious behaviorsinjurious behaviors ChangesChanges in suicide ideation and in suicide ideation and

    communication about suicidecommunication about suicide Aggressive and violent behaviorAggressive and violent behavior Child abuse and neglectChild abuse and neglect Other lifeOther life--threatening behaviorsthreatening behaviors

  • 74

    TherapyTherapy--Interfering Behaviors: Patient Interfering Behaviors: Patient

    Behaviors that interfere with therapy processBehaviors that interfere with therapy process Not attending sessions (individual, group, etc.)Not attending sessions (individual, group, etc.) Not collaborating in treatmentNot collaborating in treatment Not complying with agreements (e.g., agreedNot complying with agreements (e.g., agreed--

    upon solutions in chain analysis)upon solutions in chain analysis)

    Behaviors that interfere with other patientsBehaviors that interfere with other patients

    Behaviors that will likely burn out the therapist or Behaviors that will likely burn out the therapist or other team membersother team members Behaviors that push therapistsBehaviors that push therapists limitslimits Behaviors that reduce therapistsBehaviors that reduce therapists motivationmotivation

  • 75

    QualityQuality--ofof--Life Interfering BehaviorsLife Interfering Behaviors

    Severe dysfunctional behaviors that interfere with Severe dysfunctional behaviors that interfere with employment, education, etc.employment, education, etc.

    Health/illness related dysfunctional behaviorsHealth/illness related dysfunctional behaviors Lack of stable housingLack of stable housing Other severe mental health problems (e.g., other Other severe mental health problems (e.g., other

    severe DSM Axis I & IV Disorders) severe DSM Axis I & IV Disorders) High risk sexual behaviorHigh risk sexual behavior Extreme financial problems that interfere with Extreme financial problems that interfere with

    nutrition, safety, or life stabilitynutrition, safety, or life stability Criminal behaviors that increase the risk of Criminal behaviors that increase the risk of

    incarcerationincarceration Extreme dysfunctional interpersonal behaviorsExtreme dysfunctional interpersonal behaviors

  • 76

    Stage 1 GoalsStage 1 Goals

    SafetySafety Elimination of suicidal and selfElimination of suicidal and self--injurious injurious

    behaviors, aggression, other lifebehaviors, aggression, other life--threatening threatening behaviorsbehaviors

    StabilityStability TreatmentTreatment HousingHousing One or more relationshipsOne or more relationships Meaningful daily activities (e.g., working, Meaningful daily activities (e.g., working,

    taking care of family, education)taking care of family, education)

  • 77

    Therapist AgreementsTherapist Agreements

    Maintain confidentialityMaintain confidentiality

    Obtain consultation regularlyObtain consultation regularly

    Make every reasonable effort to conduct Make every reasonable effort to conduct competent and effective therapycompetent and effective therapy

    Obey standard ethical and professional guidelinesObey standard ethical and professional guidelines

    Be available to the patient for weekly therapy Be available to the patient for weekly therapy sessions, phone consultations, and provide sessions, phone consultations, and provide therapy backtherapy back--up as neededup as needed

    Respect the integrity and rights of the patientRespect the integrity and rights of the patient

  • 78

    TherapyTherapy--Interfering Behaviors: TherapistInterfering Behaviors: Therapist

    Some examples:Some examples: Behaviors that unbalance therapy (e.g., Behaviors that unbalance therapy (e.g.,

    too extreme acceptance or change)too extreme acceptance or change) Judgmental behaviorsJudgmental behaviors Not attending to own motivation Not attending to own motivation Providing too little or too much nurturanceProviding too little or too much nurturance Reinforcing dysfunctionReinforcing dysfunction Any disrespectful behaviorAny disrespectful behavior

  • Cornerstones of the Individual Therapy

  • Diary Card

  • Dialectical Behavior Therapy Diary Card

    Week Starting:_______________EMOTIONS: Today I Felt (Use Scale of 0-5)

    MT W TH F S S

    Anger

    Disgust

    Empty (Alone)

    Fear (Tense, Anxious, Panicky)

    Interest

    Love (Joy, Happiness)

    Physically Bad

    Sad (Depressed, Hopeless)

    Shameful/Guilty

    Unreal/Disconnected

  • URGES & BEHAVIORS: Today I Felt An Urge To: (Use A Scale of 0-5*If you Acted on the Urge)

    Target 1 Target 2 Target 3 Personal Targets

    M

    T

    W

    Th

    F

    S

    S

  • DESCRIBE WHAT WAS IMPORTANT TODAY (Especially related to your targets and your use of skills)

    M T W TH F S S

  • 84

    Diary CardDiary CardFunctions:Functions: Keeps targets clear and monitored (daily)Keeps targets clear and monitored (daily) Assessment (interval/episode)Assessment (interval/episode)

    Monitor therapy progress on primary targetsMonitor therapy progress on primary targets Monitor secondary targets, skillful alternativesMonitor secondary targets, skillful alternatives

    Used in session to set agenda (and improves Used in session to set agenda (and improves chain analysis)chain analysis)

    Reminder to practice skills; blocks avoidance Reminder to practice skills; blocks avoidance and escapeand escape

    Facilitates improvement (selfFacilitates improvement (self--monitoring)monitoring)

  • Chain Analysis

  • 86

    Behavioral Chain AnalysisBehavioral Chain Analysis

    PROMPTINGEVENT

    VULNERABILITIES

    PRIMARY TARGET (PROBLEM BEHAVIOR)

    REINFORCINGCONSEQUENCES

  • 87

    Chain Analysis Steps in DetailChain Analysis Steps in Detail1.1. Identify primary target (including diary card)Identify primary target (including diary card)2.2. Identify secondary (treatable) targets and Identify secondary (treatable) targets and

    understand determinants of behaviorunderstand determinants of behavior3.3. Focus on emotion, discriminating between Focus on emotion, discriminating between

    primary and secondary emotionsprimary and secondary emotions4.4. Identify acceptance & change solutionsIdentify acceptance & change solutions5.5. Use behavior therapy strategies to incorporate Use behavior therapy strategies to incorporate

    solutions collaborativelysolutions collaboratively6.6. Employ teaching, orienting, validating Employ teaching, orienting, validating

    strategiesstrategies7.7. Get commitment to new Get commitment to new behavior(sbehavior(s))

  • 88

    Example: Chain Analysis of CuttingExample: Chain Analysis of Cutting

    TRIGGER:INVALIDATION

    VULNERABILITIES: LONELY, TIRED, REACTIVE

    CUTTING, Thursday at 4:30

    RELIEF

    PRIMARY EMOTION: SADNESS

    JUDGMENTS or SELF-INVALIDATION IM WORTHLESS

    SECONDARY EMOTION:

    SHAME

  • 89

    Behavioral Chain Analysis: Changing Behavioral Chain Analysis: Changing Behavior & Breaking the Old PatternBehavior & Breaking the Old Pattern

    PROMPTINGEVENT

    VULNERABILITIESPROBLEMBEHAVIOR

    CONSEQUENCES

    SKILLFULBEHAVIORS

    REINFORCING

  • 90

    Example: SolutionsExample: Solutions

    PROMPTINGEVENT

    VULNERABILITIESPROBLEMBEHAVIOR

    OBSERVE & DESCRIBE

    RELIEF

    ALLOW PRIMARY EMOTION

    SELF-VALIDATE

    SOOTHE ACTIVATE

  • 91

    Treatment Targets: Treatment Targets: Links on the ChainLinks on the Chain

    Situational linksSituational links specific to the present chain onlyspecific to the present chain only lower lower generalizabilitygeneralizability prioritize only when this chain is common, prioritize only when this chain is common,

    lethal, highest order target and easier to treat lethal, highest order target and easier to treat than a more common linkthan a more common link

    Common linksCommon links links that show up on multiple chains (same links that show up on multiple chains (same

    primary target or others)primary target or others) higher higher generalizabilitygeneralizability

  • 92

    Stage 2 Stage 2 Quiet Desperation, Quiet Desperation, Emotional ExperiencingEmotional Experiencing

    Misery, andMisery, and Validating Validating EnvironmentEnvironment

    Truncated EmotionsTruncated Emotions SelfSelf--ValidationValidationPrimary TargetsPrimary Targets Decrease PTSDDecrease PTSD--related problemsrelated problems Decrease general avoidance of emotion cuesDecrease general avoidance of emotion cues Decrease secondary emotional reactions Decrease secondary emotional reactions Decrease selfDecrease self--invalidationinvalidation Decrease relationship conflictDecrease relationship conflict

    GoalsGoals Increased emotional identification, Increased emotional identification,

    experiencing, and expression; selfexperiencing, and expression; self--validationvalidation Connection to family Connection to family member(smember(s) & others) & others More validating social/family environmentMore validating social/family environment

  • 93

    Stage 3Stage 3Problems in LivingProblems in Living & Individual Well& Individual Well--BeingBeing

    DissatisfactionDissatisfaction Relationship SatisfactionRelationship SatisfactionMutual EnhancementMutual Enhancement

    Primary TargetsPrimary Targets Increased self respectIncreased self respect Solving problems in living/Solving problems in living/ Modifying dysfunctional interaction patternsModifying dysfunctional interaction patterns

    GoalsGoals Self Respect Self Respect Self EfficacySelf Efficacy Problem solving/problem management skillsProblem solving/problem management skills Connection with own valuesConnection with own values Acceptable quality of lifeAcceptable quality of life

  • 94

    Stage 4 Stage 4

    IncompletenessIncompleteness ContentmentContentment& Intimacy& Intimacy

    Goals:Goals:Enhanced self awarenessEnhanced self awarenessEnhanced mindful engagement in livingEnhanced mindful engagement in livingAcceptance & closeness of self and Acceptance & closeness of self and othersothers

    Behavioral toleranceBehavioral tolerance Relational mindfulnessRelational mindfulness WillingnessWillingness

    Synthesis of intimacy & autonomySynthesis of intimacy & autonomy

  • 95

    Understanding EmotionsUnderstanding Emotions

    Emotion Regulation Disorder

  • 96

    Primary and Secondary EmotionsPrimary and Secondary Emotions

    Primary emotions: initial response, Primary emotions: initial response, normative, typically adaptive, effectivenormative, typically adaptive, effective

    Secondary emotions: emotional response Secondary emotions: emotional response to primary emotion itself; through overto primary emotion itself; through over--learning, secondary emotional responses learning, secondary emotional responses may even become a problematic initial may even become a problematic initial emotional responseemotional response

    Goal or strategy: treat primary emotions; Goal or strategy: treat primary emotions; ignore/extinguish/refocus away from ignore/extinguish/refocus away from secondary emotionssecondary emotions

  • 97

    Secondary Emotional ReactionsSecondary Emotional Reactions

    SadnessSadnessFearFearGuiltGuiltJealouslyJealouslyShameShameFrustrationFrustration

    Anger Anger or or ShameShame

    Mediated by Mediated by judgmentsjudgments

    JudgmentJudgment

  • 98

    Example: AngerExample: Anger

    Anger as a primary emotionAnger as a primary emotion normative, justifiednormative, justified

    VERSUSVERSUS Anger as a secondary emotionAnger as a secondary emotion

    nonnon--normative or unjustified (or destructive)normative or unjustified (or destructive) escape response from a different (primary) escape response from a different (primary)

    emotionemotion

  • 99

    Example: ShameExample: Shame

    Shame as a primary emotionShame as a primary emotion normative, justifiednormative, justified

    VERSUSVERSUS Shame as a secondary emotionShame as a secondary emotion

    nonnon--normative or unjustified (or destructive)normative or unjustified (or destructive) escape response from a different (primary) escape response from a different (primary)

    emotionemotion

  • 100

    Change Negative EmotionsChange Negative Emotions

    Use anger or shame as a Use anger or shame as a signalsignal for missing for missing a primary emotion (selfa primary emotion (self--invalidation)invalidation)

    Identify the primary emotion (from the Identify the primary emotion (from the antecedent chain)antecedent chain)

    TreatTreat the primary emotion (e.g., the primary emotion (e.g., identification, labeling, selfidentification, labeling, self--validation, validation, description, acceptance or change skills)description, acceptance or change skills)

    Acknowledge the secondary emotion, then Acknowledge the secondary emotion, then ignore itignore itfocusing instead on the primaryfocusing instead on the primary

  • 101

    Change Strategies: Change Strategies: Behavior TherapyBehavior Therapy

  • 102

    Skills Training is Necessary Skills Training is Necessary When the Solution is Not in When the Solution is Not in

    the Patientthe Patients Repertoires Repertoire

  • 103

    Skills as Solutions: Use Behavior Therapy Skills as Solutions: Use Behavior Therapy To Implement SolutionsTo Implement Solutions

    PROMPTINGEVENT

    VULNERABILITIESPROBLEMBEHAVIOR

    OBSERVE & DESCRIBE

    RELIEF

    ALLOW PRIMARY EMOTION

    SELF-VALIDATE

    SOOTHE ACTIVATE

  • Skill TrainingSkill Training

  • Goals of Skills Training

    To learn and practice adaptive emotion regulation skills to replace maladaptive behaviors*

    * Note use of word maladaptive and not ineffective

  • 106

    Skill TrainingSkill Training

    Traditional Individual Skill Modules:Traditional Individual Skill Modules: MindfulnessMindfulness Distress ToleranceDistress Tolerance Emotion RegulationEmotion Regulation Interpersonal EffectivenessInterpersonal Effectiveness

    Format:Format: Homework Review (Skill strengthening, Homework Review (Skill strengthening,

    Generalization)Generalization) New Skill EducationNew Skill Education

  • Skill Acquisition Skill Application Skill Generalization

  • 108

    Skill Generalization in DBTSkill Generalization in DBT Transfer new skills to the relevant life situationTransfer new skills to the relevant life situation

    Generalization planning & homeworkGeneralization planning & homework Rehearsal Rehearsal Phone consultation (therapist or other)Phone consultation (therapist or other)

    Manage crises effectively without escalation Manage crises effectively without escalation (or external intervention)(or external intervention) Use skills, shaping toward goalsUse skills, shaping toward goals Continuity with individual DBT therapistContinuity with individual DBT therapist May be individual DBT therapist or other (e.g., May be individual DBT therapist or other (e.g.,

    crisis team)crisis team)

  • 109

    Skill OverviewsSkill Overviews

  • 110

    Core Mindfulness SkillsCore Mindfulness SkillsWise MindWise Mind

    WhatWhat Skills (any one at a time)Skills (any one at a time) Observe (just notice)Observe (just notice) Describe (put words on what you notice)Describe (put words on what you notice) Participate (act from wise mind; stop evaluating)Participate (act from wise mind; stop evaluating)

    HowHow Skills (all three simultaneously)Skills (all three simultaneously) NonNon--Judgmentally (neither good nor bad)Judgmentally (neither good nor bad) OneOne--Mindfully (inMindfully (in--thethe--presentpresent--moment)moment) Effectively (focus on what works visEffectively (focus on what works vis----vis long vis long

    term goals)term goals)

  • 111

    Distress Tolerance SkillsDistress Tolerance Skills

    Crisis survival strategies: tolerate Crisis survival strategies: tolerate distress because the alternative will distress because the alternative will make the situation worsemake the situation worse

    -- DistractDistract-- SelfSelf--soothesoothe-- Improve the momentImprove the moment-- Pros and consPros and cons

  • 112

    Distress Tolerance, contDistress Tolerance, cont

    Guidelines for accepting realityGuidelines for accepting reality Observing your breathObserving your breath HalfHalf--smilingsmiling AwarenessAwareness Radical acceptanceRadical acceptance

    Turning the mindTurning the mind WillingnessWillingness

  • 113

    Emotion Regulation SkilEmotion Regulation Skillsls

    Understand emotionsUnderstand emotions Reduce emotional vulnerabilityReduce emotional vulnerability Decrease emotional sufferingDecrease emotional suffering Change by acting opposite to painful Change by acting opposite to painful

    emotionsemotions

  • 114

    Dialectics of Dialectics of Interpersonal EffectivenessInterpersonal Effectiveness

    Understanding your goalsUnderstanding your goals Structuring the interactionsStructuring the interactions

  • Samples of DBT Skills

  • Core Mindfulness SkillsTaking Hold of Your Mind

  • Core Mindfulness Skills

    What Skills: How Skills:

    Observe Non-judgmentally

    Describe One-mindfully

    Participate Effectively

  • Core Mindfulness SkillsWhat Skills:

    Observe: Just notice the experience. Have a teflon mind. Watch your thoughts come and goDescribe: Put words on the experience. Describe to yourself what is happeningParticipate: To become one with your experience completelyletting yourself enter the moment

  • Core Mindfulness SkillsHow Skills:

    Non-judgmentally: See but dont evaluate. Accept each moment. Just the facts. Dont judge your judgingOne-mindfully: Do one thing at a time. Concentrate yourmindEffectively: Focus on what works. Act skillfully

  • Interpersonal Effectiveness

  • Priorities for Interpersonal Effectiveness

    Objectives Effectiveness Getting your objectives or goals in a situation

    Relationship Effectiveness Getting or keeping a good relationship while

    achieving your objectives

    Self-Respect Effectiveness Keeping or improving self-respect and liking

    for yourself while achieving your objectives

  • DEAR MAND= Describe the current situation

    E= Express your feelings and opinions

    A= Asset yourself by asking for what you want

    R= Reinforce or reward the person

    M= (stay) Mindful. Keep your focus on your objective

    A= Appear confident and effective

    N= Negotiate. Be willing to give to get. Offer/ask for

    alternative solutions

  • Distress Tolerance Skills

    Guidelines for Accepting Reality

    Willfulness vs Willingness

    Opposite Action

  • Radical Acceptance Freedom from suffering requires ACCEPTANCE

    from deep within of what is. Letting yourself go completely with what is. Let go of fighting reality.

    Pain creates suffering only when you refuse to ACCEPT the pain.

    Deciding to tolerate the moment is ACCEPTANCE

    ACCEPTANCE is acknowledging what is

    To ACCEPT something is not the same as judging it good

  • Willingness vs Willfulness

    Willingness Cultivate a WILLING response to each situation. Willingness is doing just what is needed in each situation. It is focusing on effectiveness

    Willfulness is Sitting on your hands when action is needed refusing to make changes that are neededWillfulness is giving up

  • Emotion Regulation

  • Goals of Emotion Regulation Skills

    Understand emotions you experience

    Reduce emotional vulnerability

    Decrease emotional suffering

  • Components of Emotions

    Face and body language

    Expression with words

    Brain change(neurochemical)

    Physical changes

    Action urges

    PromptingEvent 1

    Prompting Event 2

    Interpretation

    Aftereffects Emotion name

  • Changing Emotions by Acting Oppositeto the Current Emotion

    Fear: Do what are afraid of over and over. Approach events, places, tasks people you are afraid of

    Guilt: Repair the problem. Make things better. Commit to avoiding the mistake in the future

    Sadness: Get active, approach dont avoid

    Anger: Gently avoid the person you are angry with rather than attacking. Do something nice rather than mean or attacking.

  • Telephone Coaching

  • Skills Coaching Recognizes that problems most often occur out

    of the individual therapy session.

    Is used NOT as a therapy session, but as a way to provide coaching through a difficult moment.

    Skills coach can be but need not be the individual therapist.

    Skills are generalized to real life situations.

  • 132

    Telephone Strategies to Aid Telephone Strategies to Aid GeneralizationGeneralization

    Accepting patientAccepting patient--initiated phone calls for initiated phone calls for crises, problems, or relationship repaircrises, problems, or relationship repair Phone calls and suicidal behavior: Phone calls and suicidal behavior:

    the the 2424--HourHour rulerule

    Types of callsTypes of calls Problem solving (skill generalization, in crisis Problem solving (skill generalization, in crisis

    situation or other generalization situation)situation or other generalization situation) Checking in (using therapist as a stimulus)Checking in (using therapist as a stimulus) Repairing the relationship Repairing the relationship

    TherapistTherapist--initiated phone callsinitiated phone calls

  • 133

    Targets for Telephone CallsTargets for Telephone CallsWith primary DBT therapistWith primary DBT therapist Increase generalization of skills (coaching)Increase generalization of skills (coaching) Decrease crisis behavior (also generalization)Decrease crisis behavior (also generalization) Maintain/improve relationshipMaintain/improve relationshipWith skills trainer:With skills trainer: Decrease therapy interfering/destroying Decrease therapy interfering/destroying

    behavior, by coaching skills and validatingbehavior, by coaching skills and validating Refer client back to primary therapistRefer client back to primary therapist

  • 134

    DBT StrategiesDBT Strategies

  • 135

    Acceptance and ValidationAcceptance and Validation

  • 136

    What is Acceptance? Validation?What is Acceptance? Validation? AcceptanceAcceptance is is notnot putting energy into putting energy into

    changing the person/her experience per sechanging the person/her experience per se Instead:Instead:

    TolerateTolerate Appreciate context Appreciate context UnderstandUnderstand Participate or allow the experienceParticipate or allow the experience

    ValidationValidation is the communication of is the communication of acceptance, understanding, or legitimacy, of acceptance, understanding, or legitimacy, of the person or his/her behavior & experiencethe person or his/her behavior & experience

  • 137

    Validation: Roles of TherapistValidation: Roles of Therapist As a stimulus for improvementAs a stimulus for improvement To balance change strategies (dialectically)To balance change strategies (dialectically) Reinforce progress (shaping, skillfulness)Reinforce progress (shaping, skillfulness) PotentiatePotentiate skill useskill use Strengthen selfStrengthen self--validationvalidation Keep session moving/prevent getting stuckKeep session moving/prevent getting stuck Communicate acceptance and strengthen Communicate acceptance and strengthen

    the therapeutic relationshipthe therapeutic relationship Bring arousal downBring arousal down

  • 138

    Levels or Types of Verbal ValidationLevels or Types of Verbal Validation1.1. Staying Awake: unbiased listening andStaying Awake: unbiased listening and

    observing, paying attentionobserving, paying attention2.2. Accurate reflection (verbal & nonAccurate reflection (verbal & non--verbal)verbal)

    3.3. Articulating the patientArticulating the patients s unverbalizedunverbalized emotions, emotions, thoughts, or behavior patternsthoughts, or behavior patterns

    4.4. Validation in terms of previous learning or Validation in terms of previous learning or biological dysfunctionbiological dysfunction

    5.5. Validation in the present context: normative Validation in the present context: normative (and normalizing)(and normalizing)

    6.6. Radical Genuineness: patient is not fragile,Radical Genuineness: patient is not fragile,but is an equal human beingbut is an equal human being

  • 139

    Applications of Validation in DBTApplications of Validation in DBT

    Therapist validation of patientTherapist validation of patient Therapist selfTherapist self--validationvalidation Teaching patient validation of othersTeaching patient validation of others

    interpersonal skillsinterpersonal skills Teaching patient selfTeaching patient self--validationvalidation

  • 140

    Observing LimitsObserving Limits GenuinenessGenuineness Dialectically balancing therapist and patient Dialectically balancing therapist and patient

    benefitsbenefits sometimes must stretch limitssometimes must stretch limits sometimes must tighten limitssometimes must tighten limits

    With consultationWith consultation Deal with limits in session Deal with limits in session

    provide rationale (dialectical validation)provide rationale (dialectical validation) provide soothingprovide soothing

  • 141

    DBT Consultation TeamDBT Consultation Team

  • 142

    DBT: Community of DBT: Community of Therapists Treating a Therapists Treating a

    Community of PatientsCommunity of Patients

  • 143

    Therapist NonTherapist Non--Judgmental Stance: Judgmental Stance: Requires mindfulness and Requires mindfulness and emotion regulation, emotion regulation, plusplus

    team consultation & supportteam consultation & support

  • 144

    Consultation TeamConsultation Team A permanent function of DBTA permanent function of DBT

    DBT is a team treatment, delivered as a programDBT is a team treatment, delivered as a program Acceptance and change of the therapist, teamAcceptance and change of the therapist, team

    Multiple perspectives availableMultiple perspectives available Opposition is valued, not avoided (no Opposition is valued, not avoided (no rightright)) Synthesis is desirableSynthesis is desirable Support and validation are essentialSupport and validation are essential Enhancing treatment skills to help maintain Enhancing treatment skills to help maintain

    motivation, staying freshmotivation, staying fresh

  • 145

    Consultation TeamConsultation Team

    How to Promote anHow to Promote anEffective Consultation TeamEffective Consultation Team

  • 146

    1. DBT Consultation Agreements1. DBT Consultation Agreements To accept a dialectical philosophy To accept a dialectical philosophy To consult with the patient on how to interact with To consult with the patient on how to interact with

    other therapists and not to tell other therapists how other therapists and not to tell other therapists how to interact with patient to interact with patient

    That consistency of therapists with one another That consistency of therapists with one another (even across the same patient) is not necessarily (even across the same patient) is not necessarily expectedexpected

    That all therapists are to observe their own limits That all therapists are to observe their own limits without fear of judgmental reactions from other without fear of judgmental reactions from other consultation group members consultation group members

    To search for nonTo search for non--pejorative, phenomenological pejorative, phenomenological empathic interpretation of patientempathic interpretation of patients behavior s behavior

    That all therapists are fallibleThat all therapists are fallible

  • 147

    2. Leadership2. Leadership

    Essential to have leadershipEssential to have leadership Fixed leadershipFixed leadership Rotating leadershipRotating leadership Shared leadershipShared leadership Targets: Targets:

    program coordinationprogram coordination keep team on task, focused, engaging in keep team on task, focused, engaging in

    targets, dialecticaltargets, dialectical

  • 148

    3. Structure3. Structure Formal Formal

    AgendaAgenda Rotating mindfulness exercise/practiceRotating mindfulness exercise/practice Leadership (fixed or rotating)Leadership (fixed or rotating) Limit administrative time/discussion (except Limit administrative time/discussion (except

    during program development)during program development) Schedule for case consultation (supervision?)Schedule for case consultation (supervision?) Formal or informal adherence ratingsFormal or informal adherence ratings Therapists have explicit targets (e.g., diary Therapists have explicit targets (e.g., diary

    cards for own targets)cards for own targets)

  • 149

    Structure, continueStructure, continuedd Formal, continuedFormal, continued

    MembersMembers roles defined (change over time)roles defined (change over time) Group off task/deviating from agendaGroup off task/deviating from agenda Dialectical breakdownDialectical breakdown

    Acceptance/validation vs. change/problem Acceptance/validation vs. change/problem solvingsolving

    Focus on being right instead of effectiveFocus on being right instead of effective Monitoring judgmentsMonitoring judgments Breach in consultation team agreementsBreach in consultation team agreements Breakdown in focus (unmindful behavior)Breakdown in focus (unmindful behavior) Treating team member in nonTreating team member in non--V6 mannerV6 manner PrePre--mature solutionsmature solutions

  • 150

    4. Process4. Process

    MindfulnessMindfulness Radical acceptance of situation, each other Radical acceptance of situation, each other

    as team membersas team members Ongoing V6 (team members not fragile) Ongoing V6 (team members not fragile)

    interaction processinteraction process Honesty (with grace & skill)Honesty (with grace & skill) Acceptance Acceptance What is a What is a riskrisk? Define it carefully.? Define it carefully.

    Disclosure/validation reciprocity: create a Disclosure/validation reciprocity: create a validating team environmentvalidating team environment

  • 151

    Sample AgendaSample Agenda Mindfulness practiceMindfulness practice Set meeting agendaSet meeting agenda Crisis management/skill generalization & supportCrisis management/skill generalization & support Skill group update, supervisionSkill group update, supervision Burnout monitoring Burnout monitoring Targeted individual supervision with video/audioTargeted individual supervision with video/audio Targeted supervision with verbal updateTargeted supervision with verbal update Short, descriptive updates (minimal feedback)Short, descriptive updates (minimal feedback) InIn--depth case conceptualizationdepth case conceptualization Transitions: accept new patient, change stage, Transitions: accept new patient, change stage,

    termination, droptermination, drop--outout Administrative issues (announcements)Administrative issues (announcements)

  • 152

    Important to Note:Important to Note:

    Implicit is the clear agreement that all Implicit is the clear agreement that all members of the DBT team agree to members of the DBT team agree to practice DBT, not some other treatment, practice DBT, not some other treatment, even if another treatment is easier, is even if another treatment is easier, is more in the repertoire of one or more more in the repertoire of one or more individuals, everyone is hopeless, or individuals, everyone is hopeless, or another approach seems like a good idea another approach seems like a good idea for any reasonfor any reason

  • The Environment

  • 154

    Balance Consultation Strategy With Balance Consultation Strategy With Intervening in the EnvironmentIntervening in the Environment

    Consultation with the Patient:Consultation with the Patient: Teach the patient to be effective on Teach the patient to be effective on

    his/her own behalf withhis/her own behalf with Social networkSocial network Professional networkProfessional network

    Environmental Intervention:Environmental Intervention: Intervene on her/his behalf when the Intervene on her/his behalf when the

    shortshort--term gain is greater than the shortterm gain is greater than the short--term + longterm + long--term lossterm loss

  • 155

    Environmental InterventionEnvironmental Intervention

    Necessary when:Necessary when: The patient cannot do what is needed on The patient cannot do what is needed on

    her/his own behalf (or the environment will her/his own behalf (or the environment will not accept it from the patient) and the not accept it from the patient) and the outcome is very importantoutcome is very important

    The life of the patient or another is at stakeThe life of the patient or another is at stake The patient is a minor (legal/ethical)The patient is a minor (legal/ethical) It is humane to do so and unlikely to cause It is humane to do so and unlikely to cause

    harm to the patientharm to the patient

  • 156

    Helpful StrategiesHelpful Strategies Orient the professional network to DBT in Orient the professional network to DBT in

    general, and DBT consultationgeneral, and DBT consultation--toto--thethe--patient patient strategies in particularstrategies in particular

    Orient the client to these strategiesOrient the client to these strategies Include client as much as possible even Include client as much as possible even

    when intervening on her/his behalfwhen intervening on her/his behalf Neither criticize nor defend other Neither criticize nor defend other

    professionalsprofessionals

  • Letter to Marsha Linehan, Ph.D.

    Hi! I am in DBT. I am an Orthodox religious Jewish woman, so the DBT has some interesting application in my life.

    Firstly, I want to thank you personally for all the skills Ihave learned. I've been in treatment for close to a year;only when I began DBT about ten weeks ago did I see a tangible difference in my life, coping skills, and evendepression. Many of the things we learned can be summed up as "Why didn't I think of it myself??" But since it's part ofan official curriculum, it's much easier to take seriously,actually implement, and therefore have results. So, thankyou.

  • Now I'd like to share with you how some of theconcepts DBT parallel Jewish thought so beautifully:

    In model of emotions, we speak about interpretations.When we interpret things in a positive way, we don'tget so emotionally involved, and it is able to passuneventfully. In Judaism, where interpersonalrelationships are worked on in a real way, we have theconcept of judging others favorably. Last night I toldmy husband that I interpreted something in a goodway, and therefore wasn't upset with the person who itseemed insulted me. He replied, "In Hebrew that's

    called Dan Lkaf Zechus (judging favorably).

  • Another example: In Opposite Action you talk aboutActing opposite to what you really feel, therebystrengthening the positive emotion. Maimonides (avery great Jewish Rabbi from nearly a millennium ago)discusses something very similar. There is a phrase inHebrew Adam Nifal al pi peulosav man isinfluenced by his actions. There is a fundamental prayer which we say twice daily. Part of It reads

    Vahavta es Hashem Elokecha You shouldlove God..

  • All the scholars have a very real question on thiscommandment: We can be commanded how to act, buthow on earth can we be commanded what to feel? AndThe answer is Work on actions which will promotelove of God. We are commanded to do loving actions(such as praying, fulfilling His will) and automaticallywe will carry out the commandment to love Him.

  • Also, in Judaism there is a lot of stress on mprovimiddoscharacter traits. One very fundamental way that we aretaught to change negative emotions is to go to theopposite extreme. There is a quote from our sages,Which is the correct path? The middle path. And theway to get there is by aiming for the other end, eventuallysettling in the middle. This fits in very well in DBT whereyou discuss acting opposite to your emotion (quite similarto my second example).

  • It may be interesting to note that some Orthodox peoplehesitate to go into therapy for they are afraid that the skillstaught would conflict with our values.

    Now that I am in DBT, I know that there is no reason tohave such a fear. Its a basic character improvement,which is central to our religion. Thank you!!

  • Valuable Web Sites

    Contact for Intensive DBT Trainingwww.behavioraltech.com

    For free audio and video streaming www.borderlinepersonalitydisorder.com

    To join site for professionals www.bpdforum.com

    http://www.behavioraltech.comhttp://www.borderlinepersonalitydisorder.comhttp://www.borderlinepersonalitydisorder.com

    Dialectical Behavior Therapy (DBT) is a Comprehensive, Multi-component, Principle-driven Treatmentbased on a skills model Marsha Linehan, Ph.D.Marsha Linehan, Ph.D.DBTDBT: Evidence-Based TreatmentWhat Outpatient Studies ShowCost EfficiencyProvider Satisfaction!Who Can Benefit from DBT: Diagnostic IssuesEmotion Dysregulation DisordersBPD is the prototype emotion dysregulation disorder.Name change considerationEmotion Regulation DisorderDSM-IV Personality Disorders10 in TotalBorderline Personality Disorder (DSM-IV)Borderline Personality Disorder (DSM-IV)Acute SymptomsTemperamental SymptomsCo-morbidity/Co-occurring DisordersBorderline Personality DisorderTargets are the Behaviors, Skills are the SolutionsTheory:Bio-social or Transactional Model for the Development and Maintenance of Borderline Personality (and other Disorders oBiosocial Theory of BPDEmotion Vulnerability: Three Factors:Neuroimaging StudiesInvalidating Environment(Invalidating) Invalidating EnvironmentHealthy Emotional Processing What Goes WrongTransactional Model: Factors Influence Each Other (Reciprocal)Summary on Severe DistressDialectical Behavior TherapyCore DialecticComprehensive Treatment:Modes and Functions of DBTStandard DBT ModesDBT Functions & Modes of TherapyDBT Functions & Modes of TherapyDialectical Assumptions:Dialectical Assumption: PatientsDialectical Assumptions: TherapistStages of Treatment,andTreatment Targets by StageOverarching DBT Goals are Not:Overarching DBT Goal:Creating a Life Worth LivingPre-Treatment AssessmentGetting Started in Pre-TreatmentStage 1 Severe Behavioral Dyscontrol Behavioral ControlLife-Threatening BehaviorsTherapy-Interfering Behaviors: Patient Quality-of-Life Interfering BehaviorsStage 1 GoalsTherapist AgreementsTherapy-Interfering Behaviors: TherapistDESCRIBE WHAT WAS IMPORTANT TODAY (Especially related to your targets and your use of skills)Diary CardBehavioral Chain AnalysisChain Analysis Steps in DetailExample: Chain Analysis of CuttingBehavioral Chain Analysis: Changing Behavior & Breaking the Old PatternExample: SolutionsTreatment Targets: Links on the ChainStage 2 Quiet Desperation, Emotional Experiencing Misery, and Validating EnvironmentTruncated EmotStage 3Problems in Living & Individual Well-Being Dissatisfaction Relationship Satisfaction Stage 4 Incompleteness Contentment & IntimacyUnderstanding EmotionsPrimary and Secondary EmotionsSecondary Emotional ReactionsExample: AngerExample: ShameChange Negative EmotionsChange Strategies: Behavior TherapySkills Training is Necessary When the Solution is Not in the Patients RepertoireSkills as Solutions: Use Behavior Therapy To Implement SolutionsGoals of Skills TrainingSkill TrainingSkill Generalization in DBTSkill OverviewsCore Mindfulness SkillsDistress Tolerance SkillsDistress Tolerance, contEmotion Regulation SkillsDialectics of Interpersonal EffectivenessCore Mindfulness SkillsCore Mindfulness SkillsCore Mindfulness SkillsPriorities for Interpersonal EffectivenessDEAR MANDistress Tolerance SkillsRadical AcceptanceWillingness vs WillfulnessGoals of Emotion Regulation SkillsChanging Emotions by Acting Oppositeto the Current EmotionSkills CoachingTelephone Strategies to Aid GeneralizationTargets for Telephone CallsDBT StrategiesAcceptance and Validation What is Acceptance? Validation?Validation: Roles of TherapistLevels or Types of Verbal ValidationApplications of Validation in DBTObserving LimitsDBT Consultation TeamDBT: Community of Therapists Treating a Community of PatientsTherapist Non-Judgmental Stance: Requires mindfulness and emotion regulation, plus team consultation & supportConsultation TeamConsultation Team1. DBT Consultation Agreements2. Leadership3. StructureStructure, continued4. ProcessSample AgendaImportant to Note:Balance Consultation Strategy With Intervening in the EnvironmentEnvironmental InterventionHelpful StrategiesLetter to Marsha Linehan, Ph.D.Valuable Web Sites

Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.