Dialectical Behavior Therapy: 07/22/19 –07/23/19 Its Role ... - Dialectical... · Dialectical Behavior Therapy: Its Role in Treating the Traumatized Brain 07/22/19 –07/23/19 Jaye

Dialectical Behavior Therapy:Its Role in Treating the Traumatized

Brain

07/22/19 – 07/23/19

Jaye Neal, LCSWMartha Wetter, PhD 1

Dialectical Behavior Therapy: Its Role in Treating the Traumatized Brain

Jaye L. Neal, LCSWMartha Wetter, PhD

July 22 – 23, 2019

Agenda

Conceptualization of BPD Neurobiology of Trauma Linehan’s Biosocial

Theory DBT Modes and Functions Stages of Treatment Dialectics

Validation Skills Training DBT Techniques for

Addiction Individual therapy Phone Coaching and

Consult Group

Dialectical Behavior Therapy (DBT)

DBT is an empirically based treatment and has been identified as the treatment of choice for BPD by the American Psychiatric Association

It consists of four componentsSkills training Individual therapyPhone coachingConsult group


Brain

07/22/19 – 07/23/19


Conceptualization of BPD in DBT

Affective Dysregulation Emotional lability Problems with anger

Interpersonal DysregulationChaotic relationships Fears of abandonment

Self Dysregulation Identity disturbance/ lack of sense of self Sense of emptiness

Conceptualization of BPD in DBT, cont.

Behavioral dysregulation Suicidal behavior, threats, self-harm Impulsive behaviors

Cognitive dysregulation Dissociative responses Paranoid ideation (extreme interpersonal sensitivity)

** drop the “m” word from your vocabulary **

BPD and Childhood Trauma

Many conceptualizations of BPD do not address the chronic childhood trauma that individuals with BPD often experience (but cf. Linehan’s discussion in her book on pg. 26)

Many researchers (Schore,Van der Kolk,, Zanarini,) view psychological trauma as an antecedent to BPD

Traumatic victimization by primary caregivers is hypothesized to be one of the key etiological factors in BPD (with genetics and constitutional factors as well)

(Ball & Links, 2009; Laporte, Paris, Guttman, & Russell, 2011; Zanarini, 2000)


Brain

07/22/19 – 07/23/19


BPD, Trauma, and Complex-PTSD

Prevalence of chronic relational trauma in BPD is well established Early, severe, and chronic maltreatment and neglect ORChronic invalidation of the child’s behaviors, thoughts and

feelings

Many symptoms of Complex-PTSD (C-PTSD) overlap with BPD criteria

One strong demonstration of this overlap is the frequent occurrence of early abuse, trauma, and the presence of dissociative symptoms in individuals with BPD

Complex PTSD

Six clusters of symptoms have been suggested for a diagnosis of C-PTSD:(1) Alterations in regulation of affect and impulses, including

problems regulating emotions, persistent sadness, suicidal thoughts, explosive anger or covert anger

(2) Alterations in attention or consciousness, including forgetting traumatic events, reliving traumatic events or having episodes of dissociation

(3) Alterations in self-perception, such as a sense of helplessness, shame, guilt, stigma, and a sense of completely different from other human beings (cf. earlier client self-description)

Complex PTSD

(4) Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer

(5) Somatization, including a focus on physical symptoms and a search for medical treatment of bodily distress

(6) Alterations in systems of meaning, which may include a loss of sustaining faith or a sense of hopelessness and despair


Brain

07/22/19 – 07/23/19


Complex PTSD and BPD

Even a cursory examination of these symptoms reveals a remarkable resemblance to the symptoms of BPD, indicating that BPD may well be best conceptualized as a form of PTSD due to chronic relational trauma starting in childhood.

Since DSM-IV, a massive body of neurobiological research has accumulated revealing how chronic childhood abuse and neglect can cause pervasive, devastating, and lasting biological and psychological harm.

Importance of Interpersonal Experiences (i.e., Attachment Theory)

Human connections build neural connections Incredible growth of synaptic connections occur as

child agesWiring of the brain is governed by early experience-

every interaction counts! Thus, trauma in childhood changes brain

development

Neural circuitry

newborn 3 month old 15 month old 2 year old


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07/22/19 – 07/23/19


Secure Attachment

When parents are attuned to child’s inner states and respond appropriately, a secure attachment is built

Parent and child “resonate” with each other, so each feels “felt”

The child actively needs and seeks attunement and attachment

Prof. Ed Tronick’s Still Face Experiment shows what happens when attunement does not occur

Still Face

The Other End of the Attachment Spectrum: Neglect and Abuse

Neurobiological impact of trauma in childhoodBefore the connections

between the amygdala and orbitofrontal cortex are built, the right amygdala becomes hypersensitive to stressful conditions, holds mental models of expected danger, harbors terror and anguish, and lacks connection with other circuits for regulation


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07/22/19 – 07/23/19


Neglect and Abuse: Structural and Functional Abnormalities

Childhood maltreatment and neglect are associated with structural and functional abnormalities in different brain areas, including: the pre-frontal cortex (logic and reasoning) the corpus callosum (integrating the right and left

hemisphere) the amygdala (fear and facial recognition) the temporal lobe (hearing, verbal memory,

language function) the hippocampus (memory)

Neglect and Abuse: Effects on Neurotransmitters

Norepinephrine is increased, producing anxiety, arousal and irritability

Dopamine is increased, producing hypervigilance, paranoia, and perceptual distortions

Serotonin is decreased, leading to irritability, depression, or aggression

Endogenous opioids are not produced, leading to a predisposition to opiate-based substance abuse

Neglect and Abuse: Effects on Health

Repeated, hyperarousal of the neuroendocrine system, especially in early childhood, often leads to long-lasting physical problems Fibromyalgia, irritable bowel syndrome, chronic pelvic pain

(females), migraine headaches, psychogenic-seizures, "acid" stomach, back pain, and autoimmune illnesses such as MS or lupus or RA

As a result, individuals with BPD often have a diagnosis of somatoform disorder and often are regarded by doctors as difficult patients, because they don’t improve with treatment (cf. Dr. Burke-Harris’ findings, coming up)


Brain

07/22/19 – 07/23/19


Frequency of Childhood Trauma:Adverse Childhood Events Studies (ACEs)

V. J. Felitti, MD & R. F. Anda, MDSurvey of over 17,421 adults in the Kaiser

Permanente HMO in California<http://www.acestudy.org/>

Nadine Burke-Harris, MD

What are Adverse Childhood Events?

Abuse: Emotional Physical Sexual

Household Dysfunction: Substance abuse Mental illness Mother treated violently Incarceration of household

member Parental separation or divorce

Neglect Emotional Physical


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Relation of ACEs to mental & physical problems (Am J Prev Med 1998;14: 245-258)

Dose/ response relationship Almost two-thirds of study participants reported at least 1

ACE, and more than 1 in 5 reported 3 or more ACEs For people who reported 1 ACE, the probability of exposure

to any additional ACE was 65%-93% Persons with ≥ 4 ACEs had:

4-12x risk for alcoholism, drug abuse, depression, suicide attempt

2-4x risk smoking, poor self-rated health, > 50 lifetime sexual partners and STDs

Neuroplasticity Brain’s capacity to change neural connectivity in response to

new experiencesSynaptogenesis=formation of new synaptic connectionsNeurogenesis=birth of new neurons

These occur throughout the lifespan!


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07/22/19 – 07/23/19


Good news

Findings from three areas of research -psychotherapy, attachment, and neurobiology show that:

Psychotherapy which works is based on a relationship in which the therapist uses attuned (validating) responses to encourage and shape behavioral change (change strategies) which

work because the brain is neuroplastic

Good news

In DBT, the combination of validation and change strategies ultimately rebuilds neural networks in the client’s brain that were harmed by adverse childhood events

What makes DBT dialectical is the balance of validationstrategies with change strategies

Thus, DBT is an extremely helpful approach to address the neuro-biological effects of trauma

Study: DBT Alters Emotion Regulation and Amygdala Activity

Study conducted by Goodman, Carpenter, Tang et al, in 2014

Previous findings: Deficient amygdala habituation has emerged as a biological correlate of affective instability in BPD

Hypothesis: BPD patients would exhibit decreased amygdala activation and improved habituation, as well as improved emotion regulation, with standard 12-month DBT

Results: Hypothesis was CONFIRMED = decreased amygdala activation with DBT treatment


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07/22/19 – 07/23/19


Linehan’s Biosocial Theory of BPD

BPD is a dysfunction in emotion regulationGenes and intra-uterine factors interact

reciprocally with an invalidating environment to produce vulnerability to pervasive emotion dysregulation

The invalidating environment reflects an insecure attachment in the caregiver-infant relationship

Biological dysfunction in the

emotion regulation system

Invalidating environment

Pervasive emotion dysregulation

Biosocial Theory of BPD

Pervasive Emotion Dysregulation

High Sensitivity Immediate reactionsLow threshold for these reactions

High ReactivityExtreme reactionsHigh arousal which dysregulates cognitive processing

Slow Return to BaselineLong lasting reactionsHigh sensitivity to next emotional stimulus


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07/22/19 – 07/23/19


Invalidating Environments

In attachment-disordered, invalidating interactions, the infant/child’s communications about her inner world:Are not accepted as accurateAre not seen as valid response to eventsAre dismissed, trivialized or disregardedAre directly criticized or punishedAre attributed to socially unacceptable characteristics

(e.g., laziness, over-reactivity, lack of motivation, manipulation, lack of discipline)

Are pathologized even when normal

Consequences of Invalidating Environments

The invalidating environment does not teach the infant/child to: Trust her emotions and thoughts as valid responses to

events Identify and label emotions and thoughts in a normative

wayRegulate emotions when they become intense or

overwhelming

Consequences of Invalidating Environments

The invalidating care-giver makes problem solving seem OVERLY SIMPLE

By over-simplifying problem solving the invalidating environment does not model for the child how to: Tolerate distressForm realistic goals and expectationsUnderstand the (often slow) process of achieving goals

and expectations


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07/22/19 – 07/23/19


Consequences of Invalidating Environments The child who experiences invalidation or mistreatment is

likely to conclude that she must be unacceptable or bad to deserve such punishment or neglect

The abused or neglected child also comes to view caretakers as dangerous, rejecting, or unavailable, and the world as a dangerous place

Current threats that resemble the early invalidating relationships trigger painful childhood memories. This can leads to behavior that, although intended to keep people attached, appears so child-like and demanding that it does the opposite

Consequencesof Invalidating Environments

As stated by a trauma survivor, “if bad relationships messed me up, then it follows that I need good relationships to help me heal.”

For our purposes, good relationships in therapy represent relationships that are based on an attached, attuned, validating therapist

We will return to the topic of validation later in this training

What does DBT Consist of?

Group skills training (different from group therapy) DBT-informed individual psychotherapy Telephone skills coaching calls with client in between

sessions Therapist consultation meetings with other DBT therapists Ancillary treatments=other treatments not directly

connected to DBT (pharmacotherapy, inpatient treatment, AA, NA)


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07/22/19 – 07/23/19


DBT Functions And Modes Of TherapyFunction Mode

Enhance Capabilities Skills training; medication

Improve motivation* Individual therapy

Assure generalization of skills

Phone/email consultation

Keep therapist dialectical/balanced

Consultation meeting

Structure the environment (parents, partners, children, other treating professionals)

Consult to environment

*focusing on obstacles, distorted cognitions, and reinforcement contingencies

DBT Assumptions for Clinicians

Clients are doing the best they can Clients want to improve Clients need to do better, try harder, and be more motivated

to change Clients may not have caused all their own problems, but they

have to solve them anyway New behavior has to be learned in all relevant contexts All behaviors (actions, thoughts, emotions) are caused Figuring out and changing the causes of behavior is a more

effective way to create change than judging and blaming the client (which may well happen with BPD; e.g., “she just doesn’t want to change.”)

DBT is a STRUCTURED Treatment with Stages and Targets

Pretreatment TargetsOrientation and Commitment

OrientationExplain neurobiology of trauma to client Orient client to program

Review Patient and Therapist Agreements* with client

Agree on goals (Stage I behavioral targets)

*


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07/22/19 – 07/23/19


DBT is a STRUCTURED Treatment with Stages and Targets

Commitment Pros and cons of commitment to change Devil’s advocate approach Foot-in-the-door approach; door-in-the-face approach Review of prior commitments Shaping; Cheerleading

Foot in the Door


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07/22/19 – 07/23/19


Treatment Stages in DBT (Following Commitment) Stage I:

“get out of hell;” focus on behavioral control, safety, and skill acquisition

Stage II: Trauma work; narrating traumatic events; reduce PTSD

symptoms Stage III:

Define life goals, build self-respect, achieve dialectical view of oneself and the world (these may begin in Stages I and II)

Stage I Treatment Target Hierarchy

Three kinds of target behaviors to decrease (listed in order of importance)

Life-threatening behaviors Suicide attempts and life threatening behaviors (e.g., self-

harm, dangerous drug use) Therapy-interfering behaviors

Any behaviors that interfere with the client receiving effective treatment (e.g., non-attending behaviors, non-collaborative behaviors, non-compliant behaviors)

Stage I Treatment Target Hierarchy

Quality-of-life-interfering behaviors Substance abuse Extreme financial difficulties Criminal behavior that may lead to jail High risk sexual behaviorOther very dysfunctional behaviors:

Interpersonal (biting someone during a fight)Employment-Related (telling your boss to “f—k off”)School-Related (e.g., getting suspended/expelled)Illness-Related (e.g., refusal to treat physical illness or constant treatment

seeking)Mental Health-Related (e.g., going into hospitals, psychiatrist-hopping,

not taking meds as prescribed)


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07/22/19 – 07/23/19


Stage I Treatment Targets

Behavioral skills to increase:

Attending skills training groupMeets once a week, usually for 2-2.5 hours, for 14 monthsOrganized like a class and has 4 skills modules

Core mindfulness

Distress Tolerance

Emotion Regulation

Interpersonal Effectiveness

The Four Skills Modules of Stage I

Mindfulness, attentional awareness and control Learn to observe and describe sensory experiences, from both

internal and external sources Learn to increase awareness of the present moment Learn to participate fully in the present moment Engage the world in a nonjudgmental way

Interpersonal effectiveness Learn to ask for what you need effectively Learn to say no to unwanted requests effectively Learn to do both in a manner that maintains self-respect and/or

the relationship

The Four Skills Modules of Stage I

Emotion RegulationLearn the model for describing emotions Learn to decrease vulnerability to negative emotionsLearn to increase occurrence of pleasant emotionsLearn techniques to manage extreme emotions Distress ToleranceLearn to tolerate distress and accept reality instead of

using impulsive behaviors to relieve misery


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07/22/19 – 07/23/19


Targets in Stage II and Stage III

Stage II TargetsEmotionally process the past (i.e. trauma work)Decrease post-traumatic stress

This requires the client to be able to experience intense emotion without avoidance, learned through skills training

Stage III TargetsManage normal problems in living Increase self-validationMove toward individual goals

What Exactly Does Dialectical Mean?

A dialectic is a method of examining and discussing opposing ideas in order to find a balanced and accurate view Looking for a synthesis of the thesis and antithesis

Example: Thesis: All people are capable of evil Antithesis: All people are capable of good Dialectical Synthesis: (1) Some people are capable of good,

and some are capable of evil; (2) Most people are capable of both good and evil at times, depending on circumstances, etc.

A dialectical view leads to a balancing of extremes

A quick way to view a dialectic


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07/22/19 – 07/23/19


Dialectical Conflicts Clients Experience

Clients frequently vacillate between sympathetic arousal and parasympathetic numbing (which is why they are so often diagnosed with Bipolar I Disorder)

This pattern reflects what may be called the PTSD roller coaster

Dialectical Conflicts Clients Experience

Clients frequently vacillate between rigidly held but contradictory points of viewIt’s all my fault – It’s all their fault

Clients tend to see reality in polarized categories of “either-or” rather than “both-and” which produces a black/white view of their world and its possibilitiesSuch categorical thinking is often accompanied by the

belief that things once defined never change, so once a person has failed, she will be a failure forever


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07/22/19 – 07/23/19


DIALECTICS: How Does This Help?

This perspective helps pave the way toward finding the middle path by allowing the client to: Expand thoughts and ways of considering life situations "Unstick" standoffs and conflicts Be more flexible and approachableAvoid assumptions and blaming self and others

The middle path requires acceptance of reality as it is. This requires the balancing (synthesis) of opposites:Accepting self and others, AND also acknowledging the

need for changeBalancing self-blame with blaming others

Dialectical Issues That Must Be Balanced By Client And Therapist

Skill Enhancement vs. Self-AcceptanceProblem-Solving vs. Problem AcceptanceAffect Regulation vs. Affect ToleranceSelf-Efficacy vs. Help-SeekingTrust vs. SuspicionContemplation/meditation vs. Action

Dialectics in DBT The dialectic of acceptance vs. change runs

throughout DBT in terms of treatment, appearing as the tension between validation strategies and change strategies

Example of dialectics in DBT:You are doing the best you can, and you need to do

better, try harder, and be more motivated to change.You are responsible for your own actions and you are

not in control of everything.


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07/22/19 – 07/23/19


Validation

Is acknowledgement and acceptance of client as she isCommunicates to the client that you realize she is doing

the best she can in the moment Balances the message she needs to change, to work

harder, to act “better” Helps client feel safe Builds a solid therapeutic relationship

Validation checklists provided in your materials

Targets for Validation: Things to watch for in the therapy room

Emotional experiences, pain, suffering

Cognitive experiences, thoughts, beliefs, assumptions

Behaviors Inner strength, potential

to succeed

Levels of validation1. Stay awake2. Make accurate reflections Repeat what client said Rephrase using synonyms

3. Identify un-verbalized emotions, thoughts, behavioral urges Paraphrase using inferred meaning Reflect the emotion behind the content

4. Validate in terms of past learning or biological dysfunction “It makes sense you feel that way because in the past . . .”

5. Validate in terms of present context or normative functioning “Of course you feel that way given what just happened…”

6. Be radically genuine


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07/22/19 – 07/23/19


Validating vs. Invalidating Responses: Impact on Psycho-physiological Arousal and Emotion

12

13

14

15

16

17

18

19

20

21

0 1 2 3 4

Negative Emotional

Arousal

Time Period

Shenk & Fruzzetti, 2007

Invalidation

Validation

Stress

Validation – Or Not

Therapists may fail to validate an emotion, thought, or action (=a missed opportunity), which is different from acting invalidating toward the client

Or, they may block inaccurate or distorted expressions of a feeling or thought (e.g. “I’m worthless” or “Things will NEVER change”) and then redirect to a more accurate expression (e.g. “Of course you think that AND it is not so”)

Validation Rules

Believe and reflect that the client is capable and that her perspective is understood and important and valid in her own context

Rule: Do at least one level 5 validation each session (i.e., communicate to the client that you can see there is no other way she could have felt, or thought, or acted given the current circumstances)


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07/22/19 – 07/23/19


Validation Rules: You Cannot Do the Following Too Much

Communicate Interest: “Tell me more about that…” “How did that happen?” Body language – lean toward the client, make eye contact, nod

Hear and see correctly: “It sounds like you were really upset…” “You look like you might be scared.”

Communicate understanding “It makes sense that you did that…or felt that…or thought that.”


Give causes“Of course you feel this way, you have a sensitive nervous

system.”“Naturally you believe that, you’ve been hurt in the past.”

Be nonjudgmentalHave an accepting facial expression, that means no

frowns, no pursed lips, no tsking. This means no disapproval even though you may be disappointed or dismayed by what the client is telling you


Accentuate the correct or effective i.e., find the thing you can be positive about“Even though it didn’t work out for you the way you

wanted, you tried really hard.”“Although you were really angry and you shouted, you

didn’t hit anybody.”

Give functional validation (through behavioral response) The statement “I’m thirsty” is met with a drink


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07/22/19 – 07/23/19


Validation Rules: You Cannot Do the Following Too Much Treat the client as though she can be strong

Don’t walk on egg shells because actually that is patronizing, and communicates you believe she is weak, dangerous, crazy, or all three

Cheerlead Encourage and support your client

Be genuine Treat the client as a person you are collaborating with to solve

problems they naturally are having given their past experiences and current situation

Validation & Hope This is hard. You've done hard things

before and I believe in you.

I know there's a lot that could go wrong. What could go right?

All vibes are welcome here.

It's pretty normal to have some negativity in this situation.

It's probably pretty hard to be positive right now. I'm putting out good energy into the world for you.

Sometimes giving up is ok. What is your ideal outcome?

It's never fun to feel like that. Is there something we can do today that you'd enjoy?

It's probably really hard to see any good in this situation. We'll make sense of it all later

Toxic Positivity You'll get over it!

Just be positive!

Good vibes only!

Stop being so negative!

Think happy thoughts!

Never give up!

Just be happy!

See the good in everything.

It’s Not about the Nail


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07/22/19 – 07/23/19


When in doubt, validate!!

Balancing Communication: As Always, a Dialectic Exists

There are two primary communication styles in DBT They not only balance each other, but they must both

be used often. The therapist must learn to move back and forth between the two quickly and easilyReciprocal communication: Responsive, warm, genuine,

and appropriately self-disclosing Irreverent Communication: Off-beat, unexpected, and/or

tongue-in-cheek

Communication Strategies checklists provided

Irreverent Communication

Irreverent communication is used to: Get the client’s attentionShift the client’s affective responseGet the client to see a completely different point of view

It is used whenever the client, or both therapist and client, are “stuck” in an ineffective emotional, thought, or behavior pattern.


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07/22/19 – 07/23/19


Change Strategies: Skills Training

Validation is one side of the dialectic in DBTWe will now turn to the other side of the dialectic:

Problem solving/ change techniques used in DBT These techniques are taught in the DBT skills training

groupsCore mindfulnessDistress ToleranceEmotion RegulationInterpersonal Effectiveness

Core Mindfulness

Mindfulness skills are central to DBT; these skills underpin and support all other DBT skillsCore Mindfulness skills are the only skills that are

highlighted the entire yearThey are both taught in a 7-week unit and reviewed

for two sessions at the beginning of each of the other three skills units

The focus of Core Mindfulness skills is learning to be in control of one’s attention


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Core Mindfulness

It is the act of consciously focusing the mind in the present moment without judging the moment as good or bad

When mindful, we are aware in and of the present moment. We are alert and awake, like a security guard at a school

But we are NOT rigidly clinging to the present moment (as if we could keep a present moment from changing if we cling hard enough)

Mindfulness practice can literally change your brain!


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07/22/19 – 07/23/19


Mindfulness Research

Holzel, Carmody, Vangel et al. (2011) conducted a controlled longitudinal study to investigate pre–post changes in brain gray matter attributable to participation in a mindfulness program

The results indicated that participation in mindfulness is associated with an increase in the amount of gray matter in brain regions involved in learning and memory, emotion regulation, self-reflective processing, and perspective-taking

Core Mindfulness

The Mindfulness Skills include:What skills (what you do)

Observe Describe Participate in the present moment

How skills (how you do the What skills) Nonjudgmentally One-mindfully (with focus) Effectively (that is, willingly and as skillfully as possible)

Core Mindfulness

DBT teaches there are three states of mind that humans may be in: Emotion Mind Reasonable MindWise Mind

Wise Mind is the state of mind in which both the right brain and the left brain work together; it is seeing the value of both reason and emotion; it is finding the middle path between these two states of mindWise mind is needed to make skillful, balanced decisions and is

developed through mindfulness practice


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Core Mindfulness: The Takeaway

Intentionally focusing on the present moment, without judging it or denying it or holding onto it, and bringing your focus back when it wanders, again and again and again, is all that is needed to practice mindfulness and reap its benefits.

MINDFULNESS CAN BE PRACTICED ANYTIME, ANYWHERE, AND WHILE DOING ANYTHING if you are focused in the present


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Interpersonal Effectiveness is the next module in skills training, running approximately eight weeks

It is designed to teach clients how to have effective interpersonal relationships so they can develop, maintain, and improve relationships

The goals in this module are: Learn to achieve your objectives with others skillfully Build new relationships, strengthen current relationships, and end

destructive ones Act in a way that develops or maintains your self-respect


Relationships can create enormous stress, especially for people who had chronic relational trauma in childhood

Clients in DBT frequently vacillate between avoidance of conflict and intense confrontation

This pattern of behavior, and others’ reactions to it, increases emotional vulnerability and distress

A lack of interpersonal skills is a primary problem for individuals with DBT


Obstacles that get in the way of being interpersonally effective:Not having the interpersonal skills you needYou don’t know what you want from another personYour emotions control what you doYou act on your short-term wants instead of considering

your long-term goalsOther people do not respond despite your acting skillful Your (distorted) thoughts (“myths”) impair your ability to

act skillful


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Three priorities are identified in interpersonal interactions: To achieve an objective or goal To maintain or improve a relationship To maintain or improve self-respect

Learning to identify which priority is most important is critical for success in relationships

Achieving any of these priorities requires different skills: DEAR MANGIVE FAST

Interpersonal Effectiveness (DEAR MAN)

Use DEAR MAN when you want to obtain a specific objective D=Describe the situation (who, what, when, and where)

concisely to the person E=Express feelings and opinions about the objective A=Assert your wishes (ask for what you want or refuse the

other person’s request) R=Reinforce the person for granting your request or accepting

your refusal (e.g., verbal praise, an offer to reciprocate, or even a hug if appropriate)

Interpersonal Effectiveness (DEAR MAN) M=(stay) Mindful of one’s goals

Stay focused in the present moment and don’t get thrown off track by anything the other person says. When necessary be a “broken record.”

A=Appear confident No stammering, no whispering, adequate eye contact,

calm/steady tone of voice and rate of speech. (These skills need to be practiced).

N=Negotiate when necessary Be ready and willing to reduce the request or to modify the

refusal if necessary.


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A= Appear Confident

Start at 1:31

Interpersonal Effectiveness (DEAR MAN GIVE)When maintaining the relationship is a priority in an

interaction GIVE is the set of skills describing how to do DEAR MAN.

G=(be) Gentle How you make the request (it is tone of voice, body posture,

reasonable eye contact—overall acting non-threatening). I =(act) Interested

Show interest in any responses the other person makes. V=Validate the other person’s concerns

This means acknowledge hearing whatever they may say. E=(use an) Easy Manner

That is, act a little humorous or light-hearted.

Interpersonal Effectiveness (DEAR MAN FAST)When self-respect is a priority in an interaction FAST is the

set of skills describing how to do DEAR MAN. F=(be) Fair

Pay attention to both your rights and the rights of the other person. A=(no) Apologies

Do not begin with “I’m sorry.” Apologies imply that one is wrong. This can reduce one’s sense of self-respect over time.

S=Stick to one’s values Do not sell out one’s values just to obtain an objective or another

person’s friendship T=(be) Truthful

Don’t lie, don’t exaggerate, because a pattern of dishonesty overtime erodes self-respect


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Additional Interpersonal Effectiveness Skills

The interpersonal effectiveness module also includes:How to build new relationships and end destructive ones*How to walk the middle path (balancing acceptance and

change in relationships; recovering from invalidation in relationships)

*How to end destructive relationships is a very complicated topic for DBT clients and generates MUCH discussion in skills group

Emotion Regulation Skills

Problems regulating emotions are central to problems DBT clients face

As we noted earlier, for PTSD clients, painful emotions start quickly, are very intense, and take a long time to return to baseline

Linehan believes that often suicidal impulses come from believing it would be easier to be dead than to go on feeling extreme emotions

Emotional Vulnerability

There is no doubt that the emotions DBT clients experience are extremely painful! And frequent, and long-lasting

These are not sensations anyone would choose to have So, a person having such emotions is NOT choosing to

be dysregulated IN ORDER TO get attention or gain some desired goal (i.e., is not being manipulative)


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Emotion Regulation: Functions of Emotions

Emotions cannot be viewed as “bad;” they are the limbic system’s responses to precipitating events

Emotions have 3 basic functions from an evolutionary standpoint:

1. To motivate action2. To communicate to others3. To communicate to ourselves

Emotion Regulation Skills

There are four goals in the Emotion Regulation module:

1. Understand and name your emotions Including the functions of emotions, why regulating emotions is hard,

model for describing emotions, ways to describe emotions2. Change unwanted emotions Including how to check the facts, use opposite action, and problem

solving3. Reduce vulnerability to emotion mind ABC and PLEASE

4. Manage extreme emotions to avoid making things worse

Goal 1: Understand and name your emotion Includes: Anger, Disgust, Envy, Fear, Happiness, Jealousy,

Love, Sadness, Shame, and Guilt DBT teaches a model for describing emotions, which

includes:Synonyms for emotion Prompting events for emotion Interpretations of prompting eventsBiological changes that occurExpressions and actions of the emotionAftereffects of the emotion


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Goal 2: Change (unwanted) Emotional Responses Check the facts:

Do your emotional reactions fit the facts of the situation? Emotions may be understandable, but NOT justified

Opposite action:When your emotions do NOT fit the facts, or when acting on your

emotions is not effective, acting opposite may well change your emotional reactions

Problem solving:When the facts themselves are the problem, changing them (if

possible) or accepting them (if necessary) will reduce negative emotions (e.g. leaving a job or even a relationship)

Goal 3: Reduce Vulnerability to Emotion Mind

“ABC” A = Accumulate positive experiencesB = Build masteryC = Cope ahead

“PLEASE” Treat PhysicaL illness Balance EatingAvoid mood-Altering substances Balance Sleep Get Exercise

Goal 3 continued: Emotion Regulation

One problem with these skills is they are all change skills and they require self-management abilities

Often DBT clients demonstrate few self-management abilities

Tom Lynch, Ph.D. developed a set of skills with the acronym VITALS to teach self-management


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Emotion Regulation: VITALS

V= Validate the “I don’t want to”; of course you don’t want to eat veggies, exercise, avoid drugs

I= Imagine doing the behavior calmly and without resistance (cf. sports psychology – Tiger Woods)

T= Take very small steps (e.g., eat one carrot) A= Applaud yourself (lots of verbal praise) L= Lighten your load (do things ahead of time) S= Sweeten the pot (the real reward – like a cookie)

Goal 4: Managing Extreme Emotions

Identify when skills are not working=frontal lobe is shutdown and emotion mind rules

Use the crisis survival skills from Distress Tolerance unit (up next)

Be mindful of current emotion (sit with the feeling without acting – very hard without lots of mindful PRACTICE)

Recall that all emotions pass and when this one does, try to figure out what went wrong that allowed it to get so extreme

Distress Tolerance Skills

These skills involve learning to get through a crisis without engaging in behaviors that make things worse

Pain and distress are part of life. The refusal to accept this immutable fact increases the pain, turning it to suffering, that is, pain plus HATING the pain

The ability to tolerate distress in the moment is crucial for any attempt to change one’s behavior. Otherwise impulsive actions interfere with efforts to make desired changes


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Distress Tolerance

The six sets of Crisis Survival Strategies are: The STOP skillPROS and CONS TIP your body chemistryDistract with Wise Mind ACCEPTSSelf-soothe with the five senses IMPROVE the moment

These skills are NOT intended to solve the crisis, but instead, to help survive painful moments without harming oneself or making things worse in the long run

Distress Tolerance: STOP Skill

The STOP skill helps clients avoid acting impulsively on their emotional urges

S=Stop; freeze; don’t move a muscle or open your mouth T=Take a step back from the situation (e.g. take 5 slow, deep

breaths) O=Observe the present situation (gather information about

what is going on) P=Proceed mindfully (by evaluating the most effective option

to take, in light of your goals, and following that option)

Distress Tolerance: TIP

TIP Skills are ways to reduce emotional arousal rapidly Each of these skills has the effect of quickly changing

physiological responses, thereby causing a reduction in emotional arousal

T= Temperature (ice pack or cold water on the face to elicit the dive response)

I= Intense aerobic exercise P= Paced breathing and Paired muscle relaxation


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Distress Tolerance: Pros and Cons

This skills involves listing the positive and negative aspects of tolerating distress and the positive and negative aspects of not tolerating it.

The goal is for the person to face the fact that accepting reality and tolerating distress lead to better outcomes than do rejecting reality and refusing to tolerate distress.

Example DBT Pro and Con Rubric

Tolerating DistressActing on impulse

Pros

Cons

An easier way to look at it

Pros of cutting: Feel better; relief Less anxious More in control Pain is physical- makes it

easier to care for Fog lifts, Feels like I can

breathe I get what I deserve Snap back to reality It’s inevitable, really

Cons of cutting: Cycle keeps going Have to explain cuts to

husband Feel a need to hide/ lie Shame Scars Can escalate May need to go to hospital I’ll feel terrible after effects

wear off Doesn’t solve the problem

Urge: “I want to cut”


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Distress Tolerance: Wise Mind ACCEPTS This set of skills involve distracting one’s attention from events

that set off the distress. A = Activities (Engage in activities that are neutral or opposite

to the emotion and will distract your attention) C = Contributing (Do something nice for someone) C = Comparisons (Compare oneself to others or to self in a

past difficult time) E = Emotions (Actively generate a different emotion) P = Pushing away (Leave situation mentally or physically) T = Thoughts (Distract with other thoughts; read a book) S = Sensations (Generate intense physical sensations such as

smelling a strong odor or eating a Warhead candy)

Distress Tolerance: Self- Soothing

This skill involves comforting, nurturing and being gentle and kind to oneself

It is based on the five senses = taste, touch, vision, hearing, and smell

DBT clients often have great difficulty self-soothingMay not believe they deserve kindness or gentleness, or

may believe it is selfish to do it for themselves.

It is a crucial skill for DBT clients and is best taught by having each client put together a self-soothing kit

Self-soothing Kits


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Distress Tolerance Skills: Self- Soothing Vision: Looking at a beautiful sight or scene Hearing: Listening to soothing sounds or music Smell: Smelling soothing aromas (such as lavender)

through lotions, scented candles, essential oils Taste: Eating small amounts of comfort foods, such as

dark chocolate or herbal tea Touch: Feeling something soft, like velvet or fur, or

your dog or cat

The final set of distress tolerance skills involves Improving the Moment by replacing negative feelings or thoughts with more positive ones

Three approaches are available:1. Cognitive techniques having to do with

changing appraisals of oneself or appraisals of the situation

2. Physiological techniques involving changing body responses to the crisis with techniques like relaxation and slow deep breathing (cf. TIP skills)

3. Acceptance-focused techniques

Distress Tolerance: IMPROVE

Distress Tolerance: Acceptance

Acceptance includesRadical Acceptance – complete acceptance, from deep

within, of both oneself and reality as it is in the moment Turning the mind toward acceptance--choosing to accept

reality as it isWillingness—acting willing vs. acting willful (the “I will not

act like a 2-year-old” skill; also termed “adulting”)Half smiling and willing hands - accepting reality with one’s

bodyMindfulness of current thoughts – observing one’s thoughts

without judging them; activates frontal lobes


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Distress Tolerance: Acceptance

Acceptance Approval

Acceptance DOES NOT mean approval

One must accept that Hitler killed millions of people, but one need not approve. This point must be made to clients over and over and over again – acceptance does not mean approval!!!

Seven Basic Skills for Addiction-Related Behaviors

1. Dialectical Abstinence 2. Clear Mind 3. Community Reinforcement 4. Burning Bridges 5. Building New Ones 6. Alternate Rebellion 7. Adaptive Denial These skills focus on “backing down from addiction”

Addiction: What is it?

Definition of addiction: any repetitive behavior that an individual is unable to stop, despite negative consequences of the behavior and the person’s best efforts to stop It is usually helpful to focus on one addiction at a time

An addiction does not have to only be a result of substances that foster physical dependence In the brain, a reward is a reward, regardless of whether it comes

from a chemical or an experience And when there is a reward (e.g. gambling, eating, sex,

shopping), there is risk of getting trapped in a compulsive urge to get the reward


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Addiction: What is it?

Once people get addicted, the pleasure of the behavior (degree, intensity or amount of time in which it is pleasurable) may go down, but the urge to engage in the behavior will increase and intensify

At that point, the addictive behavior is not reinforced by pleasure but by the desire for relief form intense and unpleasant urges, as well as the urge to re-experience the original high

DBT focuses on a relapse prevention model: the intent is to foster abstinence from addictive behaviors and maximize harm reduction if there is a relapse. Relapse prevention identifies high-risk situations and uses problem solving skills to develop ways to avoid and/or to cope skillfully with such situations.

Dialectical Abstinence

A relapse prevention approach synthesizes a focus on absolute abstinence whenever one is abstinent even for a moment with a focus on harm reduction following every slip, even when it is very small Abstinence = complete abstinence, which means never again

engaging in the addictive behavior at any time for any reason Harm Reduction = minimizing the harm done by a slip into

addictive behavior. This acknowledges there may be slips, tries to minimize the damage, and is sympathetic to failures to achieve complete abstinence. The basic goal is to manage lapses so that lapses don’t turn into relapses and despair

Dialectical Abstinence

The Dialectical Tension: On the one hand, clients agree that they value living up to their

potential and building a life worth living, and that addictive behavior is not compatible with this goal

On the other hand, even with this commitment, clients accept that they might have a lapse and once again engage in the addictive behavior. Thus, they need a harm reduction plan

Dialectical Abstinence as a Synthesis = the search for a synthesis (in other words, a combination of parts) between abstinence and harm reduction. Both exist and both must be acknowledged and applied depending on the situation


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Pros and Cons of Abstinence vs. Harm Reduction

The pro of abstinence is that people who commit to abstinence stay abstinent from their addictive behavior longer

The con of abstinence is that it usually takes longer for people to recommit to abstinence once they’ve slipped

People who commit to harm reduction usually recommit to sobriety more quickly after a slip, compared to those who have committed to abstinence

How to Do Dialectical Abstinence

1. The client must find a way to make a strong commitment to abstinence

2. They need a plan to stay abstinent 3. They must plan for harm reduction if a lapse occurs

Included here is Distress Tolerance handout 17A to guide you in helping clients plan for both of the above.

Client Plan for Abstinence

Make a strong verbal commitment to abstinence Set a goal to stop addictive behavior; set a specific date to

stop Make a verbal commitment to yourself, and share it publicly

with other people When faced with the urge to engage in addictive behavior,

REJECT the idea that it is OK to give in for the moment, and then plan to go back to abstinence

This may be viewed as “slamming the door shut” on addictive behaviors For example: Olympic athletes must think and say that they are

going for the gold. If they thought or said that winning a bronze medal would be “just fine,” their training mentality, motivation and ultimately performance would very likely be decreased.


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Client Plan for Harm Reduction

Abstinence over the long run requires both committing to abstinence and planning for lapses

For example: A person practicing dialectical abstinence is like the quarterback in a football game. After the play is initiated, all efforts are oriented to run the full distance to touchdown. The person practicing dialectical abstinence takes a similar approach: running like mad in the direction of the goal (abstinence), stopping only if he falls, and ready to get up and resume with full intent to obtain a touchdown

So: prepare for the possibility of lapses so that if a slip occurs, it is dealt with promptly and effectively by accepting it nonjudgmentally and getting back up onto the wagon.

Client Relapse Prevention Plan

Decide who to call. How will you remember to get right back to abstinence? What will you do to motivate yourself to get right back to abstinence? What skills will you use?

Rehearse implementing your dialectical abstinence (crisis) plan. If you do slip, immediately fight with all your might the

“abstinence violation effect.” This occurs after a lapse when a person feels guilty, ashamed and out of control and chooses to give up and give in to urges to use ALL OUT

After a lapse, recommit yourself to 100% total abstinence, telling yourself this was the last time you will ever slip BUT preparing again to find a harm reduction path if needed in the future

Client Types of Mind: Addict Mind Addict Mind: The state of mind when you have given in

to your addiction. You are ruled by your addiction, urges to engage in your addictive behavior govern your thoughts, emotions and behaviors

In addict mind, you are willing to do whatever is necessary to get the “high.” You are willing to lie, steal, hide, break promises, and even deny that you are an addict

Addict Mind Behaviors: Engaging in the addictive behavior, glamorizing

addiction, stealing to pay for addictive behaviors, lying, hiding, isolating, etc.


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Client Types of Mind: Clean Mind

Clean Mind: you are in “clean” mind when you have not engaged in the problem behavior for a period of time, and you are obliviousto the dangers and temptations of relapsing

In clean mind, you may feel invincible. The danger is that you will not avoid triggers and addiction cues and may fail to use relapse prevention strategies

Clean Mind Behaviors: Thinking you have learned your lesson and do not have to worry any more about the addiction; going into environments where others engage in the addictive behaviors, seeing and living with people who have the addiction, acting as if all you need to get over your addiction is willpower

So, clean mind sounds good, but is a risky state to stay in

Client Types of Mind: Clear Mind

Clear mind is the synthesis between clean mind and addict mind. In clear mind, you are clean, while at the same time you stay aware of the dangers of relapse and actively engage in behaviors to prevent a lapse or relapse

Of course, it is the safest place to be Clear Mind Behaviors: You are abstinent and vigilant re

temptation. You are acutely aware that without skills, intense urges can return and be acted on at any moment. You stay in close touch with your skills

Replacing Addictive Behaviors

Stopping addictive behaviors requires replacing reinforcers of addiction with reinforcers of abstinence

Willpower is not sufficient to change behavior (or else we would all be perfect)

The goal is to make a lifestyle without the addictive behavior more rewarding than a lifestyle with the behavior. So the client must: Increase the number of pleasant activities engaged in that do

not involve addiction. Search for people to spend time with who aren’t addicted


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Techniques for Clients that Help Avoid other addicts Teach nonaddicted friends or loved ones about

reinforcement. Ask them to be vigilant for when you are abstinent, and give you lots of reinforcement (praise or M&Ms)

Monitor your abstinence motivation: When your motivation drops off, review your plan for dialectical abstinence and again do the pros and cons for abstinence vs. addictive behavior

Another (Dialectical)Technique: Client Abstinence Sampling

This involves trying out abstinence to see what it is like and to see if you find any benefits from abstinence

This is like doing a personal experiment; you do not have to commit for the long term until you see how it goes

Although the short term emotional high and relief of addiction will not be there (the pros), neither will the terrible consequences of the addictive behavior (the cons). How to do this:Commit to a specific number of days of abstinence To get through, implement your dialectical abstinence planObserve and describe (mindfulness skills) all the positive events

occurring when you are not engaging in addictive behaviors

More Techniques: Client Burning Bridges

Burning bridges is a skill of radical acceptance, commitment, and action, all directed toward never engaging in the addictive behavior again

The action component refers to actively cutting off, and removing from your life, all connections to potential triggers for the addictive behavior; you burn the bridge to addictive behavior so that this behavior is no longer an option. This will likely involve some changes to your social media contacts! Like blocking people…


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Burning Bridges: How to do it1. Identify and make a commitment to get rid of everything in your life that makes addiction possible2. List everything in your life that contributes to addictive behavior. NOW is

the time for complete honesty=no holding back3. So, get rid of these things:

Phone numbers, email address, and other contact information of people who enable your addiction

Clothes, paraphernalia and household items associated with addiction Cash or secret credit cards that can be used to buy drugs Items in your house that facilitate the addiction (e.g., do not keep alcohol

or bongs or steel wool in your house)4. List and do things that will interfere with addiction: tell the truth about your behavior to others; tell friends and family you have quit the behavior

Building New Bridges: How to do it

1. Find pleasurable but nonaddictive images and smells to think about when you have an unwanted craving. These need to engage the visual and olfactory systems of you brain, and “steal” space (i.e., distract from)the craving.

Example: Whenever you crave a drink, eat a cookie, smell an essential oil such as lavender. Look at a favorite photo. Keep the visual images and the smells “alive” to reduce the craving for alcohol.

2. Surround yourself with new smells, new tastes, new sensory input (e.g., ice on your face) that change your attentional focus.

Example: When you crave cocaine, smell something that you find pleasant but that is not like cocaine, such as perfume, or pine needles, or even smelling salts (this requires you have these items available, so PLAN AHEAD!)

Yet Another Technique: Engage in Urge Surfing

Urge surfing is like surfing or riding a wave: instead of trying to stope its movement, you surf on top of it.

Urge surfing is a form of mindfulness: by using the mindfulness skills of observing and describing, you can “surf” over urges to engage in addictive behavior.

The key to urge surfing is NOT reacting: You must step back and not react. Notice the urge, moment by moment, particularly how, like a wave, it evolves and shifts over time.

Urge surfing involves retraining the brain: When people give into their urges and engage in addictive behaviors, they reinforce the link between having an urge and acting on it. Urge surfing detaches the urge from engaging in the behavior.

Urge surfing involves imagery: imagine yourself on a surfboard riding the waves. Keep this image in you mind to help you remember that urges don’t last forever. This urge WILL go away. And the thought “I need a drink” can be seen as simply a thought, NOT a fact.


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And Yet Another Technique: Alternate Rebellion When addiction functions as a way to rebel, giving up

addiction seems to require you give up rebellion With alternate rebellion, you can satisfy the need to act

rebellious without destroying yourself or blocking your way to achieving important goals

So, you choose another apparently rebellious, but nondestructive behavior to substitute for the addictive behavior

So you can fulfill the desire to rebel in a creative way, rather than suppressing it, judging it, or mindlessly giving in through addiction

Alternate Rebellion: some examples

Dress in a very flamboyant style Leave the lights on all day Get a tattoo, temporary or not Color your hair like a rainbow or bleach it platinum,

temporary or not Open all the windows in your home Stop cleaning for a while Put an irreverent bumper sticker on your car Kiss your dog (cat, horse, potbelly pig) on the lips

One Final Technique: Adaptive Denial

Adaptive denial refers to convincing yourself (adamantly) that you don’t want to engage in the addictive behavior when the urge hits, or that the addictive behavior is not a possibility

Tell yourself that engaging in the addictive behavior is simply not possible and that you want something else besides the addictive behavior. Tell yourself this is simply a FACT right now

Tell yourself to put off the addictive behavior, for five minutes, then another five minutes, and so on. Each time, tell yourself you have to stand it for five minutes only. Nothing more!!!


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Individual Therapy in DBT

“Skills training tries to cram the skills into the person, and individual psychotherapy tries to

pull them out.”

Individual Therapy in DBT

The aim of individual therapy is to integrate these skills into the client’s daily life and to increase the frequency of their use.

Individual Therapy in DBT First Stage Targets:

Decreasing life threatening behaviorsDecreasing therapy-interfering behaviorsDecreasing quality-of-life interfering behaviors Increasing Behavioral Skills

Core MindfulnessInterpersonal EffectivenessEmotion RegulationDistress Tolerance

Second Stage Target:Decreasing posttraumatic stress


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Individual Therapy in DBT: How to pull the skills outFirst: Diary Cards

Each individual session, after a couple minutes of check-in, ask “Do you have your diary card?”

If client has it, review it with client and determine an initial agenda for the session

If the client doesn’t have it, ask whether she filled it out, what happened to it, and ask her to fill it out right now.

Diary Card example coming up!


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07/22/19 – 07/23/19


Using the DBT Diary Card

In order to benefit from the diary card, the client must fill it out! This may require

How to get a commitmentExplain to the client why it is a crucial aspect of treatment Inform the client that the diary card will make sessions

more effective and allow better monitoring of her thoughts, emotions and behaviors.


So, at the beginning of treatment, the therapist hands the client a diary card and says: “Here is a form that will be extremely important for us to

use to stay focused on what is going on in your daily life that is giving you great distress. Sometimes therapy sessions can get off track and focus on the most recent problem, but not the problem that caused the greatest misery in the last week.”


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Continue: “So, I want you to rate each day of the week all the urges,

impulses, feelings and actions you had. Then we can pick the ‘worst’ day you had and explore what exactly made it feel so bad. By doing this weekly, over time we will be able to identify patterns in your life that lead to emotional distress and problem behaviors. And once these are identified, we can work to find ways to change them.”

Such an explanation of leads to increased commitment


Recall, after an initial greeting and brief check in, which might take anywhere from 30 sec. to several minutes (but no longer), the therapist asks for the diary card

Try not to: Look over the card and then announce the session agenda

Instead: Be collaborative when creating the session agenda. Identify target behaviors on the diary card and obtain agreement of the focus of the session (keeping in mind the target hierarchy)


Effective review not only determines the session’s focus, but also involves: Cheerleading the client’s completion of the DC Encouraging mindful attentiveness to treatment goals Validating the pain that produces these thoughts and

actions Validating the difficulty of staying on track.


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If the client has failed to complete the DC effectively (or at all), the therapist:Asks what interfered with the completion of the cardExplains again why the card is so important to treatmentObtains a commitment to complete the card for the next

week

In most cases, the therapist will request the diary card to be filled out during session, which reinforces the importance and gathers the necessary information


Once the therapist has used the DC to determine current level of substance use, decisions must be made on what to focus on in the session.

If SA risk is high, this will be the focus of the session. This target behavior will be addressed with a behavioral chain analysis (BCA). The first function of the BCA is to determine the variables

that led to the client’s experience of increased substance use

The second function is as the initial step in a problem-solving sequence, i.e., how to solve (manage) the problem of increased substance use

Individual Therapy in DBT: How to pull the skills out (From Diary Card To Problem Solving Strategies)

The therapist uses the diary card to determine if the client engaged in target behaviors throughout the week These target behaviors then become the focus of the session for

problem solving

Problem solving is a two stage process for the client: Understanding and accepting the problem at hand (solving

problems requires first accepting the existence of a problem)

Generating, evaluating, and establishing effective solutions.

This process is implemented with a behavioral chain analysis.


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Individual Therapy: Behavioral Chain Analysis

Chain analyses are one of the most important strategies in DBT. They are the first step in problem solving.

A chain analysis must be carried out collaboratively. It occurs in the (dialectical) context of both validation

and a focus on future change. It must contain sufficient detail to give an accurate

picture of the internal and external events associated with the problem behavior.

Behavioral Chain Analysis worksheet provided



Describe the specific problem behavior For example, throwing a chair, cutting, suicidal behavior

(more on that later), missing group or therapy appointmentsBe very specific and detailed. No vague terms. Identify exactly what you did, said, thought or felt. Describe the intensity of the behavior Describe the problem behavior in enough detail that an actor

in a play or movie could recreate the behavior exactly


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Individual Therapy: Behavioral Chain Analysis Describe specific prompting event that started the

whole chain of behaviorStart with the environmental event that started the

behavior. Always start with some event in the environment. Possible questions: What was going on right before the problem startedWhat were you doing, thinking feeling or imagining at the

time?Why did the problem behavior happen that day instead of

the day before?

Individual Therapy: Behavioral Chain Analysis Describe vulnerability factors that were in place before

the precipitating event. What factors in yourself or your environment made you more vulnerable to engage in the problem behavior?

Areas to examine are: Physical illness; unbalanced eating or sleeping; an injury Use of drugs or alcohol; misuse of prescription drugs Stressful events in the environment Intense emotions, such as sadness, anger, fear, loneliness Events that bridge you back into childhood distress


Describe in detail the chain of events that led to problem behaviorWhat next? What exact thought (or belief), feeling, or action followed

the precipitating event? What thought, feeling, or action followed that? What next? What next? Etc.

For each link in the chain, ask: Is there a smaller link I could describe?


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What are the consequences of this behavior?How did other people react immediately and later?How did you feel immediately following the behavior and

later?

Describe different responses to the problemCircle each point or link where if you had done something

different you would have avoided the problem behavior.What coping behaviors or skillful behaviors could you have

used?

Individual Therapy: Behavioral Chain Analysis Describe prevention strategies

How might you have kept the chain from starting by reducing your vulnerability factors?

Do you need to make a repair for the consequences of the behavior?

Individual Therapy: Choosing Problem Solving Techniques

A chain analysis allows the therapist to determine what problem solving techniques would be most effective

The best technique is ascertained by the answers to four sets of questions related to the chain analysis

These four techniques are: skills training, contingency management, exposure, and cognitive restructuring


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Skills Training: Technique One

Question to answerDoes the client have the skills to avoid the problem

behavior in her repertoire, that is, does she know how to: Regulate emotions? Tolerate distress? Respond to conflict? Act mindfully? Manage her behavior?

If answer is NO, Target behavioral skills training, focusing in individual

therapy on making sure client practices these skills in her everyday life (cf. information from diary card)

Contingency Management: Technique Two Questions to answer

Are ineffective behaviors being reinforced?Do ineffective behaviors lead to positive outcomes?Are effective behaviors followed by neutral or punishing

outcomes, or are rewarding outcomes delayed? If YES,

Attempt to alter reinforcement contingencies through careful assessment of both what behaviors are being reinforced and what behaviors are lacking reinforcement.

Contingency Management

Some very powerful reinforcers involve the quality of the therapeutic relationship.

Once a strong positive relationship has been developed, the most effective reinforcer available to the therapist is expression of warmth and approval in the relationship (e.g. gold stars).

And, on the other hand, dialectically, the withdrawal of warmth (done VERY judiciously) is used as an aversive consequence of non-attentive, non-collaborative behaviors.


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Contingency Management

Confrontation and withdrawal of therapist approval and warmth can be extremely aversive for the DBT client

In fact, they can be so aversive that the therapist has to use them not only with very great care, but also in very low doses and very briefly.

Expressions of disappointment or dismay can be very effectiveSuch expressions may be verbal or non-verbal. (This does

NOT MEAN you get to express anger or high levels of frustration.)

Exposure Procedures: Technique Three

Questions to answerAre effective behaviors inhibited by unwarranted fears or

guilt? Is the person emotion-phobic?Are there patterns of avoidance or escape behaviors?

If YES, Exposure based procedures are required.

“Professor Gallagher and his controversial technique of simultaneously confronting the fear of heights, snakes, and enclosed spaces.” (=extreme exposure technique)


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Exposure-Based Procedures

Many DBT clients are emotion-phobic, often due to past traumatic events This has left them with unresolved emotional reactions that

they have attempted to avoid or reduce by drug abuse, dissociation, self-harm and/or suicidal actions.

The procedures used in DBT require non-reinforced exposure to images or thoughts that prompt fear, sorrow, guilt, shame or anger, while blocking or reversing automatic, maladaptive emotions and behaviors.

N.B. Clients dislike exposure techniques and thus they need to be applied in small does with lots of validation.

Cognitive Structuring: Technique Four

Questions to answerAre effective behaviors inhibited by faulty beliefs and

assumptions?Do these faulty beliefs appear to lead to negative feelings

and/or unskillful actions?

If YES, Then cognitive modification procedures are necessary. Think CBT.

Cognitive Restructuring

Clients often: Engage in selective attention, magnify and exaggerate

the negative aspect of events, form absolute conclusions, view the world in a categorical, black vs. white manner; and they do these things very rigidly.

When questioning or challenging inaccurate cognitions, it is important to remember:Cognitive procedures should always be blended with

validation. Most DBT clients have spend their entire lives listening to others accuse them of distorting and misperceiving events (the invalidating environment), so validation really is crucial.


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Cognitive Restructuring

One of the most important “facts” to learn in DBT is that thoughts ARE NOT facts.

This must be pointed out time and again (and again), because clients have often accepted every thought they have as a fact (e.g., “I need a drink.”)

Here, the client benefits from regarding thoughts as mental events that will pass, like cars on a train, which will move on unless a person jumps aboard.

Phone Coaching

The primary rationale: to provide the client with access to the therapist during a crisisAllows for skills generalization to everyday lifeAllows client to reduce her emotional distress and engage

in more effective behavior with therapist support In that moment, the therapist is acting as the client’s

frontal lobe

Phone Coaching

In Linehan’s and our experience very few DBT clients actually abuse telephone privileges, and in fact, often fail to call when they should

Educate client about these calls24 hour ruleAny limit setting? Length of time to wait for a call backWhat to do if therapist is not immediately availableHow long a call should lastNO TEXTING!


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Phone Coaching

Phone coaching calls are NOT meant for:Analyzing a crisisGenerating solutions to the crisis ORSolving a crisis (no behavioral chain analysis or therapy

over the phone). Phone coaching calls ARE meant for:

Getting through a crisis without doing something that makes it worse (distress tolerance skills)

Analyzing and solving can be done in the next therapy session

Phone Coaching

When a call happens:Get brief description of the current situationValidate client’s emotionsDetermine what skills have been used thus far (if any) If client has tried skills prior to calling, praise herAsk what skills have been helpful in the past (if applicable). Suggest skills such as: TIP, Distract, or Self-Soothe If call occurs in the evening, ask if the client has taken her

PM medications. If she has not, have her set the phone down and take them immediately

Consultation Group in DBT

Linehan believes that it is extraordinarily difficult to deliver effective treatment in DBT without a consultation group, because:DBT clients engage in the three most stressful client

behaviors there are: suicide attempts, suicide threats, and hostility

They also communicate their intense suffering at every turnProgress in therapy is much slower than with other clients


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Consultation Group in DBT

Clients often beg their therapist to help them immediately and threaten suicide if they fail

This would not be so stressful if they could be helped immediately, but usually they cannot

Therapists end up feeling incompetent, ineffective, and helpless in a situation where they very much care and want to succeed.

The consultation group was designed as a way to help therapists cope with these problems

The Brain in the Palm of Your Hand

Daniel Siegel

Mindfulness Skills

In summary, the mindfulness skills teach suicidal clients how to focus their attention in the present moment, observing and describing this moment nonjudgmentally, thereby reducing emotion mind (limbic system) arousal before suicidal urges turn to actions


Brain

07/22/19 – 07/23/19


Mindfulness Resources: Free Guided Meditations

Tara Brach: https://www.tarabrach.com/guided-meditations/

Headspace app: https://www.headspace.com/ Honest guys:

https://www.youtube.com/user/TheHonestGuys/videos Kristen Neff: http://self-

compassion.org/category/exercises/#guided-meditations Audio Dharma: http://www.audiodharma.org/ UCLA: http://marc.ucla.edu/mindful-meditations


The skills topic rated second in efficacy for decreasing suicidal urges was Distress Tolerance.

Across the large range of distress tolerance skills taught in DBT:Adults rated the TIPP and PROS/CONS skills as most helpfulAdolescents believed this distinction fell to the Activities skill


Distracting with Activities Activities involve doing things that fill one’s attention or

short-term memory with images and sensations different from those evoked by the crisis.

Activities can affect physiological responses and expression of emotions directly.

Adolescents said they like activities because they are practical and easy to initiate. This includes the temperature component of the TIPP skills,

because in school a student can almost always get to the bathroom to put cold water on her eyes.


Brain

07/22/19 – 07/23/19


Assessing and DecreasingSuicidal Behaviors

In summary, the DBT diary card, the behavioral chain analysis and the skills taught in Skills Training, especially the ones described above, are crucial to reducing suicidal ideation and action. Their use gives clients an alternative to suicide as a solution to misery.

Their practice allows new neural networks to be constructed and new behaviors to replace old solutions.

Ultimately they provide the foundation for the client to find the path to a life worth living.

Questions, comments, concerns?

Documents

Dialectical Behavior Therapy: 07/22/19 –07/23/19 Its Role ... - Dialectical... · Dialectical Behavior Therapy: Its Role in Treating the Traumatized Brain 07/22/19 –07/23/19 Jaye