Transcript Dr. Paulette Aasen`s presentation on DBT

Dialectical Behavior Therapy
Paulette Aasen, Ph.D.
Director of Psychology Services
West Central Human Service Center
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Bismarck, ND
(701) 328-8888
Badlands Human Service Center
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Dickinson, ND
(701) 227-7500
February 10, 2014
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.”
Foundations of DBT

DBT is a synthesis of three paradigms:
◦ 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
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)
Bio-Social Model
Biological Sensitivity
AND Invalidating Environment =
Dsyregulation Disorder Symptoms
Invalidating
Environment
Invalidating
Environment
Invalidating
Environment
Biology
Biology
Biology
Bio-Social Model (cont.)
High Sensitivity
 High Reactivity
 Slow Return to Baseline
 Often “Transactional” with the
Environment

Slow Return to Baseline
9
8
7
Emotions
6
5
4
3
2
1
0
Average
Dysregulated
Threshold
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.”
Dialectical Paradigm
From DBT Self Help at http://www.dbtselfhelp.com
Dialectics: A Model for Change
Thesis
Antithesis
Synthesis
Movement Over Time
Primary Dialectic in DBT
Acceptance
Change
Dialectical Dilemmas
Emotional
Vulnerability
Active
Passivity
Unrelenting
Crisis
Biological
Social
Apparent
Competence
Inhibited
Experiencing
Self-Invalidation
Dialectical Strategies
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Balance Treatment Strategies
Enter the paradox
Metaphor
Devil’s Advocate
Extending
Wise Mind
“Lemonade out of lemons”
Allowing natural change
Dialectical Assessment
Behaviorism Paradigm
From DBT Self Help at http://www.dbtselfhelp.com
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

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.

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.

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.

Hierarchy of Targets
 Individual Therapy
1. Life threatening behaviors
2. Therapy interfering behaviors
3. Quality of life interfering behaviors
4. Increasing behavioral skills
Client Agreement

Client and Therapist BOTH sign the
agreement to acknowledge what it is they
are agreeing to in the therapy
relationship.
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

Commitment Strategies
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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
Commitment Strategies (cont.)
Therapist uses principles of SHAPING
to elicit commitment
 Therapist generates hope by
CHEERLEADING
 Therapist and client agree on
HOMEWORK

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

Self-Verification Theory
Validation = Self-Verification
 Invalidation of Self-Construct leads to
AROUSAL!!! (Sense of out-of-control)
 HIGH AROUSAL + OUT-OFCONTROL leads to >>>>
 Failure to process New Information
=
 NO NEW LEARNING!

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

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
DBT Skills Group
Screening session
 1-year commitment
 Both client and therapist sign agreement
 Agreement includes statements regarding
homework completion and attendance
 Co-facilitators

Hierarchy of Targets
 DBT Skills Group
1. Therapy destroying behavior
2. Skills acquisition, strengthening, and
generalization
3. Therapy interfering behaviors
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

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 http://www.dbtselfhelp.com
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
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Kabat-Zinn, 1990
5 Stages of Accomplishment
1.
2.
3.
4.
Denial
I can’t
do it!
Maybe I
can do it!
Uncertainty
Resistance
Panic
There’s no
way I can
do it!
AAAARGH!
What if I
can’t do it?!
5.
Acceptance
ALL RIGHT!
I DID IT!
LET’S
PARTY!
CONGRATULATIONS!
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.
DBT Associates

Christine Kvidera, MSW, LICW
7362 University Ave. NE, Suite 101
Fridley, Minnesota 55432
Phone & Fax: (763) 503-3981
www.dbtassociates.com
Email: [email protected]