Dialectical Behavioral Therapy:Creating a Life Worth Living

Presented by Niki Serravalle

What to expect….

• The theory–Quick overview

• The skills–Few examples

• How it relates to us and what we do

Cheese face

What is DBT:

• Developed by Dr. Linehan, Washington University to treat persons with Borderline Personality Disorders. (1991)

• A combination of CBT and Eastern meditative practices.

Dialectical Behavioral TherapyDialectical Behavioral Therapy

Marsha Linehan

What is the Dialect in DBT?

• The term Dialectics refers to opposing forces that create a whole or a synthesis. DBT focuses on finding a balance in opposing forces.

More on Dialects

DBT makes three basic assumptions: – (1) all things are interconnected – (2) change is constant and inevitable and – (3) opposites can be integrated to form a closer

approximation of the truth. In DBT, the patient and therapist are working to resolve the

contradiction between self-acceptance and change

ChangeAcceptance

The theory

Individuals are born with a biological predisposition for emotional

dysregulation who are then subjected to an invalidating environment where

they learn maladaptive behaviors which are reinforced over time.

Treatment that specifically designed for persons with BPD and high suicidal behaviors

Symptoms of a person with BDP•Make frantic efforts to avoid real or imagined abandonment. •Have a pattern of difficult relationships caused by alternating between extremes of intense admiration and hatred of others. •Have an unstable self-image or be unsure of his or her own identity. •Act impulsively in ways that are self-damaging•Have recurring suicidal thoughts, make repeated suicide attempts, or cause self-injury through mutilation, such as cutting or burning himself or herself. •Have frequent emotional overreactions or intense mood swings, including feeling depressed, irritable, or anxious. •Have long-term feelings of emptiness. •Have inappropriate, fierce anger or problems controlling anger. The person may often display temper tantrums or get into physical fights. •Have temporary episodes of feeling suspicious of others without reason (paranoia) or losing a sense of reality.

DBT Goals

• The focus of DBT is on helping the individual learn and apply skills that will decrease the effects of emotion dysregulation and unhealthful attempts to cope with strong emotions.

• Create a life worth living by improving coping skills, interpersonal effectiveness and problem solving.

The hierarchyDBT targets behaviors in a descending hierarchy:• decreasing high-risk suicidal behaviors• decreasing responses or behaviors (by either therapist

or patient) that interfere with therapy• decreasing behaviors that interfere with/reduce

quality of life• decreasing and dealing with post-traumatic stress

responses• enhancing respect for self• acquisition of the behavioral skills taught in group• additional goals set by patient

Diary Cards

How DBT Works…• Individual session that improving the client’s motivation to work

toward obtaining a life worth living• DBT focuses on group skills training to enhance Mindfulness,

Interpersonal Effectiveness and Distress Tolerance and Emotional Regulation.

• Telephone consultation is to ensure generalization of skills and effective problem-solving strategies in daily living

• The commitment to therapy is imperative to success in treatment. Individual and therapist commit to goals prior to beginning.

• A weekly consultation team meeting is held between DBT therapists for the purpose of enhancing each therapist’s own motivation and capability to effectively treat BPD clients

The Contract States…

• To accept a dialectical philosophy (at least 1 year of therapy)

• The individual will participate in therapy and follow all given directives. Even when they don’t want to. (Irreverence)

• The therapist believes that the individual is doing the best they can at all times, that behavior is a result of their past experiences, and there is a willingness to change. (Dialect)– No one can fail at DBT, the treatment fails.

Therapy Interfering Behaviors (TIB)

• arrives late• leaves early• passive or helpless• not do diary card (homework)• excessively talks (hard for therapist to talk)• complains but does not work in session• excessively angry• excessively judgmental/critical of therapist

Assumptions….• Clients are doing the best they can• Clients want to improve• Clients needs to do better, try harder and be motivated

to change• Clients have not caused their problems, but they are

forced to solve them• Their lives are unbearable (suicidal)• Clients must learn new behaviors• Clients can not fail in therapy• Therapists need support (interdisciplinary: staff

meetings a MUST)

Core Concepts (skill models)

• Mindfulness: Paying attention on purpose• Distress tolerance: Bear pain skillfully• Emotional regulation: Manage emotions

instead of being managed by them• Interpersonal effectiveness: All the skills come

together in a synergistic way

State of our Mind

• Emotional Mind: thoughts are being controlled by our emotions. Unable to be reasonable.

• Reasonable Mind: think logically, be rational about what is occurring. No emotions.

• Wise Mind: The balance of emotional mind and reasonable mind. Goal of DBT

States of Mind Diagram

Reasonable Reasonable MindMind

EmotionalEmotional Mind Mind

Wise MindWise Mind

Mindfulness Exercise

• Feel• Smell• Imagine/experience• Taste• Listen• Hear

Mindfulness

• Is paying attention on purpose

• Being non-judgmental• In the moment, present,

in the here and now• Increases awareness of

all senses

Research suggests

Mindfulness practice will….– Reduce stress

• Lowers blood pressure• Improves circulation

– Elevate mood• Brain and immune function improves• Able to recovery from negative faster

– Improve Productivity• Feel better, better work

Mindfulness SkillsThe “What” Skills The “How” Skills

• Observe: attending to emotions/behavior without trying to end (increases awareness)• Describe: apply verbal labels to behavioral and environmental events (separates emotion from thought)•Participate: action with attention, not mindless participation

• Non-judgmentally: experiencing the world around us without judgments; separate our thoughts and feelings from what's actually going on • Effectively: Use the skills that you are learning; do what works. • One-mindfully: sustained attention on the present moment; do one thing at a time

Emotional RegulationEmotions can frequently be very intense and labile, which means they change often. Emotions often drive behavior (problems to be solved). A lot of the behavior focuses around finding ways to get those emotions validated or to get rid of the pain. DBT teaches skills to manage these emotions more effectively. In the past they learned to not feel emotions because they were taught to (smile and be nice even when you feel angry or upset-invalidating environment). These emotions are a secondary response to a primary emotion (feels ashamed because I was angry).

Emotional Regulation Skills

1. Identifying and labeling emotions 2. Understanding the function of emotions3. Identifying obstacles to changing emotions4. Reducing vulnerability to “emotion mind”5. Increasing positive emotional events6. Increasing mindfulness to current emotions7. Taking opposite action

Emotional Regulation Skills:Identifying and Labeling Emotions

1. Prompting event2. Interpretation3. Phenomenological experience: physical sensation of

emotion4. Behavior expressing emotion5. After effects of the emotion on other areas of life

Event Interpretation Emotion

See bff with bf They are talking about me Anger

See my car with flat tire Someone did this to me Anger

Getting negative points Staff is out to get me Anger

See staff laughing They are making fun of me Sadness

Emotional Regulation SkillsReducing vulnerability to “emotional mind”: PLEASE MASTER

PLEASE MASTER

Treat PhysicaL Illness Take care of your body, see a doctor when needed

Balance Eating Don’t eat too much or too little, stay away from foods that make you feel emotional

Avoid mood Altering Drugs Non-prescribed drugs and ALCOHOL

Balance Sleep Get the amount that makes you feel good

Get Exercise Build up to 20 minutes a day

Act MASTERy Do one thing at a time to make yourself feel confident and in control

Distress Tolerance

• Acceptance of reality is not equivalent to approval of reality.

• DBT assumes pain and distress are a part of life; they cannot be entirely avoided or removed. Therefore one has to learn to tolerate and survive. Accept life as it is in the moment.

• DBT teaches how to bear pain skillfully.• Distress Tolerance skills address impulsivity in

high risk behaviors.

Distress Tolerance Skills

• Distracting• Self-soothing• Improving the moment• Thinking of the pros/cons

The most important aspect of these skills is the radical acceptance of the dialect…

Distracting…• WISE mind accepts:

ActivitiesContributing (changes focus from self to others, creates a

sense of meaning in life, giving back)Comparisons (changes focus from self to others by

examining how others cope)Emotions (replace with positive ones)Pushing away (leave situation causing stress, blocking, only

used in ER)Thoughts (fill head with thoughts that provide powerful,

positive physical reactions)

Sensations (hold ice cubes, snap the bands)

Improving the Moment

• IMPROVE:Imagery: Imagine relaxing scenes, things going well, or other things

that please you

Meaning: Find some purpose or meaning in what you are feeling

Prayer: Either pray to whomever you worship, or, if not religious, chant a personal mantra, LET GO

Relaxation: practice deep breathing, use self soothing

One thing in the moment: stay present

Vacation: take a brief break, allow yourself to be taken care of

Encouragement: cheerlead yourself

Pros/Cons SkillTo get opposite action:• Pros/Cons of new

behavior• Mindfulness of current

emotion/urge• Break overwhelming

tasks into small pieces and do first step– something always

better than nothing• Problem solve; Build

mastery

Pros/Cons of new behavior:•Postpone behavior for a specific small amount of time (fully commit)•Distract, relax, or self-soothe•Postpone behavior again

•Do the behavior in slow motion•Do the behavior in a very different way•Add a negative consequence for behavior

Interpersonal Effectiveness

The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.

Interpersonal Effectiveness SkillsFocuses on developing skills that address problem solving. They balance the dialect between maintaining the relationship and maintaining self respect. Difficult to do with populations that vacillate between all or nothing (avoidance of conflict and intense confrontation).

1.Objectives effectiveness- prioritizing achievable objective goals 2.Relationship effectiveness- prioritizing a conflict-free relationship 3.Self-respect effectiveness- prioritizing acting within your own principles so that you feel comfortable with how you approached the situation

Interpersonal Effectiveness Skills

The Skills1.Attending to Relationships2.Balancing the Wants-to-Shoulds ratio in Life and Relationships3.Building Mastery and Self Respect

Interpersonal Effectiveness Skills GIVE

Gentle: Use appropriate language, no verbal or physical attacks, no put downs, avoid sarcasm unless you are sure the person is alright with it, and be courteous and non-judgmental.Interested: When the person you are speaking to is talking about something, act interested in what they are saying. Maintain eye contact, ask questions, etc. Do not use your cell phone while having a conversation with another person!

Validate: Show that you understand a person’s situation and sympathize with them. Validation can be shown through words, body language and/or facial expressions.

Easy Manner: Be calm and comfortable during conversation, use humor, smile.

Skill for maintaining relationships

Interpersonal Effectiveness

DEARMAN - getting somethingThis acronym is used to aid one in getting what he or she wants when asking.Describe your situation.Express why this is an issue and how you feel about it.Assert yourself by asking clearly for what you want.Reinforce your position by offering a positive consequence if you were to get what you want.Mindful of the situation by focusing on what you want and ignore distractions.Appear Confident even if you don’t feel confident.Negotiate with a hesitant person and come to a comfortable compromise on your request.

Interpersonal EffectivenessBalancing priorities with demands:Priorities are those things you want, are important to youDemands are those things other people want, important to them

FAST - keeping self-respectThis is a skill to aid one in maintaining his or her self-respect. It is to be used in combination with the other interpersonal effectiveness skills.Fair: Be fair to both yourself and the other person.Apologies: Don’t apologize more than once for what you have done ineffectively, or apologize for something which was not ineffective.Stick to Your Values: Stay true to what you believe in and stand by it. Don’t allow others to get you to do things against your values.Truthful: Don’t lie. Lying can only pile up and damage relationships and your self-respect.

Skills applied…

Problem solving and change strategies are again balanced dialectically by the use of validation. It is important at every stage to convey to the individual that their behavior, including thoughts feelings and actions are understandable, even though they may be maladaptive or unhelpful.

Therapist skills

• Radical Acceptance• Validation: communicates validation by listening,

reflecting, and highlighting the valid or “kernel of truth” in the client’s phenomenal experience

• Reciprocal communication: being responsive, warm, and engaged; using self-disclosure; and being genuine.

• Irreverent communications aim to get the patient’s attention, shift the response, and help the patient see a different point of view.

DBT for kids

PLEASE MASTER becomes SEEDS Grow

Emotion regulation handout 10Keeping control of your emotions

SEEDS GROWSickness needs to be treated You need to take care of yourself

and your body. See your doctor and take your medicine

Eat right You need to eat good food. Do not eat too much or too little

Exercise every day

Do some exercise every day. Stay in shape

Drugs are bad

Stay away from drugs and alcohol. They make you out of control

Sleep Get enough sleep at night so you are not tired during the day

GROW every day

Do something you are good at every day and try doing something new every day

Diary Card looks like

THANK YOU

Questions….