Dialectical Behavior Therapy. Treatment for Borderline Personality Disorder Nina Salamone. Defining Features of BPD. EMOTION DYSREGULATION Emotional Lability (Frequent Mood Changes) Problems with Anger INTERPERSONAL DYSREGULATION Chaotic Relationships Fears of Abandonment.
Treatment for Borderline Personality Disorder
Emotional Lability (Frequent Mood Changes)
Problems with Anger
Fears of Abandonment
Confused sense of self (e.g., not knowing where they fit in)
Sense of Emptiness
Suicidal and Self-Injurious Behaviors/Threats
Impulsive Behavior (e.g., alcohol/drug abuse, binge eating, stealing)
High Emotion Vulnerability
-low threshold for emotional reaction
-high arousal dysregulates cognitive processing
Slow return to baseline
-contributes to high sensitivity to next emotional stimulus
Biological Vulnerability + an Invalidating Environment
INVALIDATION means to DENY another person’s
take on a situation or to JUDGE it.
Examples of INVALIDATION include:
“How can you feel that way?”
“That makes no sense.”
“That is so stupid.”
“You are so selfish.”
“You have no reason to be upset.”
The individual does not learn to:
Dialectical behavior therapy (DBT) is a specialized form of cognitive-behavioral therapy. It was originally developed to treat adults and adolescents demonstrating intense mood swings; relationship difficulties ; frantic efforts to avoid abandonment ; confused thinking; impulsive behavior ; and recurrent suicidal behaviors including suicidal ideation, intentional self-injury, and history of multiple suicide attempts.
In individual DBT, the client and primary therapist begin by establishing a committed, collaborative working relationship while clearly defining the client’s treatment goals. A comprehensive behavioral assessment is completed that includes past and current history of problematic behaviors, prior treatment experiences and life goals.
In weekly 90-minute DBT Skills Groups, the focus is on learning and mastering four skills modules which include core mindfulness skills, distress tolerance skills, emotion regulation skills, and interpersonal effectiveness skills.
Phone or e-mail consultation between sessions with the primary therapist is encouraged in DBT. Calls or e-mails to the primary therapist focus on decreasing suicide crisis behaviors; increasing skillful behaviors in everyday life; and resolving interpersonal crises, alienation, or a sense of distance between the client and the therapist
In DBT, there is a strong emphasis on a team-approach to treatment. DBT therapists commit to obtaining weekly case consultation with colleagues within a treatment team meeting format. The goal is to maintain adherence to DBT principles and to conduct caring, compassionate, competent and effective therapy.
Life-threatening behaviors (e.g., overdosing, cutting, making suicide threats)
Therapy-Interfering behaviors (e.g., not completing diary cards, missing sessions, not telling the truth)
Quality-of-Life Interfering behaviors (e.g., using drugs & alcohol, binging/restricting food, risky behaviors)
Increase: Behavioral Skills
& Middle Path Skills
Practicing mindfulness can help you to avoid situations
where you lost awareness and have less control over your behavior
A Wise Mind Involves:
Taking in the whole of a situation – including observable facts, your emotions and values, other people’s feelings and points of view, and possible consequences of behavior.
Using this information to make a wise or effective decision about what you should do, how you can view the circumstances, and how to take care of your emotions.
“What” Skills & “How” Skills
(Observe, Describe, Participate)
(Non-judgmentally, One-mindfully, Effectively)
Observe your experience at the level of pure sensation without getting caught in it and without putting words to it.
Put words to your observed experience.
Unglue opinions from facts.
Just acknowledge what’s happening.
Accept each moment as is.
Avoid using judgment words as a short-hand for descriptions. Instead of saying “stupid”, “bad”, or “weird”, ask yourself, “What do I mean by that descriptively?”
When you find yourself judging, don’t judge your judging.
Non-judgmentally does not mean approval.
Doing one thing at a time with awareness by bringing your entire attention to this moment.
If other actions, thoughts, or strong feelings distract you, let go of these distractions and return to what you are doing again and again.
Doing what you need to do to accomplish your goals.
Acting based on what will work best in the long run, rather than what will make you feel better in the short run.
Acting as skillfully as you can in the situation you’re actually in, not the one you wish you were in.
Asking yourself, “Would I rather be ‘right’ or get what I want?”
Acting with your Wise Mind, rather than your Emotion Mind.
Letting go of anger, vengeance, and ego.
Playing by the rules.
“It’s a crisis!
What do I do ?”
What is it?
Learning to use skills to increase the ability to tolerate/accept distress and
to bear pain more effectively.
Distress Tolerance skills work toward
tolerating and surviving crises and with
accepting life as it is in the moment
because pain and distress are part of life.
Thinking of the advantages and disadvantages of doing a harmful behavior.
Focus on the light at the end of the tunnel. Remember times when you felt better.
Goal is to do what works in the short-term and long-term!
Freedom from suffering requires acceptance from deep within of what is.
Pain creates suffering only when you refuse to accept the pain.
To accept something does not mean to acknowledge it as good.
Deciding to tolerate the moment is Acceptance
An Act of Choice”-you have to turn your mind toward the acceptance road and away from the rejecting road.
The commitment to accept does not equal acceptance- it just turns you towards the path.
Willingness is doing just what is needed.
It is focusing on being “effective.”
Willingness is listening to your Wise mind, acting from your inner self.
The Goal of Emotion Regulation is to
Myths About Emotions
Staying out of “Emotion Mind”
Remember the ABC’s
Do pleasant things that are possible now.
Make changes in your life so that positive events will occur more often.
Build a “Life Worth Living.”
Do at least one thing each day to build a sense of accomplishment.
Plan for success, not failure. Do something difficult, BUT possible. Gradually, increase the difficulty over time.
COPE AHEAD OF TIME WITH
Rehearse a plan ahead of time so that you are prepared to cope skillfully with emotional situations.
Decide what coping skills you want to use in the situation. Be specific.
Imagine the situation in your mind as vividly as possible. Imagine yourself IN the
situation and rehearse in your mind coping effectively.
OPPOSITE ACTION WORKS WHEN
Getting the “thing” I want
Getting and Keeping a Good Relationship
Keeping or Improving Self-Respect and Liking for Yourself
Tell the person exactly what you are reacting to…..stick to the facts.
Express your feelings and opinions about the situation. Use phrases such as
“I want” and “I don’t want,” instead of “I need,” “you should,” or “I can’t.”
Assert yourself by asking for what you want or Saying No clearly. Assume that others will not figure it out or do what you want unless you ask. Assume that others cannot read your mind. Don’t expect others to know how hard it is for you to ask directly for what you want.
Reinforce or reward the person ahead of time by explaining the consequences. Tell the person the positive effects of getting what you want or need. Tell him or her (if necessary) the negative effects of your not getting it. Help the person feel good ahead of time for doing or accepting what you want. Reward him or her afterwards.
Keep your focus ON YOUR OBJECTIVES. Maintain your position. Don’t be distracted.
Appear EFFECTIVE and competent.
Use a confident voice tone and physical manner; make good eye contact. No stammering, whispering, staring at the floor, retreating, saying, “I’m not sure,” etc.
Be willing to give to get. Offer and ask for alternative solutions to the problem. Reduce your request. Maintain no, but offer to do something else or to solve the problem another way. Focus on what will work.
Be courteous and temperate in your approach. No attacks, No threats, No judging
LISTEN and be interested in the other person.
Validate or ACKNOWLEDGE the other person’s feelings, wants, difficulties and opinions about the situation.
Be nonjudgmental out loud: I can understand how you feel, but…”,
“I see that you are busy, and…”
(Use an) Easy manner
Use a little humor. SMILE. Ease the person along. Be light-hearted. Wheedle. Use a “soft sell” over a “hard sell.” Be political.
Be fair to YOURSELF and to the OTHER person.
No OVERLY apologetic behavior. No apologizing for being alive, for making a request at all. No apologizing for having an opinion, for disagreeing.
Stick to Values
Stick to YOUR OWN values.
DON’T LIE, ACT HELPLESS when you are not. Don’t EXAGGERATE. Don’t make up excuses.
The goals of this module are to help group members effectively manage family dilemmas by using:
Balancing Acceptance and change, and “walking the middle path”
Working on acceptance
Working on change
Dialectics teaches us that:
Validation communicates to another person that his or her feelings, thoughts, and actions make sense and are understandable to you in a particular situation.
REMEMBER: Validation ≠ Agreement
Self-validation involves perceiving your own feelings, thoughts, and actions as accurate and acceptable in a particular situation.
When you validate another person:
When you validate yourself:
Behaviorism is a set of strategies or principles used to increase behaviors we do want and reduce behaviors we don’t want (in our selves and others).
Reinforcers: Consequences that result in more of a behavior. Reinforcers provide information to a person about what you want that person to do.
Positive reinforcement: Increases the frequency of a behavior by providing a rewarding consequence (e.g., praise, a compliment, or an A on an exam).
Negative reinforcement: Increases the frequency of a behavior by removing a negative consequence.
Examples: taking aspirin to get rid of a headache, doing homework to get Mom to stop nagging, or self-cutting to decrease or avoid negative feelings (although DBT teaches skills to manage this better).