Transcript DBT Dialectical Behaviour Therapy

Random bits of DBT
Dialectical Behaviour Therapy
A principle-driven treatment for severe
and chronic, multi-diagnostic, difficultto-treat clients
Angelique O’Connell
Acknowledgements:
The materials presented here are adapted from the work of Marsha Linehan and Behavior
Tech Training Programmes USA.
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So…Who is it for?
• It is for the severe and chronic multidiagnostic difficult to treat client with both
Axis I and II disorders.
• It’s for those that experience a pervasive
dysfunction of the emotion regulation
system - Dysregulation of emotion,
cognition, behaviour, interpersonal
relationships, & self.
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Why was it developed?
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Marsha et al (1970’s onward) identified that the
CBT approach was less successful with this
particular client group. Three major problems
were identified:
1. Clients found unrelenting focus on change
inherent to CBT invalidating.
2. Clients unintentionally positively reinforced
their therapist for ineffective treatment, while
punishing for effective therapy.
3. The volume of problems and severity of
problems made it impossible to ues the
standard CBT format.
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So,
Marsha Linehan added the concepts of
Validation and Dialectics to CBT
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Acceptance
• Added Acceptance based interventions,
(frequently referred to as validation
strategies) .
• These did not exclude the emphasis on
change – the two enhanced the use of one
other
• And by weaving acceptance and change
together, Dialectics came into play.
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Dialectics…
• Provides means for therapist to balance
acceptance and change in each session.
• Prevents therapist and client from getting stuck
in the rigid thoughts, feelings and behaviours
that can occur when emotions run high – as they
often do with the client group.
• Dialectical world view that emphasises holism
and synthesis enables therapist to blend
acceptance and change
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DBT states that…
• BPD results from the interaction of
biological vulnerability with invalidation
over time
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Why beneficial
• DBT addresses the relationship between the individual
and his/her environment (family/work/school/peers).
• DBT aims to replace problem behaviours with skilful
behaviours.
• DBT helps people create a life worth living. A life with
both positive and negative aspects and all of these
aspects are necessary and valuable.
• DBT aims to improve quality of life, to help people learn
to value themselves and each other and to teach a
DIALECTICAL WORLDVIEW.
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Dialectical… what?
• All people have something unique and valid to offer.
• The importance of avoiding viewing the world in black
and white terms - instead see the shades of colour.
• There is always more than one way to see a situation
and more than one opinion, idea or dream
• Therefore, there is no absolute truth.
• Two opposite ideas can be true at the same time.
• Considering all points of view before integrating them
into our own personal view of the world.
• Change is the only constant
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DBT Assumptions about Clients
• Clients are doing the best they can
• Clients want to improve
• Clients must learn new behaviours in all relevant
contexts
• Clients CANNOT fail DBT
• Clients may not have caused all of their own problems,
but they have to solve them anyway
• Clients need to do better, try harder, and/or be more
motivated to change
• The lives of suicidal, borderline individuals are
unbearable as they are currently being lived
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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 the utmost
importance in the conduct of DBT
• The therapeutic relationship is a real relationship
between equals
• Principles of behaviour are universal, affecting therapist
no less than clients
• Therapists treating(BPD) self injuring clients need
support
• DBT therapists CAN fail
• DBT can fail even when therapists do not
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Therapist characteristics
Oriented to Change
Unwavering centredness
Benevolent Damanding
Nurturing
Compassionate Flexibility
Oriented to acceptance
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Skills training and individual
therapy
• Modules – mindfulness, interpersonal
effectiveness, distress tolerance, emotion
regulation.
• Individual – assist in generalising the skills
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Groups for teens
• Skill building rather than therapy
• Participants have same level of
emotionality
• Rules about disclosure
• Confidentiality and respect
• Rules about interactions and relationships
outside of the group environment
Diary Cards
• Monitor relevant behaviour occurring outside of
therapy
• Allows therapist to follow use/practice of skills
• A good starting point for conversation
• Where the therapist identifies behaviour/problem
to target in chain analysis.
• Modify diary card to ‘fit’ you’re client, but keep
the key components
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Consultation Group
• Where therapists meet to support each
other working dialectically, while
observing limits, maintaining commitment,
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Functions of validation
• To strengthen clinical progress
• As acceptance to balance change
• To strengthen self-validation
• As feedback
• To strengthen the therapeutic relationship
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Emotional validation strategies
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Encourage emotional expression
Teach emotion observation and labelling
Read emotions
Directly validate emotions
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Levels of validation
1.
Staying awake: unbiased listening and observing
2.
Accurate reflection
3.
Articulating the unverbalised emotions, thoughts, or
behaviour patterns
4.
Validation in terms of past learning or biological
dysfunction
5.
Validation in terms of present context or normative
functioning
6.
Radical Genuineness
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Cheerleading strategies
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Assume the best
Encourage
Focus on strengths
Contradict/modulate external criticism
Be realistic
Stay near in a crisis
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DBT Skills Modules
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Mindfulness
Interpersonal effectiveness
Emotion regulation
Distress tolerance
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Stylistic strategies: Irreverent
Communication
• Reframing clients communication in an
unorthodox, offbeat manner
• Plunging in where angels fear to tread
• Using a confrontational tone
• Calling the clients bluff
• Oscillating intensity
• A style that’s unhallowed, impertinent, and incongruous
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Irreverence cont…
• The intent of irreverent communication is to help
provide psychological distance for client to
observe and describe ongoing events and
processes in their lives.
• Do this by keeping the individual just off balance
enough to shake up her typically rigid, narrowbounded approach to life, to herself and to
problem solving.
• To highlight both poles of the dialectic without
denying either!
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Observing limits
• Simple in theory and difficult in practice
• It’s the application of problem-solving strategies,
and contingency management procedures to
client behaviours that threaten or cross the
therapist’s personal limits,
• T must be aware of which client behaviours they
are able and willing to tolerate, and which are
unacceptable. This info must be given to client in
timely fashion. (short term and long term behrs)
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• Not observing limits is therapy threatening
– interferes with therapist ability or
willingness to carry on with therapy. Can
lead to burnout, termination of therapy, or
otherwise cause harm to client.
• By observing limits the therapist takes
care of the client, by taking care of
themselves!
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Behaviour Analysis
• One of most important, and one of most
difficult sets of strategies in DBT
(key error is one of assessment)
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BA strategic checklist
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Define the problem behaviour
Conduct chain analysis
Generate hypotheses
Avoid … colluding with client in avoiding
behavioural analysis of targeted
behaviours, …and unduly bias information
gathering to prove therapists own theory of
client’s behaviour.
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Conducting a Chain Analysis
• Choose a specific instance of behaviour to
analyse.
• Develop an exhaustive step-by-step
description of the chain of events leading
up to and following the behaviour.
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Attending to the links of the Chain
• Where to start? Ask the client when the problem
began. Maladaptive behr is viewed as occurring
within a context or episode that for the purpose
of analysis has a beginning, middle (the behr in
question) and an end.
• Clients can usually tell you when the episode
began – at least roughly.
• Overall goal: To link the behaviour to
environmental events; especially the ones they
may not think are linked/effect their behaviour.
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Filling in the links
• Think in terms of very small units of
behaviour – the links in the chain.
• Get info about what’s going on
environmentally and behaviourally (what
client was doing, thinking, feeling,
imagining.
• You want to know how client got from one
link to the next – from here to there…
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Where to stop?
• The chain needs what leads up to the
problem behaviour as well as info about
the consequences.
• Therapist wants to identify what is
reinforcing (maintaining) the problematic
behaviour.
• Brief analysis of in session behaviours.
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Generate hypotheses about
factors controlling behaviour
• Use theory to guide analysis
– (about actions, cognitions, biological or
sensory responses and the environment).
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Analyse chain of events
moment-moment over time
Vulnerability
Problem behaviour
Prompting event
links
consequences
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Possible solutions
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Solve problem
Change emotional reaction to problem
Tolerate the problem
Stay miserable
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DBT case management strategies
• Environmental intervention
– Intervene in the environment when the short term gain is worth the
long term loss in learning.
– When client unable to act on own behalf and outcome is very
important
– When environment is high in power
– To save the life of the client or avoid substantial risk to others
– When it is the humane thing to do and will cause no harm
– When the client is a minor
– Strategies – provide info to others independent of client, advocate
for client, enter the clients envt to give assistance
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Case management strategies
cont...
• Consultation-to-the-patient (client)
– The primary role of therapist is to consult to
the client about how to manage their own
social/professional network
– Strategies – orient client and network to the
approach, consult about how to manage other
professionals, consult about how to manage
other members of the whole interpersonal
network
• Consultation-to-the-therapist
– Need for therapist supervision/consultation
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Consultation Group
• Where therapists meet to support each
other working dialectically, while
observing limits, maintaining commitment,
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Accepting reality
• Acceptance does not mean agreeing, or
liking
• Willingness – doing what is needed in each
situation, cultivating a Willing response to
each situation
• Willfulness – like sitting on your hands when
action is needed, trying to change the
situation rather than your response to it, its
giving up, its trying to fix every situation or
refusing to tolerate the distressful moment
Distress Tolerance skills: crisis
survival
• Reduction of acute destabilising emotions
and symptoms. Helps you feel better.
– Grounding
– Relaxation – observing your breath, deep
breathing, measuring breath with footsteps, follow
breath while listening to music
– Distract and soothe
– One thing in the moment
– Vacation – have a duvet day
– Cheerlead yourself – I can stand it, this won’t last
forever, I will make it out of this, I’m doing the
best I can, I can do it, I am ok.
Distract !
To reduce contact with emotional stimuli
• Activity; physical exercise, clean your room, call or visit a friend
• With thoughts; Count to ten, count colours in a painting, or tree or
window, do puzzles, watch TV, read
• With emotions; act opposite to emotion, watch a comedy, listen
to emotional music, read emotional book/story
• ‘pushing away’ – build an imaginary wall between you and the
situation, or block the situation from your mind, censor
ruminating, put the pain on a shelf, box up the problem and put it
away for a while.
• Using sensations – hold ice in hand, squeeze a rubber ball, take
a hot shower, listen to loud music, snap rubber band, suck on a
lemon, cold/frozen cloth on face, henna tattoo, poor red food
colouring (heated first)
Self Soothe!
• With the 5 senses
– Vision; buy one flower, look at beautiful pictures,
look at nature, watch the stars, paint your nails,
be mindful of each sight in front of you
– Hearing; listen to beautiful/soothing/invigorating
music, sing favourite songs, listen to sounds of
nature, call weather phone to hear a human
voice, be mindful of the sounds letting them in
one ear and out the other...
– Smell; perfume, lotions, spray fragrance in the air,
boil cinnamon, bake cookies, cake or bread,
smell the roses, smell the outdoors, chai latte....
Self soothe cont...
• Taste; have a good meal, soothing drink, treat
self to dessert, sample flavours at ice cream
shop, suck on peppermint candy, chew favourite
gum, eat mindfully
• Touch; experience whatever you touch, bubble
bath, clean sheets on the bed, pet your dog or
cat, soak your feet, put creamy lotion on body,
cold compress on forehead, sink into really
comfy chair, put on silky top/scarf, brush your
hair for a long time, hug someone
Affect regulation - resistance to
tension reduction behrs
• Ask to delay or ‘hold off’ from engaging in the
behaviour for as long as possible (this
provides opportunity to develop small amount
of affect tolerance, as well as learning
distress is bearable)
• If doing it, do it to the minimal extent possible
• Clinicians take a clear stand on the
harmfulness – the aim is cessation, though
the process may be about decreasing
frequency, intensity and injuriousness.
Emotional (affect) regulation
skills
• Mindfulness
• Delay action
• Learn what the emotion IS (non judgemental observation
and description of emotion in session – but clinician do
not label – guide the labelling )
• Changing emotional responses: check on the facts,
opposite action (to emotion), problem solving, the half
smile
Emotion reg cont...
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Balance sleep, eating, mood altering drugs
Build mastery in life
Prepare ahead of time
Self validation and cheerleading
The End…
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