Dialectical Behaviour Therapy in Perth North Metro Area

1. Dialectical Behaviour Therapyin Perth North Metro Area Margaret Cole 11th July 2006

2. Goal To Build A Life Worth Living

3. Steps 1. Clear Structure 2. Do Behaviour Therapy 3. Add Validation 4. Add Dialectics 5. Add Mindfulness

4. 1. Clear Structure

5. Assumptions About Clients & Therapy 1. Clients are doing the best they can 2. Clients want to improve 3. Clients need to do better, try harder and be more motivated to change 4. Clients may not have caused all of their own problems but they have to solve them anyway 5. The lives of suicidal borderline individuals are unbearable as they are currently being lived 6. Clients must learn new behaviours in all relevant contexts 7. Clients cannot fail in therapy 8. Therapists treating borderline clients need support

6. Assumptions about Therapy & Therapists 1. The most caring thing a therapist can do is help clients change in ways that bring them closer to their ultimate goals (unwavering centredness) 2. Clarity, precision and compassion are of the utmost importance in the conduct of DBT 3. The therapeutic relationship is a real relationship between equals (there are differences in expertise but no arbitrary power differential) 4. Principles of behaviour are universal, affecting therapists no less than clients 5. DBT therapists can fail 6. DBT therapy can fail even when therapists do not 7. Therapists treating borderline clients need support

7. AgreementsTherapist Agreements EVERY REASONABLE EFFORT AGREEMENT ETHICS AGREEMENT PERSONAL CONTACT AGREEMENT CONSULTATION AGREEMENT

8. Therapist Consultation Agreements DIALECTICAL AGREEMENT CONSULTATION TO THE CLIENT AGREEMENT CONSISTENCY AGREEMENT OBSERVING LIMITS PHENOMENOLOGICAL EMPATHY AGREEMENT FALLIBILITY AGREEMENT

9. Client Agreements ONE YEAR THERAPY AGREEMENT ATTENDANCE AGREEMENT SUICIDAL BEHAVIOURS AGREEMENT THERAPY-INTERFERING BEHAVIOURS AGREEMENT SKILLS TRAINING AGREEMENT RESEARCH AND PAYMENT AGREEMENT

10. 2. Do Behaviour Therapy

11. The consequences of a behaviour affect the probability of the behaviour’s occurring again. Every therapist response experienced by the client can be neutral, punishing or reinforcing, thus every contingent response is an informal contingency procedure.

12. Behavioural Assessment There is no substitute for good behavioural analysis to determine what is prompting and maintaining maladaptive behaviour Chain Analysis

13. Assess Necessary Intervention 1. Are the behaviours in the persons behavioural repertoire? No – Behavioural Skills Training 2. Are ineffective behaviours being reinforced? Yes – Contingency Management 3. Are effective behaviours inhibited by unwarranted fears or guilt? Is the person emotion phobic? Yes – Exposure 4. Are effective behaviours inhibited by faulty beliefs and assumptions? Yes – Cognitive Modification

14. 3. Add Validation

15. Levels of Validation 1. Staying awake – unbiased listening and observing 2. Accurate reflection – summarising 3. Articulate the unverbalised emotions, thoughts or behaviour patterns – take a slight leap and read beyond what they’ve said, may be safer to use a “multiple-choice approach” 4. Validation in terms of past learning or biological dysfunction 5. Validation in terms of present context or normative functioning 6. Radical genuineness – being yourself with the client as you are with others, same tone of voice, same language, not stepping into a role

16. 4. Add Dialectics

17. Dialectics 1 - A World View 1. The Principle of Interrelatedness and WholenessSystems perspective on reality (identity is relational) 2. The Principle of PolarityReality is not static but is comprised on internal opposing forces out of which synthesis is achieved.“Contradictory truths do not necessarily cancel each other out or dominate each other, but stand side by side, inviting participation and experimentation” Goldberg (1980) 3. The Principle of Continuous ChangeChange, or process, rather than structure or content, is the essential nature of life.Role of conflict and opposition in the change process.

18. Dialectics 2Dialogue & Relationship • About balancing with the client – see-saw example • Change by persuasion • Personal account of events, exposing contradictory positions • The spirit of a dialectical point of view is never to accept a final truth or indisputable fact. • Thinking “what is being left out of our understanding?” • (To avoid splitting, which almost always results from a clinician assuming that they, and sometimes they alone, have “the truth” about a client or clinical problem)

19. Dialectical Dilemma’s Posed by Borderline Clients Active Passivity VS Apparent Competence Some times appear competent Able to cope in some situations Coping followed by crisis Difficulty generalising Passive, helpless problem solving Tries to get others to help Emotion focused coping Dilemma: Needs help but feels shame for asking Is it lack of motivation or lack of skills? Therapist too demanding vs too rescuing

20. Dialectical Therapist Characteristics Finding a balance between apparently opposing stances Oriented to Change VS Oriented to Acceptance Necessity of change Clients wish to change Principles of Behaviour Change Acceptance exactly in this moment As things are right now Inherent wisdom and “goodness” of current moment

21. “Mistakes are inevitable; what the therapist does afterwards is a better index of good therapy”Linehan

22. Dialectical Therapist Techniques Finding a balance between apparently opposing stances Validation VS Problem Solving Active observing Reflection Search for validity Active approach Behavioural focus

23. Dialectical Behaviour Patterns: Balanced Lifestyle Walking the middle path through the following areas Skill enhancement VS Self-acceptance Problem solving VS Problem acceptance Affect regulation VS Affect tolerance Self-efficacy VS Help seeking Independence VS Dependence Transparency VS Privacy

24. 5. Add Mindfulness

25. General Goal of Skills Training To learn and refine skills in changing behavioural, emotional and thinking patterns associated with problems in living, that is, those causing misery and distress.

26. General Points • Shot gun approach – some of the skills will work for some of the people some of the time • The parts of the skills are rarely new, but the combination often is • Clients need to be convinced that what they’re learning is going to be useful, relevant to them (‘marketing’ the skills) • Clients will often have attended other groups, need to discuss how this might be different (e.g. not process oriented) • Emphasize goal of long-term relief vs. immediate relief • Emphasize need for practice, practice, practice

27. The Skills • Core mindfulness • Interpersonal effectiveness • Emotion regulation • Distress tolerance

28. Mindfulness “bringing an unshakeable friendliness and deep degree of curiosity and interest to what is happening in and around you… and doing this again and again and acclimatising to this way of being” Tarchin Hearn “Mindfulness in totality has to do with the quality of awareness that a person brings to activities” Marsha Linehan

29. Interpersonal EffectivenessAsking & Saying No Objectives Effectiveness How to get what you want Relationship Effectiveness How to maintain the relationship Self-Respect Effectiveness How to keep your self-respect

30. Emotion Regulation Goals 1. Understand emotional experience 2. Reduce emotional vulnerability 3. Decrease emotional suffering

31. Distress Tolerance Surviving a situation you can’t change Crisis Survival Reality Acceptance

32. North Metro DBT Program • Referral Process • Entry to group every 6 months • 12 month commitment • 8-10 per group desirable • Weekly skills group, 2½ hours • Weekly individual therapy • Fortnightly consultation meeting • Follow-up group • Annual 2 day training for NMMHS staff • Outcomes research