1. Random bits of DBT Dialectical 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.

2. 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.

3. 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:
Clients found unrelenting focus on change inherent to CBT invalidating.
Clients unintentionally positively reinforced their therapist for ineffective treatment, while punishing for effective therapy.
The volume of problems and severity of problems made it impossible to ues the standard CBT format.

4. So,
Marsha Linehan added the concepts of Validation and Dialectics to CBT

5. 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.

6. 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

7. DBT states that…
BPD results from the interaction of biological vulnerability with invalidation over time

8. 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.

9. 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

10. 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

11. 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

12. Therapist characteristics
Oriented to Change
Unwavering centredness Benevolent Damanding
Nurturing Compassionate Flexibility
Oriented to acceptance

13. Skills training and individual therapy
Modules – mindfulness, interpersonal effectiveness, distress tolerance, emotion regulation.
Individual – assist in generalising the skills

14. 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

15. 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

16. Consultation Group
Where therapists meet to support each other working dialectically, while observing limits, maintaining commitment,

17. Functions of validation
To strengthen clinical progress
As acceptance to balance change
To strengthen self-validation
As feedback
To strengthen the therapeutic relationship

18. Emotional validation strategies
Encourage emotional expression
Teach emotion observation and labelling
Read emotions
Directly validate emotions

19. Levels of validation Staying awake: unbiased listening and observing
Accurate reflection
Articulating the unverbalised emotions, thoughts, or behaviour patterns
Validation in terms of past learning or biological dysfunction
Validation in terms of present context or normative functioning
Radical Genuineness

20. Cheerleading strategies
Assume the best
Encourage
Focus on strengths
Contradict/modulate external criticism
Be realistic
Stay near in a crisis

21. DBT Skills Modules Mindfulness Interpersonal effectiveness
Emotion regulation
Distress tolerance

22. 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

23. 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!

24. 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)

25. 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!

26. Behaviour Analysis
One of most important, and one of most difficult sets of strategies in DBT
(key error is one of assessment)

27. 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.

28. 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.

29. 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.

30. 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…

31. 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.

32. Generate hypotheses about factors controlling behaviour
Use theory to guide analysis
(about actions, cognitions, biological or sensory responses and the environment).

33. Analyse chain of events moment-moment over time
Vulnerability Problem behaviour
Prompting event
links
consequences

34. Possible solutions Solve problem Change emotional reaction to problem
Tolerate the problem
Stay miserable

35. 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

36. 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

37. Consultation Group
Where therapists meet to support each other working dialectically, while observing limits, maintaining commitment,

38. 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

39. 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.

40. 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)

41. 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....

42. 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

43. 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.

44. 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

45. Emotion reg cont... Balance sleep, eating, mood altering drugs
Build mastery in life
Prepare ahead of time
Self validation and cheerleading

46. The End…