Download ppt - New Employee Training in Dialectical Behavior Therapy Created by Shannon Olson Dialectical Behavior Therapy Specialist for The Larkin Center

New Employee Training in Dialectical Behavior

Therapy

Created by Shannon OlsonDialectical Behavior Therapy Specialist

for The Larkin Center

July 13, 2007 Created by Shannon Olson 847-695-5656 x269

A Life Worth LivingA Life Worth Living• This is the ultimate goal

of Dialectical Behavior Therapy.

• It is the goal of every client and therapist(s) working together as a collaborative team and we are all therapists.

• To do this we must start with why Larkin chose DBT and the assumptions DBT makes about both the client and therapy.

• Then we will go through the Biosocial Theory and what that means for us.

• Review what dialectics are and how DBT uses them.

• Next we will review Levels of Disorder and what they are for.

• Finally we will go over each of the 4 skills that DBT teaches and why we teach them!


Why are we “all about” DBT?• Prior to Dialectical Behavior Therapy as a treatment approach, the

majority of our clients had been behavior disordered and now the majority are mentally ill clients with behavioral problems and our B.D. approach was no longer working. Also, Larkin believes that the residential therapist is the lead for each of their 5 individual clients. However, therapists are trained differently and can direct the treatment team in a number of ways. This made life very confusing and frustrating for child care workers, activity therapists, case managers and even case workers. Not to mention the other clients on the unit!

• This confusion limited our ability to give treatment as a team, which led to a lack of unity and support. This led to staff burnout and we became less effective to meet the needs of our clients.

• DBT is a research proven model that gives us practical tools (the skills) to teach our clients and a universal way of interacting with them that reduces power struggles, treatment refusal, hospitalization and physical restraints.

• We as a treatment team have a common language and understanding as well as a “plan of attack” for providing clients with the best treatment.


“I Thought Assumptions Made An…?”

DBT understands that every person has a personal set of values, beliefs and perspectives. When so many different people come from so many different places it can send clients scurrying for cover because no one can agree on anything!

In DBT, assumptions are about ONE belief system or perspective from which we approach each client.

It is from this foundation that all treatment must stem. Otherwise we fail and so does DBT and the one who loses is the client.


DBT Assumptions about Clients

• Clients are doing the best they can in the moment.• Clients want to improve.• Clients must learn new behaviors in all relevant

contexts.• Clients cannot fail in DBT.• Clients may not have caused all of their own

problems, but they have to solve them anyway.• Clients need to do better, try harder and/or be

more motivated to change.• The lives of clients are unbearable as they are

currently being lived.


DBT Assumptions about Therapy

• The most caring things a therapist can do is help the client in ways that bring them closer to their own ultimate goals.

• Clarity, precision, and compassion are of the utmost importance in the conduct of DBT.

• The therapeutic relationship is a real relationship between equals.

• Principles of behavior are universal, affecting therapists no less than clients.

• DBT therapists can fail.• DBT can fail even when the therapists do not.• Therapists treating clients need support.


Biosocial Theory• At it’s core Biosocial

Theory takes each individual’s environment and genetic make up, and puts them together to paint the full picture of each person in order for us to know where they are coming from, what skills they already have and which skills they still need to learn.


The Biology Of Us• “Bio” (of biosocial) is the nature

part. The deficits we are born with.

• DBT says that there is a biological vulnerability to emotions:– High sensitivity to emotions– High reactivity to emotions– Slow return to baseline, or “normal”– As well as an inability to successfully

regulate emotions

• This can be caused by a vast number of reasons, like: Fetal Alcohol Syndrome, mental retardation, genetic disorders and diseases, poor or no prenatal care, maternal addictions, history of family mental illness, birth defects, etc. The list is long for what could go wrong before we are even born!


How we are loved can determine how we grow

• Nurture is all about the environment we grow up in. This is the “social” part of biosocial theory.

• Many times for our clients there’s a poor fit between the person and the environment.

• DBT calls that poor fit the Invalidating Environment, which tells us that what is being felt, thought or done is inaccurate, inappropriate, or wrong.

• That environment often rejects, punishes and makes them feel ‘less than’- and then…

• Our clients may begin to tell themselves the very same things!


Go Slow and Be Kind• So we take our time to

get to know each client because we want to know them and their unique story.

• It is with this story that we will be able to figure out, with them, what they want and need.

• That will allow us to provide the best treatment possible.


Dialectics in DBT• Dialectics means “2 points-of-view that appear

opposite AND can be true at the same time.”– Guiding Dialectic of DBT: Acceptance and

Change• Ex: ‘A client is doing the best they can in the moment AND

they need to do better.’• How can we accept the client where they are AND ask

them to change?– We understand, or validate, what they are doing based on

who they are, what they’ve been taught or what is in their history AND believe that they must be more skillful to have a better life.

– Details of Dialectics• No absolute truths• Always a chance we could be wrong

– Be open to the possibility• Consider the “and” in every situation


Emotion VulnerabilityVerses

Self-Invalidation• Emotional Vulnerability is

on the “biological” or “nature” side of Biosocial Theory. It is:– Sensitivities that we are

born with that make us more vulnerable to being controlled by our emotions

– Examples: genetic predispositions to mental illness, addictions, illnesses, Fetal Alcohol Syndrome, poor prenatal care, etc.

– Left, Cuba Gooding Jr. portrays “Radio” a mentally challenged young man who faces daily discrimination and humiliation at the hands of high school football players until their coach puts an end to it by asking Radio to join the team.


Wouldn’t it be nice if “I’m rubber, You’re glue…” actually worked?

• Self-Invalidation is the opposite of Emotion Vulnerability and is on the “social” or “nurture” side of the Biosocial Theory. It is:– All the times our clients heard that

they are stupid, their feelings are wrong or that they’ll never amount to anything that build up to the times when they tell those things to themselves.

– Then it goes from what others tell them to things they tell themselves.

– It’s like that sad saying goes, “If you hear something enough you start to believe it.”

– Negative self-talk is Self-Invalidation.– Right, Michelle Pfeiffer plays Louanne Johnson in

Dangerous Minds. Here she is trying to convince Emilio, her student, that he can change his life but he is convinced that his life is glued to the ghetto and getting out is not an option for him. Sadly, this becomes a self-fulfilling prophecy and he is killed.


Unrelenting Crisisverses

Inhibited Experiencing

• Unrelenting Crisis• Life of chaos• Difficult things happening one

after the other after the other; no break; no rest; no peace.

• Difficulties may be big or small and all add up and leave them feeling exhausted.

• By living this way, many times, in order to survive they shut down emotionally and move to the opposite which is inhibited experiencing.

Left, Steve Martin in Cheaper by the Dozen, has breakfast with his 12 children. One is trying to capture his runaway pet frog who jumps onto the table and chaos ensues.


“If I go numb no one can hurt me, but then I can’t feel joy either.”

• Inhibited Experiencing• The grieving process that gets

stuck before moving through acceptance.

• We get stuck in anger or depression and shut down emotionally.

• Without being able to move through acceptance we can’t actually move forward.

• By shutting down one emotion we shut down all of our emotions which can deepen depression.

Right, from Batman Begins Christian Bale as Bruce Wayne, revisits his parents’ graves. A tragedy that happened as a child that he carries with him into adulthood. His depression and pain are clear and his inability to enjoy love makes it certain that he is plagued by Inhibited Experiening.


Active Passivityverses

Apparent Competence• Active Passivity• This is when someone

actively works on getting you to meet their needs instead of doing it themselves.

• The passivity comes into play when the person’s needs are met by the actions of someone else instead of their own.

• Left, Bagger Vance’s (Will Smith) arrival into Rannulph Junnah’s (Matt Damon) world completely alters the course of his life in The Legend of Baggar Vance. Junnah leaves behind his lady love and his amazing golf abilities to go to war. When he returns he completely checks out of his life and drinks himself into oblivion. Vance happens upon him late one night on the golf course and challenges him, which later gives Junnah back his swing and his girl. Sometimes we all need a kick in the pants to get moving again!


Fake it till youmake it…right?

• Apparent Competence• This is when a client looks to be more

skilled than they are. It does not mean that there are no skills, but it does mean that those skills have not been learned in all areas of one’s life like school, home and work.

• Apparent Competence hides their inabilities from others while Active Passivity hides behind getting someone else to be skillful for them. It’s easy to see how a client may start out hiding their inabilities from everyone and then, possibly as shame grows, learn to hide behind someone else instead.

• Right, from the movie What Women Want Nick Marshall (Mel Gibson) presents as a charming, highly successful advertisement executive who loses his promotion to a woman because he has no idea what women want. However, he gets her fired because he steals her ideas making him look more competent than he is.


So how do we use Dialectics?

• The teeter totter is a visual aid for dialectics:

• One dialectic from each pair is on opposing sides of the beam and typically our clients will lean more heavily in one direction than the other causing an imbalance within themselves (like the picture to the left).

• DBT believes that our clients experience more pain due to being “out of balance”.

• DBT wants them to use pain as motivation to change by learning skills in order to move toward the middle of the beam and therefore create balance and less emotional suffering .

• Our job is to help the clients, by how we treat them and what skills we teach them, to use their pain/discomfort to find that balance between these dialectics.


“With all this stuff going on with each client, how do you know where to start?”

• Levels of Disorder are a way that DBT developed to help us, as a treatment team, figure out where each client’s starting point is in terms of their behaviors and needs.

• By knowing where to start we can look ahead toward discharge and what the client will act like when he or she is ready to leave Larkin Center.

• Treatment plans tend to look like a ladder over time.

– At the bottom are the behaviors we are currently seeing and at the top is the way we expect the client to behave when he or she is ready for discharge.

– All of the rungs leading from the bottom to the top are the goals that we try to help each client achieve.

• But before we can work with the client to plan their path we must first be able to recognize where each client is at in the levels of disorder.


Levels of disorderBasement Level 1: Hell/Chaos

• In Hell nothing feels good, which means reckless, destructive behaviors are obvious.

• Clients think: “If nothing feels good, I’ll do whatever might feel good right now because it’s not going to change anyway.”

• Hopelessness• Avoiding pain/living with their

reality• Testing dedication of staff

Right, Dylan Klebold and Eric Harris slaughter their classmates and teachers on April 20, 1999 in Columbine High School’s cafeteria. The lives of CHS students are thrown into complete chaos .


1st Floor Level 2: Quiet Desperation

• Previous life threatening or acting out behaviors are now internalized; They are still felt, but we can’t see them.

• They are much more fragile; need BIG rewards to keep them here.

• It’s agonizing; very sad-thinks about hell a lot.

• NOW: skills training, relationship, validation & praise to not go backwards.

• Left, a Columbine student mourns the loss of his classmates, his school and his innocence. This is exactly what Quiet Desperation looks like: silent misery and unimaginable pain.


2nd Floor Level 3:Problems in Living

• Every day life difficulties, which can be dealt with.

• Ex: Job issues, relationship problems, paying the bills, etc.

• Movement between levels or floors may be due to a lack of skills generalization to all areas of functioning

Right, A stairwell in Columbine High School without the carpet that would normally be on the stairs due to the blood stains left behind after the massacre. It was in the process of being re-carpeted. One change that can be made to improve life without changing life as we know it. The process of moving forward…that’s “problems in living.”


Attic Level 4:Incompleteness

• Hope of something more

• Search for wholeness

• May be called a spiritual journey

Left, the entry to a memorial website by those left behind for those lost in the Columbine High School Massacre. Jennifer Wallick stated in her 1999 commencement speech, “If we remember them all, then they can never leave us. Never let them go. They are waiting for us in that realm of pure blue, that mysterious place where the earth meets the sky.”


So What Does All That Mean?

• The vast majority of our clients are in level one (Hell) or level two (Quiet Desperation).

• We see a lot of aggressive behaviors, running away, promiscuity, property destruction, threats to harm others, threats to harm themselves, self-harm behaviors like: cutting, picking or scratching, pulling at hair, and drug use and abuse. Those are the more overt behaviors of clients who are in Hell.

• We also see client’s withdraw into themselves. They stop getting involved with anyone else, they drop out of activities, get very quiet, etc. It’s like they always say: “It’s the quiet ones you have to watch out for.” These are the clients we need to work hard to bond with and draw out. Now is the time to teach them some skills (which are in the pages to follow), because now is when life is at it’s most painful.

• Sometimes we are lucky enough to have a client in Problems in Living. Our goal is to get all of them there and then help them move on.


Mindfulness:States of Mind

• 3 States of Mind– Reasonable Mind (1)– Left side of the brain

• The facts; just the facts• Logical• Analytical• Flat affect; monotone

– Emotion Mind (2)– Right side of the brain

• Emotional side• Irrational thinking• Impulsive• Reactive

• Location of compassion/ empathy

– Wise Mind (3) is the goal

– Right & Left brain working together

– 1 (reasonable)plus 2 (emotion)= 3 (wise)

• Includes intuitive knowing or gut instinct

• What you know to be the truth deep in your heart when you are calm

• Again, each is important but the goal is to get to wise mind and bring together the best of Reasonable and Emotion Mind.


Mindfulness1st Acceptance Skill

Getting Control of your Mind

• Taking a hold of your mind: “What” Skills

• Observe– Simply notice the

experience– Be alert!

• Describe– Put words (facts) on your

experience

• Participate– Enter into & become one

with your experience unselfconsciously

• Taking hold of your mind: “How” Skills

• Non-Judgmentally– Remove your opinions

from the facts

• One-Mindfully– Do one thing at a time

• Effectively– Keep your eye on

YOUR OBJECTIVE


Distress Tolerance2nd Acceptance Skill

Crisis Survival Strategies

• Getting through the moment without making it worse (is our motto!)by using:

• Distract• Self-soothe• Improve the

moment• Weigh the Pros and

cons


Emotion Regulation: 1st Change Skill

How to better regulate your

emotions• Understanding

Emotions• Observe and Describe

Emotions• Understand the

Function of Emotions• Reducing

vulnerability to negative emotions

• Build Positive Experiences

• Be Mindful of Positive Experiences

• Be Unmindful of Worries• Letting go of Painful

Emotions– By Being Mindful of

Your Current Emotion• Change by Acting

Opposite to Unjustified Painful Emotions


Interpersonal Effectiveness Skills:2nd Change Skill

• OBJECT EFFECTIVENESS– Get your objectives or goals

met by asking yourself:• What specific results do I

want from the interaction?

• What do I have to do to get those results?

• RELATIONSHIP EFFECTIVENESS– Getting/keeping a good

relationship by asking:• How do I want the other

person to feel about me after the interaction is over?

• What’s needed to get (keep) the relationship?

• SELF-RESPECT EFFECTIVENESS– Keeping/improving self-

respect while achieving your objectives by asking:

• How do I want to feel about myself after the interaction is over?

• What do I have to do to feel that way about myself?


One more tool for your tool bag:

VALIDATIONVALIDATION• Validation is:

– Finding the kernel of truth or wisdom in the client’s behavior (no matter how bad it is)

– Seeing the world from the client’s point of view, and saying so! (Without knowing where our clients are coming from we fail to understand them and therefore fail in providing the best treatment possible.)

• Validation does not mean you have to:– Agree with the client– Approve of the client’s behavior, or– Convey warmth


Here’s how you VALIDATE

• Staying Awake: Unbiased listening and observing-Just be quiet and stay focused on the client.

• Accurate Reflection-saying back to them what they told you, but in different words and without judgment.

• Verbalizing the unspoken emotions, thoughts or behavior patterns- before you do this you must have a solid relationship with the client.

• Validation in terms of past learning or biological dysfuntion-what the client has been previously taught or in the context of their mental illness, learning disorders, mental impairment, etc

• Validation in terms of present context or normative functioning-Understand where they are coming from in terms of what they are going through right now or their stage in life and development

• Radical Genuineness-Being kind and real at the same time.


Here’s why we teach these skills and what our end goal is…

• Skills are taught because we believe that no one wants to live the lives our clients have, including them.

• Mindfulness activities help each client get into the present moment, because we understand that the trauma they have endured causes them to fear the future and focus on (and relive) the past.

• Distress Tolerance skills are designed to help our clients get through stressful, painful or enraging moments or experiences. These moments of distress are apart of life and cannot be avoided.

• Emotion Regulation skills help our clients gain insight into where their emotions are coming from and what’s makes them react so that they can learn ways to prevent or reduce their triggers.

• Interpersonal Effectiveness skills assist our clients in enhancing their relationships and getting their needs met in a manner that is respectful to both parties.

• We understand that they did not create all of their issues and they have to solve them anyway if they are ever going to have a life worth living. To do this they need these skills to give them better ways to cope and effectively deal with their lives and past traumas.