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Random bits of DBTDialectical Behaviour Therapy

A principle-driven treatment for severe and chronic, multi-diagnostic, difficult-

to-treat clients

Angelique O’Connell

Acknowledgements: The materials presented here are adapted from the work of Marsha Linehan and Behavior

Tech Training Programmes USA.

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So…Who is it for?

• It is for the severe and chronic multi-diagnostic difficult to treat client with both Axis I and II disorders.

• It’s for those that experience a pervasive dysfunction of the emotion regulation system - Dysregulation of emotion, cognition, behaviour, interpersonal relationships, & self.

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Why was it developed?

• Marsha et al (1970’s onward) identified that the CBT approach was less successful with this particular client group. Three major problems were identified:

1. Clients found unrelenting focus on change inherent to CBT invalidating.

2. Clients unintentionally positively reinforced their therapist for ineffective treatment, while punishing for effective therapy.

3. The volume of problems and severity of problems made it impossible to ues the standard CBT format.

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So,

Marsha Linehan added the concepts of Validation and Dialectics to CBT

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Acceptance

• Added Acceptance based interventions, (frequently referred to as validation strategies) .

• These did not exclude the emphasis on change – the two enhanced the use of one other

• And by weaving acceptance and change together, Dialectics came into play.

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Dialectics…

• Provides means for therapist to balance acceptance and change in each session.

• Prevents therapist and client from getting stuck in the rigid thoughts, feelings and behaviours that can occur when emotions run high – as they often do with the client group.

• Dialectical world view that emphasises holism and synthesis enables therapist to blend acceptance and change

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DBT states that…

• BPD results from the interaction of biological vulnerability with invalidation over time

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Why beneficial• DBT addresses the relationship between the individual

and his/her environment (family/work/school/peers).

• DBT aims to replace problem behaviours with skilful behaviours.

• DBT helps people create a life worth living. A life with both positive and negative aspects and all of these aspects are necessary and valuable.

• DBT aims to improve quality of life, to help people learn to value themselves and each other and to teach a DIALECTICAL WORLDVIEW.

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Dialectical… what?

• All people have something unique and valid to offer.• The importance of avoiding viewing the world in black

and white terms - instead see the shades of colour. • There is always more than one way to see a situation

and more than one opinion, idea or dream• Therefore, there is no absolute truth. • Two opposite ideas can be true at the same time.• Considering all points of view before integrating them

into our own personal view of the world.• Change is the only constant

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DBT Assumptions about Clients• Clients are doing the best they can

• Clients want to improve

• Clients must learn new behaviours in all relevant contexts

• Clients CANNOT fail DBT

• Clients may not have caused all of their own problems, but they have to solve them anyway

• Clients need to do better, try harder, and/or be more motivated to change

• The lives of suicidal, borderline individuals are unbearable as they are currently being lived

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DBT Assumptions about Therapy• The most caring thing a therapist can do is help clients

change in ways that bring them closer to their own ultimate goals

• Clarity, precision, and compassion are of the utmost importance in the conduct of DBT

• The therapeutic relationship is a real relationship between equals

• Principles of behaviour are universal, affecting therapist no less than clients

• Therapists treating(BPD) self injuring clients need support

• DBT therapists CAN fail

• DBT can fail even when therapists do not

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Therapist characteristics

Oriented to Change

Unwavering centredness Benevolent Damanding

Nurturing Compassionate Flexibility

Oriented to acceptance

Skills training and individual therapy

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• Modules – mindfulness, interpersonal effectiveness, distress tolerance, emotion regulation.

• Individual – assist in generalising the skills

Groups for teens

• Skill building rather than therapy• Participants have same level of

emotionality• Rules about disclosure• Confidentiality and respect• Rules about interactions and relationships

outside of the group environment

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Diary Cards

• Monitor relevant behaviour occurring outside of therapy

• Allows therapist to follow use/practice of skills• A good starting point for conversation• Where the therapist identifies behaviour/problem

to target in chain analysis.• Modify diary card to ‘fit’ you’re client, but keep

the key components

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Consultation Group

• Where therapists meet to support each other working dialectically, while observing limits, maintaining commitment,

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Functions of validation

• To strengthen clinical progress

• As acceptance to balance change

• To strengthen self-validation

• As feedback

• To strengthen the therapeutic relationship

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Emotional validation strategies

• Encourage emotional expression• Teach emotion observation and labelling• Read emotions• Directly validate emotions

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Levels of validation

1. Staying awake: unbiased listening and observing

2. Accurate reflection

3. Articulating the unverbalised emotions, thoughts, or behaviour patterns

4. Validation in terms of past learning or biological dysfunction

5. Validation in terms of present context or normative functioning

6. Radical Genuineness

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Cheerleading strategies

• Assume the best• Encourage• Focus on strengths• Contradict/modulate external criticism• Be realistic• Stay near in a crisis

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DBT Skills Modules

• Mindfulness• Interpersonal effectiveness• Emotion regulation• Distress tolerance

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Stylistic strategies: Irreverent Communication

• Reframing clients communication in an unorthodox, offbeat manner

• Plunging in where angels fear to tread• Using a confrontational tone• Calling the clients bluff• Oscillating intensity• A style that’s unhallowed, impertinent, and incongruous

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Irreverence cont…

• The intent of irreverent communication is to help provide psychological distance for client to observe and describe ongoing events and processes in their lives.

• Do this by keeping the individual just off balance enough to shake up her typically rigid, narrow-bounded approach to life, to herself and to problem solving.

• To highlight both poles of the dialectic without denying either!

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Observing limits

• Simple in theory and difficult in practice• It’s the application of problem-solving strategies,

and contingency management procedures to client behaviours that threaten or cross the therapist’s personal limits,

• T must be aware of which client behaviours they are able and willing to tolerate, and which are unacceptable. This info must be given to client in timely fashion. (short term and long term behrs)

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• Not observing limits is therapy threatening – interferes with therapist ability or willingness to carry on with therapy. Can lead to burnout, termination of therapy, or otherwise cause harm to client.

• By observing limits the therapist takes care of the client, by taking care of themselves!

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Behaviour Analysis

• One of most important, and one of most difficult sets of strategies in DBT

(key error is one of assessment)

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BA strategic checklist

• Define the problem behaviour• Conduct chain analysis• Generate hypotheses• Avoid … colluding with client in avoiding

behavioural analysis of targeted behaviours, …and unduly bias information gathering to prove therapists own theory of client’s behaviour.

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Conducting a Chain Analysis

• Choose a specific instance of behaviour to analyse.

• Develop an exhaustive step-by-step description of the chain of events leading up to and following the behaviour.

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Attending to the links of the Chain

• Where to start? Ask the client when the problem began. Maladaptive behr is viewed as occurring within a context or episode that for the purpose of analysis has a beginning, middle (the behr in question) and an end.

• Clients can usually tell you when the episode began – at least roughly.

• Overall goal: To link the behaviour to environmental events; especially the ones they may not think are linked/effect their behaviour.

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Filling in the links

• Think in terms of very small units of behaviour – the links in the chain.

• Get info about what’s going on environmentally and behaviourally (what client was doing, thinking, feeling, imagining.

• You want to know how client got from one link to the next – from here to there…

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Where to stop?

• The chain needs what leads up to the problem behaviour as well as info about the consequences.

• Therapist wants to identify what is reinforcing (maintaining) the problematic behaviour.

• Brief analysis of in session behaviours.

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Generate hypotheses about factors controlling behaviour

• Use theory to guide analysis – (about actions, cognitions, biological or

sensory responses and the environment).

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Analyse chain of events moment-moment over time

Vulnerability Problem behaviour

Prompting event

links

consequences

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Possible solutions

• Solve problem• Change emotional reaction to problem• Tolerate the problem• Stay miserable

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DBT case management strategies

• Environmental intervention

– Intervene in the environment when the short term gain is worth the long term loss in learning.

– When client unable to act on own behalf and outcome is very important

– When environment is high in power

– To save the life of the client or avoid substantial risk to others

– When it is the humane thing to do and will cause no harm

– When the client is a minor

– Strategies – provide info to others independent of client, advocate for client, enter the clients envt to give assistance

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Case management strategies cont...

• Consultation-to-the-patient (client)– The primary role of therapist is to consult to

the client about how to manage their own social/professional network

– Strategies – orient client and network to the approach, consult about how to manage other professionals, consult about how to manage other members of the whole interpersonal network

• Consultation-to-the-therapist– Need for therapist supervision/consultation

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Consultation Group

• Where therapists meet to support each other working dialectically, while observing limits, maintaining commitment,

Accepting reality

• Acceptance does not mean agreeing, or liking • Willingness – doing what is needed in each

situation, cultivating a Willing response to each situation

• Willfulness – like sitting on your hands when action is needed, trying to change the situation rather than your response to it, its giving up, its trying to fix every situation or refusing to tolerate the distressful moment

Distress Tolerance skills: crisis survival

• Reduction of acute destabilising emotions and symptoms. Helps you feel better.– Grounding– Relaxation – observing your breath, deep breathing,

measuring breath with footsteps, follow breath while listening to music

– Distract and soothe– One thing in the moment– Vacation – have a duvet day– Cheerlead yourself – I can stand it, this won’t last forever,

I will make it out of this, I’m doing the best I can, I can do it, I am ok.

Distract !To reduce contact with emotional stimuli

• Activity; physical exercise, clean your room, call or visit a friend• With thoughts; Count to ten, count colours in a painting, or tree

or window, do puzzles, watch TV, read• With emotions; act opposite to emotion, watch a comedy, listen

to emotional music, read emotional book/story• ‘pushing away’ – build an imaginary wall between you and the

situation, or block the situation from your mind, censor ruminating, put the pain on a shelf, box up the problem and put it away for a while.

• Using sensations – hold ice in hand, squeeze a rubber ball, take a hot shower, listen to loud music, snap rubber band, suck on a lemon, cold/frozen cloth on face, henna tattoo, poor red food colouring (heated first)

Self Soothe!

• With the 5 senses– Vision; buy one flower, look at beautiful pictures, look

at nature, watch the stars, paint your nails, be mindful of each sight in front of you

– Hearing; listen to beautiful/soothing/invigorating music, sing favourite songs, listen to sounds of nature, call weather phone to hear a human voice, be mindful of the sounds letting them in one ear and out the other...

– Smell; perfume, lotions, spray fragrance in the air, boil cinnamon, bake cookies, cake or bread, smell the roses, smell the outdoors, chai latte....

Self soothe cont...

• Taste; have a good meal, soothing drink, treat self to dessert, sample flavours at ice cream shop, suck on peppermint candy, chew favourite gum, eat mindfully

• Touch; experience whatever you touch, bubble bath, clean sheets on the bed, pet your dog or cat, soak your feet, put creamy lotion on body, cold compress on forehead, sink into really comfy chair, put on silky top/scarf, brush your hair for a long time, hug someone

Affect regulation - resistance to tension reduction behrs

• Ask to delay or ‘hold off’ from engaging in the behaviour for as long as possible (this provides opportunity to develop small amount of affect tolerance, as well as learning distress is bearable)

• If doing it, do it to the minimal extent possible• Clinicians take a clear stand on the

harmfulness – the aim is cessation, though the process may be about decreasing frequency, intensity and injuriousness.

Emotional (affect) regulation skills

• Mindfulness• Delay action• Learn what the emotion IS (non judgemental observation

and description of emotion in session – but clinician do not label – guide the labelling )

• Changing emotional responses: check on the facts, opposite action (to emotion), problem solving, the half smile

Emotion reg cont...

• Balance sleep, eating, mood altering drugs• Build mastery in life• Prepare ahead of time• Self validation and cheerleading

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The End…