Commitment Phase

Things to achieve before contract signing: timescale up to six weeks or more

From start to contract = commitment phase not DBTOrient to treatment build commitment test skills

Explain theory strategies diary

Provide info pros and cons homework

Client get info reasons for DBT attend group

Theory and information

What is BPD? Bio-social theory What is DBT? Skills & acceptance/problem-solving Chances of success? What will client be committing to?

COMMITMENT phase

Orienting

Explain DBT Explain bio-social model role induction, new expectations

Commitment-Setting the stage

Agree life goals and values before therapy begins

Identify target behaviours to reduce Get commitment to attending skills

group to learn new behaviours Client learns coping instead of

dysfunctional responses Ends in contract signing

Orienting client: What is BPD?

Longstanding problem Checklist of symptoms Emotion dysregulation

Relationship problems Self harm/suicide Anger Drugs/drink Specifics to client

The Bio-Social theory key points

Extreme emotion, low threshold, slow come down

Born with it/developed it/both Invalidating environment/abuse Patterns: e.g.not noticing emotion until it is

extreme Only being noticed for extreme behaviour Rewarding undesirable behaviour, punishing

desirable

Foot on brake and accelerator!

Emotional dysregulation

Low threshold

High intensity

Long recovery

What is DBT

Special therapy for BPD Can also be used for other problems Better than treatment as usual

Individual, phone, skills, consult Aim to control behaviour so can get a

life Might want other therapy later Here & now

What will I be signing up to?

Staying alive for a year Attending therapy (indiv & group) Doing homework Keeping diary

Willing not wilful Being mindful Staying in the spirit of DBT

Information for clients

Behavioraltech.com Linehan books NHS Direct site User sites (BorderlineUK; BPDWorld) Other clients/local user groups Handouts

Evidence base (*see handout)

Randomized Clinical Trials = 7 with BPD (see Lynch, Trost, Salsman, Linehan, 2007 and NICE Guidelines for BPD, 2009). 

Evidence base

Reducing: – Suicide attempts and self-injury– Medical risk– Premature drop-out– Inpatient/ER admissions and days– Drug abuse– Depression, hopelessness, anger

Increasing:– Global adjustment– Social adjustment

COMMITMENT STRATEGIES

Selling commitment : evaluating pros and cons.

  Playing devil’s advocate

  Foot-in-door and door-in-face techniques

Connecting present commitment to prior commitments

  Highlighting freedom to choose and absence of alternatives

  Shaping

Cheerleading

 

Pros and Cons

Pros Cons

Devil’s advocate

It’s going to take more time...be more effort.......you’re going to be asking yourself, ‘what am I doing bothering?’.......so why get involved in coaching???

Foot in the door

Ask for a little...when you get it, ask for a lot!

Door in the face

Ask for a lot, when you don’t get it, ask for a bit/lot less

Connect present commitments to past commitments

...but I thought we agreed.................

Freedom to choose....and absence of alternatives

Shaping..

Get a bit, reinforce, get a bit more towards target

Cheerleading

Believe in the efficacy of coaching, yourself, the person, the team

STRUCTURING THE TREATMENT-life goals

Life Goals – how to elicit

What does the client want?

Five years from now?

Job/relationship/flat/career

Scary and difficult to elicit

STRUCTURING THE TREATMENT-target behaviours

Behavioural targets hierarchy (rationale for)

Life-threatening

Therapy-interfering

Quality-of-life

“Stage 1” only

Life threatening behaviours

Self harm (e.g.cutting, burning inc ‘scratching’)

Harm to others (e.g. hitting poisoning emotional abuse)

Thoughts/images/beliefs/expectations re above

Dialectic: suicide as problem vs suicied as solution

Therapy-interfering behaviours

Patient behaviours

Non-attentive

Non-collaborative

Non-compliant

Other patients

Burn out

(limit-pushing)

Therapist behaviours

Imbalance

Change/acceptance

Flexibility/stability Nurturing/demanding

Lack of respect

Quality of Life-interfering behaviours

Substance abuse

High risk sex

Criminal stuff

Dysfunctional interpersonal

Employment

Illness-related

Housing-related

Mental-health related

Mental-disorder-related dysfunctional patterns