Clearview Treatment Programs

Community Education Series:Treating Depression with

Dialectical Behavior Therapy (DBT)

Presented byKate Roahrig, LMFT

Clearview Women’s Center

April 18, 2019

Depressive Disorders

• Major Depressive Disorder-mixed/anxious mood

• Peri/Postpartum Depression• Persistent Depressive Disorder/Dysthymia• Premenstrual Dysphoric Disorder• Seasonal Affective Disorder• Grief/Bereavement

Criteria for Major Depressive DisorderAt least 5 symptoms present in the same 2-week period and are a change in previous functioning. At least 1 symptom is either depressed mood or loss of interest or pleasure.

– Depressed mood most of the day, nearly every day, which is reported or can be observed

– Diminished interest or pleasure in activities most of the day, nearly everyday

– Significant weight loss or gain or change in appetite nearly every day– Insomnia/hypersomnia nearly every day– Observable restlessness or slower motor functions– Fatigue or loss of energy, nearly every day– Feelings of worthlessness or excessive guilt, nearly every day– Diminished ability to think or concentrate, or indecisiveness, nearly

every day– Recurrent thoughts about death or suicidal ideation/planning/attempt

Statistics• Common mood disorder- “common cold” of mental health

disorders• An estimated 16.2 million adults in the United States (6.7% of

US adults) had at least one major depressive episode. • The prevalence of major depressive episode is higher among

adult females (8.5%) compared to males (4.8%)• The prevalence of adults with a major depressive episode was

highest among individuals aged 18-25 (10.9%)• An estimated 3.1 million adolescents aged 12 to 17 in the US

had at least one major depressive episode (12.8% of US pop of 12-17yo).

• The prevalence of major depressive episode was higher among adolescent females (19.4%) compared to males (6.4%)

Source: https://www.nimh.nih.gov/health/statistics/major-depression.shtml

Common Traits of Depression• Persistent low mood• Irritability/anxiety• Slow or restless motor movements• Physical pain/discomfort• Sleep issues• Loss of interest• Change in appetite• Difficulty concentrating, memory issues, difficulty

making decisions• Thoughts of suicide/suicide attempts

Life-Interfering Results• Not able to meet responsibilities

– Job, family, etc.• Impact relationships

– Irritability, apathy• Can lead to ineffective coping techniques

– Substance use, over-sleeping, over-medicating, etc.• Change in physical health (pain, GI issues,

change in weight, fatigue, etc.)• Sleep issues• Downward spiral

Treatment Options• Medication management

• 2-4 weeks• Psychotherapy• Lifestyle changes• Often a combination of these options is

most effective

Dialectical Behavior Therapy (DBT)

Created by Marsha Linehan for high-risk suicidal clients and self-harming behaviors

• Acceptance alone = not appropriate due to high risk

• Behavioral change alone = invalidating, felt unbearable

• Balance of Acceptance and Change-based approaches - Dialectics!

Dialectical Behavior Therapy• Research shows efficacy of using DBT

with other disorders including Depression• Uses a balance of acceptance and change-

based skills– Dialectics

• DBT Assumptions• Structured

– Modes of treatment, treatment hierarchy, interventions

Modes of Comprehensive DBT

Individual Therapy

Family Sessions & Case Mgmt

Phone Coaching

Consultation Team

Skills Coaching

Group

Goal: To build a life worth living

•Define values•Set goals•Build relationships•Build mastery

Skill Module: Mindfulness• Core skill module

– Foundation of other skills– Acceptance based skills

• Increase awareness of the present moment • Accept the present moment without judgment using

“observe” and “describe” skills• In Depression, these skills allow for accurate

communication of experience• A core trait of Depression is negative self-judgment and

mindfulness skills utilize observe/describe/non-judgmental stance to reduce negative self-talk

Skill Module: Distress Tolerance• These skills help us to tolerate distress when we cannot

change it in the present moment – Acceptance based skills– Not to be used for every problem or to make your life worth

living• Acceptance leads to the ability to potentially change or

work on the distressing experiences • Depressed individuals experience misery and

hopelessness which can lead to crises/safety concerns-skills such as grounding through TIP, pros/cons, IMPROVE, and reality acceptance assist in getting through without it getting worse

Skill Module: Emotion Regulation• Goal is to reduce emotional suffering through

understanding and naming emotions, reducing vulnerabilities to painful emotions, changing unwanted emotions once they start– Not eliminate emotions– Change based skills

• Depressed individuals struggle with sleep, eating, taking medication, using substances to cope, lack of physical activity. This increases negative emotions and keeps us stuck in a cycle. Skills such as PLEASE, cope ahead, accumulate positives, opposite action, problem solving can help reduce vulnerabilities and start changing behaviors which impact emotions in the short and long-term

Skill Module: Interpersonal Effectiveness

• This skill set helps you build/maintain/repair relationships and effectively ask for what you need from others while maintaining self-respect– Change based skills

• Relationships and self-respect are often impacted by symptoms of Depression. To reduce and change the impact of those symptoms skills such as identifying goals in interactions, knowing when and how to use validation, challenging myths about asking for what you need/want, navigating challenging and invalidating interactions are taught and practiced

Target and Intervention• Target: Suicidal Ideation/Isolating• Diary Card

– Used to track target behaviors • Suicidality, Isolation, Negative self-talk, Etc.

– Assist client and therapist in setting a session agenda

– Self-management– Measure for progress

Target and InterventionDiary Card

Dialectal Behavior TherapyDiary Card

Initials ID# Filled out in session? Y N How often did you fill out this side?_____ Daily _____ 2-3x ______ Once

Date Started

Day & Date Use Suicide S-H Pain Sad Sham

eAnger Fear Illicit ETOH Prescrip OTC S-H Lying Joy Skills R

0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 # Specify # Specify

# Specify # Specify Y/N # 0-5 0-7 a

Mon

Tues

Wed

Thur

Fri

Sat

Sun

*USED SKILLS0 = Not thought about or used1 = Thought about, not used, didn’t want to2 = Thought about, not used, wanted to3 = Tried but couldn’t use them

4 = Tried, could do them but they didn’t help5 = Tried, could use them, helped6 = Didn’t try, used them, didn’t help7 = Didn’t try, used them, helped

Before After Belief in control of . . . Before After

Urge to use (0-5): Emotions:

Urge to quit therapy (0-5): Behaviors: BRTC Diary CardCopyright 1999 Marsha M. Linehan, Ph.D.

Urge to harm (0-5): Thoughts:

Target and InterventionBehavioral Chain Analysis

Target: Suicidal Ideation/Isolating

Tool to understand and change behaviors

Identify…• Prompting Event• Vulnerabilities• Links in the chain (events, thoughts, feelings, behaviors)• Problem Behavior• Consequences (potential reinforcers)

Vulnerabilities

PromptingEvent Links

ProblemBehavior

Consequences

Target and InterventionBehavioral Chain Analysis

Target and InterventionSolution Analysis

Target: Suicidal Ideation/Isolating

Where can we make changes?

• Prompting Event• Vulnerabilities (I.E. Oversleeping, not eating) • Links in the chain (events, thoughts, feelings, behaviors)• Problem Behavior• Consequences (potential reinforcers)

Vulnerabilities

PromptingEvent

Links

ProblemBehavior

Consequences

Consequences

EffectiveBehavior

Target and InterventionSolution Analysis

Target and InterventionPLEASE Skills

• Target: Sleep issues/change in appetite/ lowered activity level/not taking meds

• When our body is out-of-balance our mind and emotions may be impacted

• PLEASE skills help increase emotional resilience and reduce vulnerability to negative emotions

Target and InterventionPLEASE skills

Target and InterventionPLEASE skills

Target and InterventionPLEASE skills

Target and InterventionCope Ahead

• Target: Sleep issues/change in appetite/ lowered activity level/not taking meds

• Allows for problem-solving and planning ahead for effectively coping with difficult situations or experiences

• Reduces vulnerability to impact of potentially difficult situations and increases self-efficacy/resiliency

Target and InterventionCope Ahead

Target and InterventionDEARMAN

• Target: Not asserting needs, resulting in decreased self-worth

• DEARMAN outlines a structured way of effectively making a request or refusal of a request

• Assists in staying on track with interaction and increases likelihood person will stay in the conversation with you

Target and InterventionDEARMAN

What to do when things aren’t changingSkill: Radical Acceptance from Distress Tolerance

– Pain + Unacceptance = Suffering– What it is:

• Nonjudgmental acknowledgment of what is• Stop fighting reality and let go of bitterness

– What it is not:• Approval or agreement with what is

– When we work on acceptance, we make space for the emotional pain that can be managed which also can create opportunity for change

Resources• Suicide Prevention Hotline 1-800-273-TALK (8255)• Behavioral Tech

– https://behavioraltech.org/• National Network of Depression Centers

– https://nndc.org/resource-links/

• National Alliance on Mental Illness– https://www.nami.org/

• Families for Depression Awareness– http://www.familyaware.org/

• Anxiety and Depression Association of America– https://adaa.org/

Resources• “When Nothing Matters Anymore: A Survival Guide for

Depressed Teens” by Bev Cobain• “Out of the Darkened Room: When a Parent Is Depressed:

Protecting the Children and Strengthening the Family” by William R. Beardslee

• “The Noonday Demon: An Atlas of Depression” By Andrew Solomon

• “The Happiness Trap: How to Stop Struggling and Start Living” by Russ Harris

• “The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance” by Matthew McKay, Jeffrey C. Wood and Jeffrey Brantley

Thank You!