Dialectical Behavioral Therapy (DBT) JFKU

1. Dialectical Behavioral Therapy (DBT)JFKU Mark Purcell, PsyD & Claire Coyne, LMFT

2. Different Types of Emotions Calm Sad Estatic Anger LOVE Joy Panic Pain Embarassed Confused Guilt Worried

3. DBT Goals

4. RADICAL ACCEPTANCE • Grant me the serenity to ACCEPT the things I cannot change, • Courage to CHANGE the things I can, • And WISDOM to know the difference.

5. DBT Program Overview

6. Dialectics Finding Balance • Dialectics Involves integrating seemingly opposing views • Similar to Eastern Concepts of Non-Duality • Use the word “And” instead of “But”

7. Biosocial Theory I am Stupid... You’re so stupid! There’s something wrong with me I don’t understand why you’re so upset I don’t deserve to live I wish you were never born Confusion about self; impulsivity; emotional instability; interpersonal problems

8. Emotional Dysregulation Biological Vulnerability to Emotions (Sensitive Wiring) Low Emotional Modulation • High Sensitivity • Immediate reactions • Reactions with only a little provocation  • High Reactivity • Extreme reactions • High arousal makes thinking clearly difficult • Slow return to baseline • Long-lasting reactions • Higher sensitivity to next emotional event • Difficulties with changing one’s own emotions • Difficulties with paying attention (e.g., in class) when emotions are felt • Difficulty in stopping from acting right away when emotions are felt

9. Consequences of invalidating Environment By not validating feelings, the environment does not teach the individual to: • Label feelings • Effectively regulate emotions • Trust feelings By making problem solving seem easier than it is, the environment does not teach the individual to: • Effectively tolerate stress • Form realistic goals and expectations When communication of anger or sadness is punished and/or when only intense anger or sadness are responded to, the environment teaches the individual to: • Vary between having no emotions and having extreme emotions.

10. Types of Dysregulation • Emotional • Interpersonal • Self • Behavioral • Cognitive

11. Dialectical Behavior Therapy

12. Validation Validation communicates to another person that his/her feelings, thoughts, and actions make sense and are understandable to you in a particular situation. Validation ≠ Agreement  WHAT should we validate? • Feelings, thoughts, and behaviors in: • Ourselves • Other People WHY should we validate? • It improves relationships • Validation can show that: • We are listening • We understand • We are not being judgmental • We care about the relationship • Conflict is possible with decreased intensity and anger

13. Levels of Validation

14. Interaction of Emotions, Thoughts, & Behaviors

15. Matching Skills with Level of Dysregulation EMOTIONAL DYSREGULATION

16. Commitment Strategies • Selling it, evaluating pros and cons • Devil’s advocate • Foot-in-the-door technique • Freedom to choose in absence of alternatives • Shaping

17. Orientation Strategies • Therapeutic Alliance • Connect problems to areas of dysregulation and skill development • Define problems as targets • Link long-term goals to targets • Introduce biosocial theory • Introduce tx format/characteristics • Introduce diary cards • Review agreements • Use commitment strategies

18. Pre-Treatment Goals • Agreement on Goals • Commitment to change • Initial targets of treatment Agreement to Recommended Tx. Client agreements Therapist agreements Agreement to Therapist-Client Relationship

19. Treatment Goals Level 1: Severe Behavioral Dyscontrol Level 2: Quiet Desperation Level 3: Problems in Living Level 4: Incompleteness

20. Stage 1 Targets • Decrease • Life-threatening/high-risk behaviors • Therapy-interfering behaviors • Quality of life interfering behaviors • Increase behavioral skills • Mindfullness, distress tolerance, interpersonal effectiveness, emotional regulation

21. Therapy-Interfering Behaviors Client • Non-compliance • Non-collaborative • Non-attending • Behaviors that interfere with other clients • Pushing therapists’ limits • Reduce therapist’s motivation to treat

22. Therapy-Interfering Behavior Therapist • Extreme acceptance or change • Extreme flexibility to rigidity • Extreme nurturing or withholding • Extreme vulnerability or irreverence Disrespectful Behaviors

23. Quality of Life Interfering Behaviors • Incapacitating DSM Disorder • High risk sexual behavior • Extreme financial difficulties • Criminal behaviors • Severe interpersonal dysfuntion • Unemployment, severe school problems • Physical health, dysfunctional behaviors • Severe housing difficulties

24. Adol. Secondary Targets • Excessive leniency vs. authoritarian control • Normalizing pathological behaviors vs. pathologizing normative behaviors • Forcing autonomy vs. fostering dependence

25. Diary Cards • Track and observe behaviors in real time • Structure Session • Spring board to Chain and Solution Analysis • Integration of Skills

26. Diary Cards

27. Chain Analysis vu VULNERABILIES PROMTING EVENTS PROBLEM BEHAVIOR CONSEQUENCES

28. Solution Analysis • Identify goals, needs, desires • Generate solutions • Evaluate solutions • Choose a solution to implement • Troubleshoot solution

29. Responding to Problems • Solve the problem • Change emotional reaction to problem • Tolerate/accept the problem • Stay miserable

30. DBT Consultation Agreements • To accept a dialectical philosophy • To consult with patient on how to interact with other therapists • Consistency of therapists is not expected • Observe own limits, without judgment

31. Consultation Agreements Con’t • Search for non-pejorative, empathic interpretation of client’s behavior • All therapists are fallible

32. DBT Team Responsibilities • Plan and trouble shoot treatment • Monitoring adherence to DBT • Progress towards DBT competence • Consult to the therapist • Support to therapist and team members