1. Dialectical Behavior Therapy
Paulette Aasen, Ph.D.
Director of Psychology Services
West Central Human Service Center
Bismarck, ND
(701)
Badlands Human Service Center
Dickinson, ND
(701)
February 10, 2014

2. Overview of DBT
Developed by Marsha Linehan, Ph.D., in 1993 as treatment for clients struggling with severe & persistent emotional, behavioral, & thought difficulties, especially those diagnosed with Borderline Personality Disorder.
Dr. Linehan recently shared that she struggles with Borderline Personality Disorder.
The Goal of DBT: “Create a life worth living.”

3. Foundations of DBT DBT is a synthesis of three paradigms: Purpose:
Dialectics
Behaviorism
Mindfulness
Purpose:
Reducing dysfunctional behaviors
Increasing skillful behaviors
Building a life worth living
Client needs validating environment in which s/he is taught to regulate emotions, deal with interpersonal conflicts, tolerate distress, and find balance.
Swenson, Witterholt, & Bohus, 2007

4. Linehan Diagnosis for Borderline Personality Disorder
Emotion Dysregulation
Affective lability
Problems with anger
Interpersonal Dysregulation
Chaotic relationships
Fears of abandonment
Self Dysregulation
Identity disturbance – difficulties with sense of self
Sense of emptiness
Behavioral Dysregulation
Parasuicidal behavior
Impulsive behavior
Cognitive Dysregulation
Dissociation / paranoid ideation
(Linehan, 1993)

5. Bio-Social Model
Biological Sensitivity AND Invalidating Environment = Dsyregulation Disorder Symptoms
Invalidating
Environment
Invalidating
Environment
Invalidating
Environment
Biology
Biology
Biology

6. Bio-Social Model (cont.)
High Sensitivity
High Reactivity
Slow Return to Baseline
Often “Transactional” with the Environment

7. Slow Return to Baseline
Emotions

8. Dialectical Paradigm
Dialectics is the theory that opposites can co-exist.
Hegel: “Process of change in which a concept or its realization passes over into and is preserved and fulfilled by its opposite.”
Bohr: “The Universe is so constructed that the opposite of a true statement is a false statement, but the opposite of a profound truth is usually another profound truth.”

9. Dialectical Paradigm
From DBT Self Help at

10. Dialectics: A Model for Change
Thesis
Antithesis
Synthesis
Movement Over Time

11. Primary Dialectic in DBT
Acceptance
Change

12. Emotional Vulnerability Inhibited Experiencing
Dialectical Dilemmas
Emotional Vulnerability
Active Passivity
Unrelenting Crisis
Biological
Social
Apparent Competence
Inhibited Experiencing
Self-Invalidation

14. Dialectical Strategies
Balance Treatment Strategies
Enter the paradox
Metaphor
Devil’s Advocate
Extending
Wise Mind
“Lemonade out of lemons”
Allowing natural change
Dialectical Assessment

15. Behaviorism Paradigm
From DBT Self Help at

17. Behavior Therapy Basics
Behavioral Principles necessary to be effective
Behavior Therapy: a non-biological form of therapy that developed from learning theory. The purpose is to change maladaptive patterns of behavior.
Shaping: Divide a behavior to be learned into a series of steps.
DBT: Harm reduction model so shape clients toward that

18. DBT Assumptions about Clients
Clients are doing the best they can.
Clients want to improve.
Clients need to do better, try harder, and be more motivated to change.
Clients may not have caused all of their own problems, AND they need to solve them anyway.

19. Assumptions about Clients (cont.)
The lives of suicidal individuals with Borderline Personality Disorder are unbearable as they are currently being lived.
Clients must learn new behaviors in all relevant contexts.
Clients cannot fail in DBT.

20. 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 utmost importance in conducting DBT.
The therapeutic relationship is a real relationship between equals.

21. Hierarchy of Targets Individual Therapy Life threatening behaviors
Therapy interfering behaviors
Quality of life interfering behaviors
Increasing behavioral skills

22. Client Agreement
Client and Therapist BOTH sign the agreement to acknowledge what it is they are agreeing to in the therapy relationship.

23. Session Structure Review Diary Card Attention to Target Hierarchy
Chain Analysis on highest targeted behavior
Weave in Solution Analysis
Continue to move down hierarchy until able to discuss skills related to current life situations or session time ends

24. Commitment Strategies
Therapist discusses PRO’s and CON’s of commitment to change
Use the DEVIL’S ADVOCATE technique to strengthen commitment and build sense of control
Highlight PRIOR COMMITMENTS consumer has made
Present consumer with CHOICE stressing the freedom to choose while presenting the consequences of choices clearly and directly

25. Commitment Strategies (cont.)
Therapist uses principles of SHAPING to elicit commitment
Therapist generates hope by CHEERLEADING
Therapist and client agree on HOMEWORK

26. Validation of Consumer
Stay Awake
Accurate Reflection
Articulating unverbalized emotions, thoughts, and behavior patterns
Validation in terms of past learning or biological dysfunction
Validation in terms of current context or normative functioning
Radical Genuineness

27. Self-Verification Theory
Validation = Self-Verification
Invalidation of Self-Construct leads to AROUSAL!!! (Sense of out-of-control)
HIGH AROUSAL + OUT-OF- CONTROL leads to >>>>
Failure to process New Information =
NO NEW LEARNING!

28. Relationship Strategies
Accept the relationship as it is in the current moment, use the relationship as therapy – YOU are the Key
Use problem solving on the relationship
Attend directly to generalization of behaviors learned in the relationship

29. Combine Soothing, Validating, & Problem Solving with Observing Limits
Be honest about limits
Be consistently firm
Combine Soothing, Validating, & Problem Solving with Observing Limits
Warm Engagement:
Limits on Warmth
Coping with anger/rage at the consumer
Warm engagement and touch in psychotherapy
Genuineness

30. DBT Skills Group Screening session 1-year commitment
Both client and therapist sign agreement
Agreement includes statements regarding homework completion and attendance
Co-facilitators

31. Hierarchy of Targets DBT Skills Group Therapy destroying behavior
Skills acquisition, strengthening, and generalization
Therapy interfering behaviors
HIERARCHY??

32. Zen Practice Be Mindful to the current moment
See reality as it is without delusions
Accept reality without judgment
Focus on one’s own experiencing as a means of understanding the world
Let go of attachments that obstruct seeing and accepting reality as it is
Use skillful means
Find the middle way

33. Mindfulness Paradigm Mindfulness is at the core of
Emotion Regulation (emotions, thoughts, and behaviors).
Distress Tolerance (skills used to help us cope and survive during a crisis, distracting or soothing activities).
Interpersonal Effectiveness (skills which help us to attend to relationships, balance priorities versus demands, balance the “wants” and the “shoulds,” and build a sense of mastery and self-respect.
From DBT Self Help at

34. Mindfulness
“Paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experiences moment by moment.” (Kabat-Zinn, 2003, p. 145).
Non-Judgment
Patience
Beginner’s Mind or Child’s Mind
Trust
Non-Striving
Acceptance
Letting Go
Kabat-Zinn, 1990

35. 5 Stages of Accomplishment
I can’t
do it!
Denial
Uncertainty
Resistance
Panic
Maybe I can do it!
There’s no way I can do it!
AAAARGH!
What if I can’t do it?!

36. 5. Acceptance
ALL RIGHT!
I DID IT!
LET’S PARTY!
CONGRATULATIONS!

37. References DBT Self-Help Website http://www.dbtselfhelp.com
Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Delacorte.
Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford.
Miller, A. L., Rathus, J. H., & Linehan, M. I. (2007). Dialectical Behavior Therapy for Suicidal Adolescents. New York: Guilford.
Swenson, C. R., Witterholt, S., & Bohus, M. (2007). Dialectical behavior therapy on inpatient units. In: L. Dimeff & K. Koerner (eds.). Dialectical Behavior Therapy in Clinical Practice. New York: Guilford.

38. DBT Associates Christine Kvidera, MSW, LICW
7362 University Ave. NE, Suite 101
Fridley, Minnesota 55432
Phone & Fax: (763)