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Commitment Phase
Things to achieve before contract signing: timescale up to six weeks or more
From start to contract = commitment phase not DBTOrient to treatment build commitment test skills
Explain theory strategies diary
Provide info pros and cons homework
Client get info reasons for DBT attend group
Theory and information
What is BPD? Bio-social theory What is DBT? Skills & acceptance/problem-solving Chances of success? What will client be committing to?
COMMITMENT phase
Orienting
Explain DBT Explain bio-social model role induction, new expectations
Commitment-Setting the stage
Agree life goals and values before therapy begins
Identify target behaviours to reduce Get commitment to attending skills
group to learn new behaviours Client learns coping instead of
dysfunctional responses Ends in contract signing
Orienting client: What is BPD?
Longstanding problem Checklist of symptoms Emotion dysregulation
Relationship problems Self harm/suicide Anger Drugs/drink Specifics to client
The Bio-Social theory key points
Extreme emotion, low threshold, slow come down
Born with it/developed it/both Invalidating environment/abuse Patterns: e.g.not noticing emotion until it is
extreme Only being noticed for extreme behaviour Rewarding undesirable behaviour, punishing
desirable
Foot on brake and accelerator!
Emotional dysregulation
Low threshold
High intensity
Long recovery
What is DBT
Special therapy for BPD Can also be used for other problems Better than treatment as usual
Individual, phone, skills, consult Aim to control behaviour so can get a
life Might want other therapy later Here & now
What will I be signing up to?
Staying alive for a year Attending therapy (indiv & group) Doing homework Keeping diary
Willing not wilful Being mindful Staying in the spirit of DBT
Information for clients
Behavioraltech.com Linehan books NHS Direct site User sites (BorderlineUK; BPDWorld) Other clients/local user groups Handouts
Evidence base (*see handout)
Randomized Clinical Trials = 7 with BPD (see Lynch, Trost, Salsman, Linehan, 2007 and NICE Guidelines for BPD, 2009).
Evidence base
Reducing: – Suicide attempts and self-injury– Medical risk– Premature drop-out– Inpatient/ER admissions and days– Drug abuse– Depression, hopelessness, anger
Increasing:– Global adjustment– Social adjustment
COMMITMENT STRATEGIES
Selling commitment : evaluating pros and cons.
Playing devil’s advocate
Foot-in-door and door-in-face techniques
Connecting present commitment to prior commitments
Highlighting freedom to choose and absence of alternatives
Shaping
Cheerleading
Pros and Cons
Pros Cons
Devil’s advocate
It’s going to take more time...be more effort.......you’re going to be asking yourself, ‘what am I doing bothering?’.......so why get involved in coaching???
Foot in the door
Ask for a little...when you get it, ask for a lot!
Door in the face
Ask for a lot, when you don’t get it, ask for a bit/lot less
Connect present commitments to past commitments
...but I thought we agreed.................
Freedom to choose....and absence of alternatives
Shaping..
Get a bit, reinforce, get a bit more towards target
Cheerleading
Believe in the efficacy of coaching, yourself, the person, the team
STRUCTURING THE TREATMENT-life goals
Life Goals – how to elicit
What does the client want?
Five years from now?
Job/relationship/flat/career
Scary and difficult to elicit
STRUCTURING THE TREATMENT-target behaviours
Behavioural targets hierarchy (rationale for)
Life-threatening
Therapy-interfering
Quality-of-life
“Stage 1” only
Life threatening behaviours
Self harm (e.g.cutting, burning inc ‘scratching’)
Harm to others (e.g. hitting poisoning emotional abuse)
Thoughts/images/beliefs/expectations re above
Dialectic: suicide as problem vs suicied as solution
Therapy-interfering behaviours
Patient behaviours
Non-attentive
Non-collaborative
Non-compliant
Other patients
Burn out
(limit-pushing)
Therapist behaviours
Imbalance
Change/acceptance
Flexibility/stability Nurturing/demanding
Lack of respect
Quality of Life-interfering behaviours
Substance abuse
High risk sex
Criminal stuff
Dysfunctional interpersonal
Employment
Illness-related
Housing-related
Mental-health related
Mental-disorder-related dysfunctional patterns
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