Presentation on theme: "A Brief Introduction to Dialectical Behaviour Therapy"— Presentation transcript:
1 A Brief Introduction to Dialectical Behaviour Therapy Dr. Nathalie Lovasz, C.Psych (Supervised Practice)Head of Adult DBT Program – The Mindfulness ClinicDr. Andrew Spice, C.Psych (Supervised Practice)Head of Adolescent DBT Program – The Mindfulness Clinic
2 Agenda Overview of DBT Definition, development, research, adaptations Section 1: Assessment and Case ConceptualizationAreas of Dysregulation: Signs that DBT may be helpfulTheoretical modelStages of treatment; organizing treatment targets hierarchicallySection 2: TreatmentCore treatment strategies: Validation and chain analysisDBT SkillsDistress ToleranceEmotion RegulationInterpersonal EffectivenessMindfulnessSection 3: Additional Issues in DBTDBT and Other ProfessionalsRecommended ReadingsFurther Training
3 What is DBT? Comprehensive cognitive-behavioural treatment Developed by Dr. Marsha Linehan at University of WashingtonOriginally developed to treat chronically suicidal clients diagnosed with Borderline Personality DisorderFound to be effective for suicidal clients with multiple other co-occurring behavioural problems
4 Development of DBTCBT did not work for clients with chronic suicidality and BPDChange focus was invalidatingClients unintentionally reinforced therapists for behaviours that were not helpful and punished/extinguished helpful behavioursUnrelenting crisis interfered with treatment/skills acquisitionSolutions: Validation, Dialectics, Treatment Hierarchy, Multi-modal treatment
5 Research Findings DBT has been found to reduce Suicidality Parasuicidal behaviorTreatment drop-outHospitalizationsSubstance UseDepression, Hopelessness, Anger(Linehan et al., 1991;1999; Koons et al., 2001, Verheul et al., 2003)
6 Adaptations of DBT Substance Use Adolescents/Children Binge Eating Bipolar DisorderCouplesInpatient
7 Components of a DBT Program Individual (DBT) TherapyWeekly Skills Training GroupPhone CoachingTherapist Consultation TeamDBT-informed Therapy:Any treatment that does not include ALL FOUR of the above componentsE.g. CBT therapy that incorporates some DBT skillsGroup only Skills TrainingSkills Group + Individual Therapy without Phone CoachingSkills Group, Individual Therapy, Phone Coaching but no consultation team
9 Symptoms of Borderline Personality Disorder Emotion DysregulationImpulsive/Self-Damaging BehavioursSuicide/Self-harmUnstable Emotions/MoodIdentity/Self DysregulationIntense Anger/Difficulty Controlling AngerUnstable Sense of Self/IdentityInterpersonal DysregulationFeelings of EmptinessUnstable/Intense RelationshipsCognitive DysregulationFrantic Efforts to Avoid AbandonmentStress Related Paranoid ThoughtsBehavioural DysregulationDissociation
10 Identify Areas of Dysregulation in a Practice Case Choose one of the two case vignettes provided. Identify as many areas of dysregulation as possible in the case vignette:EmotionInterpersonalCognitiveBehaviouralIdentity/Self
11 EMOTIONAL VULNERABILITY Biosocial Model of BPDEMOTIONAL VULNERABILITYEmotional Sensitivity: More easily triggered emotionsResponding with intense emotions to things that may not cause any emotion for someone else“Thinner emotional skin”Emotional Reactivity: More intense emotionsHigher emotional baselineSlow Return to Baseline: Emotions that stick around longer
12 Biosocial Model of BPD INVALIDATION Emotional Fit: It can be difficult for people with less intense emotions to understand or teach those with more intense emotions how to manage their emotionsDenial/Suppression of Emotions: With more intense emotions, people either doubt and ignore their emotions until they explode or become more intense in emotional expressionsReciprocal Effects: Emotions that are more intense than average are more likely to be dismissed by othersAbsence/Abuse/Neglect: These can also teach people to ignore, doubt, or push away emotions
13 Biosocial Model of BPDEMOTIONAL VULNERABILITY + INVALIDATION = BORDERLINE PERSONALITY DISORDER
14 Apply the Biosocial Model to a Practice Case Choose one of the vignettes provided. Identify any information you have that applies to the Biosocial Model:Emotional VulnerabilityExperiences of Invalidation
15 Stages of Treatment Stage I: Stabilization Focus: Goal: Treatment Hierarchy:Reduce Life-Threatening BehavioursReduce Therapy-Interfering BehavioursReduce Quality-of-Life-Interfering BehavioursIncrease Skills that Replace Ineffective CopingGoal:Move from behavioural dyscontrol to control to achieve a normal life expectancy
16 Target Hierarchy in Stage I Life-Threatening BehavioursSuicideNSSITherapy-Interfering BehavioursE.g. Missing sessions, not completing homework, behaviours that interfere with therapist’s motivation to treat clientQuality-of-Life-Interfering BehavioursE.g. Substance use, eating disordered behaviours, inability to keep employment, educational IssuesSkills AcquisitionTo replace dysfunctional behaviours
17 Stages of Treatment Stage II: Suffering in Silence Focus: Goal: Address inhibited emotional experiencingReduce PTSD symptomsGoal:Move from quiet desperation to full emotional experiencing
18 Stages of Treatment Stage III: Build a Life Worth Living Focus:Problems in LivingGoal:Life of ordinary Happiness and UnhappinessStage IV: Address Issues of Meaning (Optional)Spiritual FulfilmentConnectedness to Greater WholeMove from incompleteness to ongoing capacity for Experiences of Joy and Freedom
19 Practice 3Identify stages of treatment and applicability of the treatment hierarchy to a practice caseChoose one of the provided case vignettes. List any therapy goals you and the client might choose to work onIdentify at what stage of treatment you would work on each of these goalsFor Stage I Goals, create a treatment hierarchy:Life-Threatening BehavioursTherapy-Interfering BehavioursQuality-of-Life Interfering BehavioursSkills Acquisition
21 Core DBT StrategiesValidation and problem-solving form the core of DBTAll other strategies built around themProblem-solving strategies are change-basedAnalyzing behaviour, committing to change, taking steps to changeValidation strategies are acceptance-basedEngaging client in understanding actions, emotions, and thoughts
22 Core DBT Strategies: Validation VALIDATION MEANS:Communicating to the client that their responses make sense and are understandable within current life contextFinding the kernel of truth in the client’s perspective or situationAcknowledging causes of emotions, thoughts, and behaviours
23 Core DBT Strategies: Validation IMPORTANT THINGS TO VALIDATE:Emotions: Feelings, wanting, suffering, difficultiesThoughts: Beliefs, opinions, or thoughtsActionsAbilitiesREMEMBER:Every invalid response makes sense in some wayValidation is not necessarily agreeingValidation doesn’t mean you like itOnly validate the valid
24 A “How To” Guide to Validation PAY ATTENTION: Listen actively with body and mind.REFLECT BACK: Say back what you heard descriptively and non-judgmentally.READ MINDS: Be sensitive to what is not being said by the client. Be open to correction.UNDERSTAND: Look for how the client’s emotions, thoughts, and actions make sense given their history, state of mind, or current situation, even if you don’t approve of the behaviour, emotion, or action itself.
25 A “How To” Guide to Validation ACKNOWLEDGE THE VALID: Show you are taking the client seriously by what you say and doSHOW EQUALITY: Be yourself! Treat the client as an equal, not as fragile or incompetent
26 Practice 4 Practice validation Get into pairs One person will be the “storyteller,” one person will be the “validator”The storyteller tells a story of something that recently happened to them and that elicited some emotionThe validator listens and responds only with validationSwitch roles
27 Core DBT Strategies: Chain Analysis Core problem-solving strategyPurpose: examine events and situational factors leading up to and following a problematic response
28 Steps of a Chain Analysis Choose a specific instance of behavior to analyzeDescribe the behavior specificallyTopography (“What exactly did you do?”; “What exactly do you mean by that?”)Frequency (“How many times did you do that?”)Intensity (“How intense was the feeling on a scale?”)
29 Steps of a Chain Analysis Determine antecedentsLink client’s behavior to environmental eventsInternal and external eventsAsk when the problem began“What set that off?”“What was going on the moment the problem started?”Fill in links in terms of small units of behaviorDoing, feeling, thinking, imaginingOnce one link is described, determine the next“What next?”“How did you get from feeling like you wanted to talk to me to calling me on the phone?”
30 Steps of a Chain Analysis Determine consequencesThose influencing problem behaviour by maintaining, strengthening, or increasing itE.g., preferable events, stopping of aversive events, opportunities to engage in preferable behavioursAssess external and internal eventsDetermine function of the behaviour
31 Sample Chain Analysis Behaviour: Overdose (with suicidal intent) Thought: “I can’t live without him”Thought: “He will leave me”Event: Fight with boyfriendVulnerability: IntoxicatedEmotion: PanicThought: “Will be better if I’m dead”Action: Walk to bathroom and get pillsUrge: Take pills to forgetEmotion: DespairAction: Take pillsEvent: Picked upby EMSEvent: Boyfriend visits in hospitalEmotion:Love and affection
32 DBT Behavioral Chain Analysis Worksheet Name: _______________ Date: ______ Target Behavior: _________________________Types of Links: A Actions B Body Sensations C Cognitions E Events F FeelingsChain Analysis: Solution Analysis:Things in myself and my environment that made me vulnerable:Ways to reduce vulnerability in the future:VulnerabilityFactorsPrompting Event: Ways to prevent prompting event in future:EActual Behaviors and Events: Skillful alternative behaviors:ProblemBehaviorConsequencesand Harm (Immediate and delayed)Consequences in the environment? Plans to repair, correct, and over-correct harm:Consequences in myself?Adapted from Marsha Linehan’s Chain Analysis Worksheet by Seth Axelrod, PhD 2/13/04
33 Practice chain analysis using a practice case Get into pairsChoose one of the two vignettes providedOne person will role play the client, one person will role play the counsellorChoose a specific behaviour from the case vignette to chain analyze e.g., cutting, waiting for faculty member in the parking lotRole play a chain analysis of this behaviour. The counsellor will have to ask as many questions as needed to “fill in the links of the chain”
35 Distress Tolerance “How to get through a crisis without making things worse”
36 Distress Tolerance: Crisis Survival Skills CRISIS SURVIVAL SKILLS are needed:When client is in a situation that isHighly stressfulShort-termCreating intense pressure to resolve the crisis nowANDActing on emotions and urges will make things worseClient cannot make things better right awayClient must temporarily tolerate painful events and emotionsCRISIS SURVIVAL SKILLS are not for:Everyday useSolving all of life’s problemsMaking life worth living
37 STOP Skills Stop Take a step back Observe Proceed mindfully Do not just react. Stop! Freeze! Do not move a muscle! Your emotions may try to make you act without thinking. Stay in control!Take a step backTake a step back from the situation. Get unstuck from what is going on. Let go. Take a deep breath. Do not let your feelings put you over the edge and make you act impulsively.ObserveTake notice of what is going on inside and outside of yourself. What is thesituation? What are your thoughts and feelings? What are others saying or doing?Proceed mindfullyAct with awareness. In deciding what to do, consider your thoughts and feelings, the situation, and the thoughts and feelings of other people. Think about your goals. What do you want to get from this situation? Which actions will make it better or worse?
38 PROGRESSIVELY RELAX YOUR MUSCLES TIPP SkillsTIP YOUR TEMPERATUREINTENSELY EXERCISEPACE YOUR BREATHINGPROGRESSIVELY RELAX YOUR MUSCLES
39 TIPP SkillsTip the TEMPERATURE of your face: use ice water to calm yourself down fast by changing the response of your autonomic nervous systemPut your face in a bowl of ICE WATER (30 seconds)OR splash ICE WATER on your face,OR hold a gel ICE pack (or zip-lock ICE WATER) on your face.INTENSELY EXERCISE to calm down a body revved up by emotionEngage in intense exercise, if only for a short while.Expend your body’s stored up physical energy by: Running, Walking , Fast Jumping, Playing Basketball, Weight Lifting, etc.
40 TIPP Skills PACE YOUR BREATHING BY SLOWING IT DOWN Slow your pace of inhaling and exhaling way down (on average 5 to 7 breath cycles per minute).Breathe deeply from the abdomen.Breathe more slowly out than when breathing in (for example, 4 seconds in and 8 seconds out).PROGRESSIVELY RELAX YOUR MUSCLESStarting with your hands, moving to your forearms, upper arms, shoulders, neck, forehead, eyes, cheeks & lips, tongue & jaw, chest, upper back, stomach, buttocks, thighs, calves, ankles, feet.TENSE (5 seconds), then let go and RELAX each muscle (all the way).NOTICE the tension. NOTICE the difference when relaxed.
41 Pros and ConsUse PROS and CONS anytime you have to decide between two courses of action.ProsConsActing on Crisis UrgesResisting Crisis Urges
42 A way to remember these skills is the acronym “ACCEPTS” DistractionA way to remember these skills is the acronym “ACCEPTS”Activities:Refocus your attention on the task you have to get doneTV, events, exercise, internet, sports, hobbiesContributing:Volunteering, help a friend, encourage someoneComparisons:Compare how you are feeling now to a time when you felt differentDifferent Emotions:Books, stories, movies, musicPushing Away:Leave the situation; block thoughts from your mindOther Thoughts:Counting; puzzlesOther Sensations:Squeeze a rubber ball; hold ice; go out in the rain
43 Self-Soothing Vision: A way to remember these skills is to think of soothing each of your FIVE SENSES:Vision:Stars at night; pictures in a book, nature, candlesHearing:Soothing music; invigorating music; sounds of nature; sounds of the citySmell:Soap, incense, coffee, essential oils, boil cinnamonTaste:Favourite foods; soothing drinks; chew gumTouch:Hot baths; pet your dog or cat; creamy lotion; comfortable clothing
44 Group Discussion 1Discuss how Distress Tolerance skills may be helpful to our practice casesAt your table, choose one case vignette.How could these distress tolerance skills help the client in the vignettes accomplish their treatment goals?How would you teach these skills to a client?
45 Emotion Regulation “How to understand emotions, change ineffective emotions, and be less vulnerable to negative emotions”
47 Model of Emotion: Observe and Describe Emotions Prompting EventWhat set off the emotion?Emotioni.e., anger, fear, joyInterpretationsThoughts, judgments, beliefsExperiencingBody changesAction Urgese.g., withdraw, attack, eatExpressingBehaviours – what you said or didAftereffectsConsequences – your state of mind; others’reactions; reinforcements
48 Opposite Action Fear Urge: Freeze, run, avoid Changing ineffective emotions by ACTING OPPOSITE to the emotionFearUrge: Freeze, run, avoidOpposite action: ApproachAngerUrge: Attack, hit, yellOpposite action: Gently avoid; do something niceSadnessUrge: Withdraw, cry, isolateOpposite action: Get activeGuilt/ShameUrge: Hide/avoidOpposite action: Face the music; repair mistakes
49 Group Discussion 2Discuss how Emotion Regulation skills may be helpful to our practice casesAt your table, choose one case vignette.How could these emotion regulation skills help the client in the vignettes accomplish their treatment goals?How would you teach these skills to a client?
50 Interpersonal Effectiveness “How to get your needs met while maintaining your relationships and self-respect”
51 Identifying Interpersonal Priorities Goal EffectivenessWhat do I want from the other person?Relationship EffectivenessHow do I want the other person to feel about me?Self-Respect EffectivenessHow do I want to feel about myself?
52 Goal Effectiveness – DEAR MAN Effectively making a requestWhat to say: DEARDescribe: Describe the situation. Stick to the facts.Express: Express feelings using “I” statements.Assert: Ask for what you want.Reinforce: Explain positive effects of getting what you want.
53 Goal Effectiveness – DEAR MAN Effectively making a requestHow to say it: MANMindful: Keep your focus on what you want.Appear confident: Make eye contact; confident tone of voiceNegotiate: Be willing to give to get. Ask for the other person’s input.
54 Practice using DEAR MAN to make a request Get into pairsOne person will make a request using DEAR MAN for something a person might ask of another personSwitch roles
55 Mindfulness “How to pay attention to the present moment without judgment, rejection, or attachment”
57 Non-judgmental Notice, but don’t evaluate as “good” or “bad” Acknowledge harmful and helpful, but don’t judgeE.g., replace “You’re a jerk” with “I feel mad when you do that”Catch judgments so that you have more control over your emotionsStepsNotice judgmentsDon’t judge your judgmentsReplace judgments with descriptions (things you can see, hear, feel, taste, touch)
58 Practice non-judgmental Get into pairsThink of a difficult client you have worked with or choose a client from the case vignettesDescribe your client to the other person without judgmentFor the listener: pay attention and note any judgments that occurSwitch roles
59 Additional Issues in DBT Interacting with Other ProfessionalsFurther TrainingRecommended Readings
60 DBT and Other Professionals Ancillary mental health treatments are acceptable in DBTHowever, there can be only one primary individual therapist at a time“Consultation to the patient” approach:Teach the client to act as their own agent in obtaining appropriate careDo not intervene, solve problems, or act for the patient with other professionalsRationale:Teaching effective self-careDecreasing “splitting”Promoting respect for the client
61 When Another Professional Calls: Obtain as much information about the situation as they will giveProvide caller with necessary information the client cannot give, and verify information client has givenTell them to follow their normal proceduresAsk to talk to the clientCoach client on how to best cope with situation and interact with the professionals
62 Further Training and Certification Training OpportunitiesBehavioral TechFounded by Marsha LinehanGold Standard for TrainingOnline workshops/training, Web Shorts, Multi-day Workshops, Consultation, Intensive Trainings for Individuals and TeamsOshawa Psychotherapy Training InstituteFacilitated by Clinicians from CAMHFour-part Training – 2 days each, often offered to suit 9-5 work schedules (evening and weekend)Parts can be taken individually
63 Further Training and Certification Training OpportunitiesCAMHDialectical Behaviour Therapy Certificate ProgramFour-part training – A-D, 8 evenings eachThe Mindfulness ClinicSupervision, Consultation, Individualized WorkshopsDBT Training Courses may be offered in the futureParts can be taken individually
64 Further Training and Certification DBT CertificationOffered through Linehan InstituteRequires:Graduate Degree from Accredited InstitutionLicensed as independent mental health provider40-hours of Didactic DBT TrainingCompletion of Treatment with at Least Three DBT cases using full-mode DBT12-months and current participation on DBT consultation teamRead skills manual, complete all homework in skills manual, facilitate teaching of all skills in manual in individual or group formatExamLetter of RecommendationWork Product DemonstrationDemonstrated Mindfulness ExperienceOther Certification Programs Exist but do not offer the same standards/credibility
65 Options for Treatment Referrals in Ontario Publically FundedToronto, ONCentre for Addiction and Mental HealthDavenport Perth Neighbourhood Centre – Surfing Tsunamis ProgramLondon, ONLondon Health Sciences Centre – Victoria HospitalHamilton, ONSt. Joseph’s Health Care DBT Program
66 Options for Treatment Referrals in Ontario Private Treatment OptionsThe Mindfulness Clinic: Toronto, ONComprehensive Adult and Adolescent DBT ProgramIndividual TherapyAdult Skills Training GroupsAdolescent Multi-Family Skills Training GroupsPhone CoachingWeekly Therapist Consultation TeamMore info:
67 Options for Treatment Referrals in Ontario Private Treatment OptionsBroadview Psychology: Toronto, ONBehavioural Health: Guelph, ONComprehensive DBT ProgramDr. Carmen Weiss & Associates: Burlington, ONGroup and Individual DBT-based Treatment
70 ReferencesDimeff, L. A., & Koerner, K. (Eds.) (2007). Dialectical Behavior Therapy in clinical practice: Applications across disorders and settings. New York: Guilford Press. Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, Koerner, K. (2011). Doing Dialectical Behavior Therapy: A practical guide. New York: Guilford Press. Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of Dialectical Behavior Therapy in Women Veterans with Borderline Personality Disorder. Behavior Therapy, 32, Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, Miller, A. L., Rathus, J. H., & Linehan, M. M. (2006). Dialectical Behavior Therapy with suicidal adolescents. New York: Guilford Press. Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , Stijnen, T., & Van Den Brink, W. (2003). Dialectical Behaviour Therapy for Women with Borderline Personality Disorder, 12-month, Randomised Clinical Trial in The Netherlands. British Journal of Psychiatry, 182,