Transcript Slide 1

Amy Copeland, M.S., LPC
From
Psychoanalysis
to…DBT?!
What
happened??
 Recognize and diagnose the characteristics of
Borderline Personality Disorder (BPD) and the
psychosocial influences.
 Utilize Dialectical Behavior Therapy (DBT) skills in
working with clients diagnosed with Borderline
Personality Disorder.
 Applying the treatment and working with the
challenges of treating the client with the disorder.
 A set of skills that is taught to people in services who
decide they want to commit to the DBT treatment
program.
 People who commit to DBT learn skills to deal with
relationships, emotions, chaos, trauma, pain,
suffering, loss of identity and acceptance.
 DBT focuses on problem solving, acceptance and
building a life worth living.
 DBT is a clinical treatment program created by Marsha
Linehan (PH.D) for people who struggle with
relationships, balancing emotions, coping with chaos,
and being in the present.
 DBT was originally started out as a treatment for people
diagnosed with Borderline Personality Disorder (BPD).
 Marsha Linehan felt a treatment was needed for this
disorder because of the high suicide rate associated
with this diagnosis and the many struggles clinicians
faced working with people diagnosed with BPD.
 DBT grew out of failed attempts to apply Cognitive
Behavioral Therapy (CBT) and behavioral therapy (BT)
to people who were constantly suicidal and suffering
from trauma.
 Marsha noticed people she was working with
experienced invalidation from therapy, withdrawal from
therapy, clients would feel the need to “attack” the
therapists who applied CBT and BT treatment
techniques in therapy. CBT and BT were too rigid and
invalidating at times to the pain and suffering people
were trying to cope with.
 Marsha and her colleagues discovered they were unable to
teach people how to deal with conflicts and chaos because
the treatment team was constantly addressing a crisis.
 People who were in CBT and/or BT treatment often
expressed dissatisfaction with therapist because therapists
disagreed with hospitalization when a person felt suicidal.
(Most people used hospitalization as a coping skill instead
of trying to exist with suffering.)
 Also the person in therapy was pleasant with the therapist
when the therapist and the person focused on topics that
the person wanted to discuss in therapy. Therefore, that
made it hard for therapist to tackle issues that interfered
with the person gaining control of their lives.
 People can’t find happiness in their life if diagnosed
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with BPD.
People diagnosed with BPD are attention seekers and
manipulative.
People diagnosed with BPD rarely commit suicide.
People diagnosed with BPD don’t make progress and
will always be hospitalized
People diagnosed with BPD caused all their
problems.
 People diagnosed with BPD can find happiness and purpose in
their life. DBT is about “building a life worth living!”
 People who are labeled as attention seekers or as manipulative are
only trying to get their needs met and have learned doing certain
behaviors have “rewarded” them with what they were needing from
others.
 10% of people diagnosed with BPD commit suicide every year. This
is higher those not in services and/or lack of services
 People diagnosed with BPD have the same ability to recover from
their illness just like any other illness.
 People can’t be entirely blamed for the problems in their life, but
we do have to deal with them regardless of whose fault it is. Being
unhappy with life is the motivation to change what we can.
 Commonly in women who have history of abuse.
 (discussion)
 Exhibited commonly in self destructive behaviors.
This is commonly due to the validating and
invalidating environments.
 (discussion of invalidating environments: ‘no wonder
you behave this way as … how could you not … that’s all
you’ve known your whole life’)
According to the Diagnostic and
Statistical Manual of Mental
Disorders, Borderline Personality
Disorder is…
…A pervasive pattern of instability of
interpersonal relationships, self-image,
and affects, and marked impulsivity
beginning by early adulthood and present
in a variety of contexts, as indicated by five
(or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment.
Note: does not include suicidal or self mutilating
behaviors.
Intense fear of abandonment. “I will be alone forever”
What does it look like: Girl calling boyfriend 150 times a
day and waiting on the door step for him to come home.
Husband showing up at wife’s work demanding to talk
to wife right away because the wife did not answer the
phone and he tried to call five times in a row.
2. A pattern of unstable, intense interpersonal
relationships characterized by alternating between
extremes of idealization and devaluation.
What does it look like: Experiences intense up and down
emotions and beliefs regarding people in their life based
off experiences between them and the other person(s).
Reacts to people intensely based off feelings, beliefs and
assumptions. “I hate you, don’t leave me!” May go to
extremes to keep relationships or push away
relationships in fear of being hurt.
High expectations of others … and when the person’s
needs are not met, the emotional reactions are extreme.
“I’m mad at you because you did not cook me dinner.”
3. Identity disturbance: markedly and persistently
unstable self-image or sense of self.
Feeling like “I don’t know who I am ?”and/or feeling
constantly misunderstood.
4. Impulsivity in at least two areas that are potentially
self-damaging (e.g., spending, sex, substance abuse,
reckless driving, binge eating). Note: Do not include
suicidal or self-mutilating behavior covered in
Criterion 5.
The person may do impulsive things without thought of
consequences and/or feel they could care less about the
consequences.
5. Recurrent suicidal behavior, gestures, or threats, or
self-mutilating behavior.
Repeated attempts of suicide and/or self-harm
behaviors; constantly has thoughts and feelings of
wanting to commit suicide. Fantasizes about death.
“Keeping the door open to suicide”.
6. Affective instability due to a marked reactivity of mood
(e.g., intense episodic dysphoria, irritability, or anxiety
usually lasting a few hours and only rarely more than a
few days).
Has extreme reactions or many intense feelings/moods
within a day or two and struggles returning to
balanced emotions.
7. Chronic Feelings of emptiness.
Is feeling or have felt for long periods of time feelings of
emptiness and loneliness.
8. Inappropriate, intense anger or difficulty controlling
anger (e.g., frequent displays of temper, constant anger,
recurrent physical fights).
The person maybe unable to control highly intense
fierce anger and/or been in a lot of physical fights.
9. Transient, stress-related paranoid ideation or severe
dissociative symptoms.
Feels loss of time or becomes disconnected from reality.
Person may have beliefs that other people are working
against them and/or feel they themselves are “evil”.
 To learn and
refine skills in
changing
behavioral,
emotional, and
thinking patterns
associated with
problems in
living, that is,
those causing
misery and
distress.
Behaviors to Decrease:
1. Interpersonal chaos
2. Labile emotions, moods
3. Impulsiveness
4. Confusion
Behaviors to Increase:
1. Interpersonal effectiveness
skills
2. Emotion regulation skills
3. Distress tolerance skills
4. Core mindfulness skills
DBT helps people cope with crisis, have meaningful
relationships, and regulates emotions all in the process of
building a life worth living and finding happiness.
(People commit suicide because they are not happy and
are overwhelmed by sadness and feel like they are
suffering.)
The skills give clients more control of their lives. Puts
their life back in the client’s hands along with skills,
commitment and support of a treatment team.
Mindfulness
• Stronger sense of self, increasing attention to the
moment, gain control over thinking, increasing
awareness of self and environment.
Interpersonal
Effectiveness
• Healthier relationships, gain skills to improve
relationships and self respect/self-worth, learn how to
get along with others despite our/their flaws and
strengths.
Emotion
Regulation
• Balance intense array of emotions, control reactions and
express emotions in a effective way, building more
positive experiences and learning how to be skillful
holistically.
Distress
Tolerance
• Learn how to make healthy choices in stressful
situations/ crises and skills to tolerate pain. Learn to
exist with trauma & move beyond suffering. Finding the
“middle path” in order build a life worth living.
 RESONABLE MIND – “COOL” attitude most of the time,
Logic, planning, work/volunteer, problem solving and
reasoning.
 EMOTIONAL MIND - “HOT” Intense feeling, experience
many emotions, yell, love, hate, fight, creativity and often
react with the moment.
 WISE MIND – “Warm” integration of both minds, gut
feeling, deep truth and understanding the bigger picture
without judgment.
 Goals of Interpersonal Effectiveness
 Getting your objectives or goals in a situation met
 Getting or keeping a good relationship
 Keeping or improving self-respect and liking yourself
 Situations for Interpersonal Effectiveness
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Attending to relationships
Balancing priorities vs. demands
Balancing the wants-to-shoulds
Building master and self-respect
 Factors Reducing Interpersonal Effectiveness
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Lack of skill
Worry thoughts
Emotions
Indecision
Environment
Understand Emotions You Experience
• Identify (observe & describe) emotion.
• Understand what emotions do for you.
Reduce Emotional Vulnerability
• Decrease negative vulnerability (vulnerability to emotion mind).
• Increase positive emotions.
Decrease Emotional Suffering
• Let go of painful emotions through mindfulness.
• Change painful emotions through opposite action.
THOUGHTS
EVENT
EMOTIONS
BODILY
SENSATIONS
ACTION
Accumulate Positive Experiences
• In the short term – do pleasant things that are possible right
now!
• In the long term – make changes in life so positive events will
occur more often – build a life worth living!
Build Mastery
• Schedule one or more activities each day to build a sense of
accomplishment.
Cope Ahead of Time With Emotional Situations
• Create a plan ahead of time so that you are prepared to cope
skillfully with emotional situations. Imagine yourself coping
effectively.
Emotion
Problem Solving
Anxiety / Fear
1. Remove the threat
2. Avoid the threat
Sadness
1.
2.
3.
4.
5.
Anger
1. Overcome the obstacle
2. Stop further attacks
3. Avoid threatening people
Retrieve what you have lost
Accumulate positives
Increase contact with rewarding people
Avoid thinking about what you have lost
Radically Accept
Emotion
Envy
Jealousy
Problem Solving
1.
2.
3.
1.
2.
Improve yourself and your life
Get others to be fair
Avoid people who have more than you
Protect what you have OR
Leave the relationship
Shame
1. Find a new group that fits your values or that likes
your personal characteristics OR
2. Change your behavior to fit in OR
3. Avoid groups who disapprove of you
Guilt
1.
2.
3.
4.
Repair the transgression/wrongdoing
Make things better, repair the harm
Commit to avoiding that mistake in the future
Accept the consequences gracefully
If an emotion we want to change is NOT JUSTIFIED,
then use OPPOSITE ACTION by following these steps:
1. Figure out what emotion you are feeling
2. What is the action that goes with that
3. Ask yourself: Do I want to change the emotion?
4. Figure out the opposite action
5. Do the opposite action ALL THE WAY!
Action Urge
Example
Opposite
Action
Anxiety / Fear
Avoid
Approach
Sadness
Withdraw
Get Active
Anger
Attack
Gently Avoid/
Be Decent
Envy
Sabotaging,
Criticizing
Count Your
Blessings
Jealousy
Accusing,
Spying
Let go of controlling
others / Share
Shame / Guilt
Hide
Be Open
Emotion
Distress Tolerance is about Crisis Survival
Strategies. One of the important set of
strategies is Accepting Reality. There are
three basic principles of accepting reality:
1. Radical Acceptance
2. Turning the Mind
3. Willingness over Willfulness
 Freedom from suffering requires ACCEPTANCE from deep
within of what is. Let yourself go completely with what is.
Let go of fighting reality.
 ACCEPTANCE is the only way out of hell.
 Pain creates suffering only when you refuse to ACCEPT the
pain.
 Deciding to tolerate the moment is ACCEPTANCE.
 ACCCEPTANCE is acknowledging what is.
 To ACCEPT something is not the same as judging it good.
 Acceptance of reality as it is requires an act of CHOICE.
It is like coming to a fork in the road. You have to turn
your mind towards the acceptance road and away from
the “rejecting reality” road.
 You have to make an inner COMMITMENT to accept.
 The COMMITMENT to accept does not itself equal
acceptance. It just turns you toward the path. But it is
the first step.
 You have to turn your mind and commit to acceptance
OVER AND OVER AND OVER again. Sometimes, you
have to make the commitment many times in the space
of a few minutes.
 Willingness is DOING JUST WHAT IS NEEDED in
each situation, in an unpretentious way. It is focusing
on effectiveness.
 Willingness is listening very carefully to your
WISE MIND, acting from your inner self.
 Willingness is ALLOWING into awareness your
connection to the universe – to the earth, to the floor
you are standing on, to the chair you are sitting on, to
the person you are talking to.
 Willingness is throwing yourself into life and
participating as best you can.
 Willfulness is SITTING ON YOUR HANDS when
action is needed, refusing to make changes that are
needed.
 Willfulness is GIVING UP.
 Willfulness is the OPPOSITE OF “DOING WHAT
WORKS,” being effective.
 Willfulness is trying to FIX every situation.
 Willfulness is REFUSING TO TOLERATE the
moment.
 Notice you are being willful – observe your
willfulness, identify it, and describe it.
 Radically accept that you are being willful. Turn your
mind toward acceptance, and make a commitment to
be willing and to participate in reality as it is.
 Ask yourself “what is the threat”? What do you fear
you might lose by being willing.
1.
2.
3.
4.
5.
Need a committed DBT team to work with
clients.
Need to adhere to the practice of DBT (keep
DBT pure).
Must be able to work as hard as the client.
Must practice DBT in your own life.
Create a DBT program that has consultation
meetings, skills group, individual therapy,
access to coaching calls and skill coaches.
1.
2.
3.
4.
5.
Keeping empathy for clients (keeping hope for
the client even if they don’t have it).
Getting clients committed to DBT program.
DBT homework, showing up to therapy and skills
group (don’t work harder than the client).
Starting a new program – Tweak, tweak, and
more tweak.
Team members may struggle with each other’s
style. Keep the balance of differences and still
honor each other.
Websites:
www.dbtselfhelp.com
www.behavioraltech.org
Books
1. “I hate you, don’t leave me” authors: Jerold Kriesman
and Hal Straus.
2. “Don’t shoot the dog” author: Karen Pryor
3. “Cognitive Behavioral Treatment of Borderline
Personality disorder” author: Marsha Linehan
4. “Skills training Manuel for Borderline Personality
Disorder” author: Marsha Linehan