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Dialectical Behavior Therapy for Borderline Personality Disorder Milton Z. Brown, Ph.D. Alliant International University DBT Center of San Diego www.dbtsandiego.com.

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Presentation on theme: "Dialectical Behavior Therapy for Borderline Personality Disorder Milton Z. Brown, Ph.D. Alliant International University DBT Center of San Diego www.dbtsandiego.com."— Presentation transcript:

1 Dialectical Behavior Therapy for Borderline Personality Disorder Milton Z. Brown, Ph.D. Alliant International University DBT Center of San Diego

2 A first DBT session is a lot like a first DBT class Clients and students should know what to expect and make an explicit and firm informed commitment

3 Class Participation Modeling is essential – TIB, like arriving late – Awake – ask about nonverbal behaviors in class – Awake – comment on dysfunctional behaviors – DONB - problematic comments (e.g., judgment) Practice is essential – in-class role-play – practice awake and DONB on other in class – weekly practice of DBT skills – daily sitting mindfulness practice

4 Commitment Identify goals of client (or students) Clear and thorough discussion of what therapy (or class) could involve and why Collaborative discussion of what can be done to help client (or students) meet their goals Elicit explicit and firm commitment to specific behaviors Devil’s advocate strategy – highlight disadvantages of committing – highlight choice: “Are you sure? You don’t have to”

5 Commitment from Patient 1. By the end of the first session – commit to no suicide before the next session – removing lethal means 2. By the end of the fourth session – long-term commitment to not attempting suicide – long-term commitment to no self-harm – to work on therapy interfering behavior (target #2) – to do diary card and therapy homework – to engage in regular structured productive activities – to work on not avoiding everything

6 Commitment to Patient 1. Commit to four sessions – to decide if you can help the client – for client to decide if she will commit to therapy 2. By the end of the fourth session – make a time-limited commitment (e.g., 1 year) – specify progress required for you to agree to additional therapy after time period ends

7 DBT Interventions are based on Theory of BPD and Theories of Change

8 Development of BPD Linehan’s Biosocial Theory Biological and environmental factors account for BPD BPD individuals are born with emotional vulnerability BPD individuals grow up in invalidating environments Reciprocal influences between biological vulnerabilities and an invalidating environment lead to a dysfunction in the emotion regulation system. Mutual coercion (don’t repeat this!)

9 Development of BPD Linehan’s Biosocial Theory BPD individuals grow up in invalidating environments their emotions and struggles get trivialized, disregarded, ignored, or punished (even when normal) non-extreme efforts to get help get ignored only extreme communications/behaviors taken seriously sexual abuse Why? parents are cruel (invalidated or abused as children) low empathy and skill: don’t understand child’s struggle

10 Development of BPD Linehan’s Biosocial Theory BPD individuals learn to invalidate themselves – intolerant of their own emotions and struggles (punish, suppress, and judge their emotions, even when normal) They easily “feel invalidated” by others They still influence others via extreme behaviors – self-injury/suicidality to get help – aggression, self-injury, and suicidality to get others to back off

11 Most Good Treatments Don’t Work for BPD Patients BPD has been associated with worse outcomes in treatments of Axis I disorders such as… Major depression Anxiety disorders Eating disorders Substance abuse probably because BPD patients have low tolerance for change-focused treatments.

12 Why DBT was Developed? 1. BPD patients resist efforts to change them 2. BPD patients insist you help them change 3. Parasuicidal behaviors destroy therapy 4. Many behaviors interfering with therapy 5. Too hard for a single therapist to respond to crises and provide both skills training 6. Burnout and negative reactions to patients are common and often lead to iatrogenic behaviors.

13 13 Acceptance and Change BPD clients often feel invalidated when: – others focus on change (they feel blamed), but also insist that their pain ends NOW – others try to get them to tolerate and accept BPD clients need to – build a better life and accept life as it is – feel better and tolerate emotions better Only striving for change is doomed to fail – blocking emotions perpetuates suffering – disappointed when change is too slow The Central Dialectic

14 14 Numerous serious problems – suicidal behavior and nonsuicidal self-injury – multiple disorders – crisis-generating behaviors (self-sabotage) Too many therapy-interfering behaviors – non-compliance – strong emotional reactions to therapists – therapist overwhelm, helplessness, and burnout – therapists judge/blame clients Theory of BPD

15 15 Core Problem: Emotion Dysregulation pervasive problem with emotions high sensitivity/reactivity (i.e., easily triggered) high emotional intensity slow recovery (return to baseline) inability to change emotions inability to tolerate emotions (emotion phobia) – vicious circle (upward spiral) – desperate attempts to escape emotions – vacillate between inhibition and intrusion – inhibited grieving – history of invalidation for emotions – self-invalidation and shame inability to control behaviors (when emotional) Theory of BPD

16 THE PROBLEM CUE EMOTIONDYSREGULATIONEMOTIONDYSREGULATION PROBLEM BEHAVIOR Alcohol & Drugs Self-injury Aggression PROBLEM BEHAVIOR Alcohol & Drugs Self-injury Aggression TEMPORARY RELIEF AVOIDANCE OR ESCAPE Reinforcement strengthens this whole process Reinforcement strengthens this whole process e.g., interpersonal conflict (abandon, invalidation) e.g., interpersonal conflict (abandon, invalidation) e.g., others back off

17 It is incompatible with a life-worth living 1. It is an escape behavior that removes the opportunity to learn new ways of dealing with difficult events (compare to drugs) 2. Continued sensitivity to triggers (suffering) 3. Strengthens self-hatred and shame. 4. Causes relationship and medical problems 5. I care about someone and let it continue Why Self-harm Must Stop

18 Core Problem: Avoidance Denial of problems (avoiding feedback) Non-assertiveness and social avoidance Drug and alcohol abuse Self-injury, suicide attempts, and suicide Self-punishment, self-criticism (block emotions) Dissociation and emotional numbing Anger to block other (more painful) emotions Anger to divert away from sensitive interactions Hospitalization to escape stressful circumstances Theory of BPD

19 Acceptance and Change Soothing versus pushing the client Validation versus demanding The Central Treatment Dialectic

20 20 The Central Treatment Dialectic Balancing Acceptance and Change Balance therapist strategies – validation and Rogerian skills – CBT: problem-solving, skills, exposure, cognitive restructuring, contingency management Balance coping skills – skills to change emotions and events – acceptance skills are necessary since not enough change occurs and not fast enough

21 21 DBT Targets Serious problem behaviors targeted immediately and directly – suicidal behavior and nonsuicidal self-injury – excessive hospitalization – therapy-interfering behaviors Start with stabilization (coping skills) – reduce life chaos (problem solving) – build structure (e.g., work) – distraction and emotion regulation

22 Principles of DBT Functions: Enhance capabilities Improve emotion regulation Activate non-mood-dependent behavior Enhance motivation Assure generalization Structure the environment Enhance capability and motivation of therapists

23 23 Principle-driven treatment – minimal use of protocols – flexible use of multiple strategies – based on behavioral analysis (theory of client) – based on theory of BPD – function supersedes form Multiple modes and strategies – skills training separate from individual – telephone skills coaching – consultation team (therapist support) DBT is a Principle-Driven Treatment

24 Individual therapy – weekly sessions (usually 60 minutes) – telephone skills coaching – telephone crisis management Skill training (usually group of 5-10) – clients do not talk about self-injury or suicidal intent or behavior – very structured didactic format – not a process group DBT Strategies

25 DBT INTERVENES CUE EMOTIONDYSREGULATION Regulate or tolerate distress EMOTIONDYSREGULATION Regulate or tolerate distress PROBLEM BEHAVIOR Teach how to stop this behavior PROBLEM BEHAVIOR Teach how to stop this behavior TEMPORARY RELIEF AVOIDANCE OR ESCAPE Reduce power of triggers and emotion vulnerabillity Reduce power of triggers and emotion vulnerabillity Teach alternative ways to avoid or distract Teach alternative ways to avoid or distract Stop problem behavior or reinforcement Stop problem behavior or reinforcement Without escape, emotion dysregulation should improve Without escape, emotion dysregulation should improve Teach how to prevent triggers X X X X

26 DBT INTERVENES CUE EMOTIONDYSREGULATION Regulate or tolerate distress EMOTIONDYSREGULATION Regulate or tolerate distress PROBLEM BEHAVIOR Stop behavior: self-management PROBLEM BEHAVIOR Stop behavior: self-management TEMPORARY RELIEF AVOIDANCE OR ESCAPE Non-reinforced exposure, PLEASE, increase pos events Non-reinforced exposure, PLEASE, increase pos events Crisis Survival Skills Stop reinforcement (extinction) Problem solving or stimulus control Problem solving or stimulus control X X X Without escape, emotion dysregulation should improve Without escape, emotion dysregulation should improve

27 27 Focus on Emotion Regulation Reduce emotional reactivity/sensitivity – exercise, and balanced eating and sleep – exposure therapy Reduce intensity of emotion episodes – heavy focus on distraction early on, which is a less destructive form of avoidance Increase emotional tolerance – mindfulness – block avoidance Act effectively despite emotional arousal DBT Strategies

28 Self-injury Intervention Options Prevent, avoid, or solve interpersonal conflict Reduce emotional reactivity to conflict Regulate and tolerate emotions Alternative short-term escape (e.g., distraction) Behavioral control (e.g., highlight disadvantages, reduce opportunities/means) Stop relief – naltrexone – do not back off

29 Dialectical Behavior Therapy Treatment Strategies Problem-solving Skills-focus* (new skills manual) Exposure and opposite action Reinforcement principles Cognitive modification Support/Validation/Acceptance Dialectical Strategies

30 Levels of Validation Listen and pay attention Show you understand – paraphrase what the client said – articulate the non-obvious (mind-reading) Describe how their behaviors/emotions… – make sense given their past experiences – make sense given their thoughts/beliefs/biology – are normal or make sense now Communicate that the client is capable/valid – actively “cheerlead” – don’t treat them like they’re “fragile” or a mental patient

31 Validation What (“yes, that’s true” “of course”) Emotional pain “makes sense” Task difficulty “It IS hard” Ultimate goals of the client Sense of out-of-control (not choice) How Verbal (explicit) validation Implicit validation – acting as if the client makes sense – responsiveness (taking the client seriously)

32 Increases client willingness to change Strengthens therapeutic relationship Reinforces staying in therapy Reinforces clinical progress Provides feedback to shape behavior Increases self-validation by modeling validation Increases positive expectancies (believing in client) Functions of Validation

33 Self-Validation Get the patient to say: “It makes perfect sense that I … because…” – it is normal or make sense now – of my past experiences – of the brain I was born with – of my thoughts/beliefs Get the patient to act as if she makes sense: – non-ashamed, non-angry nonverbal behavior – confident tone of voice

34 Marsha / Stacey Chain Analysis From session 2 video write on white board

35 Agenda Mindfulness practice – today – regular practice DBT Listserve Chain analysis Self-validation rational-emotional role-play Observing limits

36 Problem Solving Functional analysis (chain analysis) Solution analysis – accept, tolerate, mindfulness – change, regulate – self vs. environment Anticipate and solve obstacles Skills acquisition (model) Rehearse – “dragging out new behavior” Commitment

37 Problem Solving Targeting Figuring out what to focus on: Self-injury Therapy-interfering behavior Emotion regulation and skillful behavior – shame and self-invalidation (judgment) – anger and hostility (judgment) – dissociation and avoidance In-session behavior

38 Do detailed behavioral analyses to discover: – environmental trigger – key problem emotions (and thoughts) – what happened right before the start of the urge? – what problem did the behavior solve? and conceptualize the problem (i.e., identify factors that interfere with solving the problem) Understand the Problem

39 Identify factors that Interfere with solving the problem Lack of ability for effective behavior Effective behavior is not strong enough Thoughts, emotions, or other stronger behaviors interfere with effective behavior Understand the Problem

40 DBT Assertiveness Skill DEAR MAN GIVE FAST Assertiveness is an effective alternative for anger and aggression helplessness (depression)

41 Therapy Interfering Behaviors (TIB) arrives late leaves early passive or helpless not do diary card excessively talks (hard for therapist to talk) complains but does not work in session excessively angry excessively judgmental/critical of therapist

42 CBT for Anger Work on anger collaboratively – motivational interviewing style (no labels) – frame the choice as “right versus effective” – validate what is valid Problem solving – act on anger when it helps reduce a threat Skills training Cognitive restructuring (be careful!) Exposure

43 Skills Training for Anger Gently avoid (time out) – postpone for a specified amount of time – distraction – pros and cons Relaxation Assertive communication (DEAR MAN GIVE) Empathy and explicit validation (no “should”) Get help for a “reality check” – Ask a friend: “Am I over-reacting?” – What am I failing to understand about other person? – Is it worth the battle/loss (even if I am right)?

44 Cognitive Restructuring for Anger Empathic interpretations of others – notice “shoulds” – external attributions (current causes) benefit of the doubt times client’s intent has been misunderstood – historical causes Ask rather than assume Humor Acceptance and forgiveness

45 Exposure for Anger Thoroughly assess triggers In vivo exposure – role-play – verbal barbs – homework Imaginal exposure – client can write a script in advance Opposite action – validation – opposite thinking?

46 Responding to Anger in Session Discourage simple venting/catharsis Link behavior to clients goals Refuse to talk about anger-inducing situations when not productive Validate/apologize/repair to the extent that therapist made a mistake. Do not avoid the issues that prompt the anger if they are reasonable to deal with – do not back down or appease

47 In-Session TIB Protocol Problematic Behavior Excess EXTINCTION: block behaviors – “that’s ineffective” (broken record technique) – return to the trigger or first emotion Validate or use humor/irreverence Comment on the therapy interactions (process) Illusion of choice in absence of alternatives Elicit collaboration (turn the tables) EXTINCTION: Do not respond (at all!)

48 TIB Protocol Problematic Behavior Excess Other Consequences Correction-Overcorrection (repair) Negative judgment from therapist Vacation from therapy Therapy termination

49 “Boundaries” in DBT = Observing Limits Hold natural rather than arbitrary limits Keep your sanity Model and reinforce effective interpersonal behavior Reinforce independent coping

50 Common Contingencies in DBT Observing limits “drag out new behavior” “talk it to death” (miss out on other topics) fill out diary card in session; make it useful schedule phone calls (not contingent on problems) withdraw warmth (or slightly aversive tone) minimize impact of hospitalization 24 hour rule

51 Contingency Management: Dragging Out New Behavior Redo dysfunctional in-session behaviors “Hold the patient hostage" until they emit an adaptive behavior – shaping of successive approximations – modeling, encouragement, validation Persist like “water over rocks (nagging)

52 Rational-Emotional Role-Play 1. Assess nuances of the intricate web of negative thoughts lingering – present rational thoughts to counter negative – instruct client to thoroughly discredit rational thoughts – model to client how to counter tricky negative thoughts 2. Have client rehearse rational thoughts – play role of Devil’s advocate (speak neg. thoughts) – prompt client to counter negative thoughts

53 Four Skills Modules Mindfulness Distress Tolerance – surviving crises – accepting reality Emotion Regulation – reduce vulnerability – reduce emotion episodes Interpersonal Effectiveness – assertiveness

54 "you can't say goodbye to something until you say hello to it" No-where to Now-here Be Loving and Openhearted with My Emotions

55 Skills for Reducing Emotions Distraction – activities with focused attention – self-soothing Intense exerciseTIP Relaxation – progressive muscle relaxation – slow diaphragmatic breathing – HRV biofeedback Temperature – ice cubes in hands* – face in ice water (whole body dunk)

56 Relaxation Training Progressive Muscle Relaxation Slow breathing – breathe from the diaphragm – 5-6 breaths per minute (4 sec in, 6 sec out) – exhale longer than inhale – maximize HRV

57 Skills for Persistent Worry Focus on physical sensations Imagery desensitization vs. coping imagery Check the facts (relax or solve problem) Acceptance – with the mind (“what is IS” “makes sense” “everything is as it should be”) – with body (relax muscles; breathe slowly) – with face (half-smile) – through acceptance actions (act “as if”)

58 Skills for Reducing Behavior Pros/Cons of new behavior Mindfulness of current emotion/urge Postpone behavior for a specific small amount of time (fully commit) – Distract, relax, or self-soothe – Postpone behavior again Do the behavior in slow motion Do the behavior in a very different way Add a negative consequence for behavior

59 Skills for Increasing Behavior To get opposite action: Pros/Cons of new behavior Mindfulness of current emotion/urge Break overwhelming tasks into small pieces and do first step – something always better than nothing Problem solve; Build mastery

60 DBT Treatment Outcomes DBT has better outcomes than TAU/TBE on: suicidal behavior (self-injury) psychiatric admissions and ER treatment retention angry behavior global functioning All treatments show improvement on: suicide ideation depressed mood trait anger

61 DBT Treatment Outcomes Tx YearFU Year DBTTBEDBTTBE Suicide Attempt23%47% Psych ER43%58%23%30% Psych Inpatient20%49%23%24% Linehan DBT Replication Study

62 DBT Treatment Outcomes Effects of DBT are not simply due to: – session attendance – getting good therapy (TBE) – therapist commitment and confidence Expert therapists are better than treatment as usual UW Replication Study

63 63 Is DBT feasible in the Real World? Research patients have severe problems and multiple diagnoses Treatment can provide a cost savings – sessions 3 hrs/wk + phone calls Is treatment is too hard for average therapists to learn competently? – ongoing evaluation, consultation, and training is worth the cost Many settings/clients require adaptations – little is known about core change process


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