DBT The Serenity Prayer in Action Betsy F

DBT – The Serenity Prayer in Action Betsy F. Amey, LCSW-C Katharine C. Blakeslee, LCSW-C The Tuerk Conference, April 17 th, 2015 Baltimore, Maryland

Goals of this presentation: 1. 2. 3. 4. 5. To demonstrate how DBT is an effective treatment modality for substance use disorders; To explore how DBT and 12 -Step approaches are similar, following spiritual principles to effect positive changes in those some have regarded as “hopeless; ” To show the integral role of dialectics/paradoxes of acceptance/change , confrontation/affirmation, in the recovery process; To show both approaches emphasize progressing from initial admission of a problem, through several steps, toward “a life worth living” (learning “the Wisdom to know the Difference”); To use an understanding of DBT to further clarify why 12 -Step approaches are so effective (“how it works”)

A Dialectical Stance in the Recovery Process: The Serenity Prayer “Lord, Grant me the Serenity to Accept the things I cannot change; The Courage to change things I can; and the Wisdom to know the difference. ” � -- From Reinhold Neibuhr

Problem for Therapists �“. . . Patients experience both promptings for acceptance and promptings for change as invalidating their needs and experience as a whole, with predictable consequences of emotional and cognitive dysregulation and failure to process new information. ” (Dimeff & Linehan, 2008) �Acceptance and Change are equally important. �Dialectics means that change happens through dialogue (attraction rather than promotion) By engaging the opposites, change can happen. 4 4

People who experience the following -� Emotional dysregulation � Affective Lability � Problems with anger � Cognitive Dysregulation � Dissociation � Paranoia � Interpersonal dysregulation � Chaotic Relationships � Fears of Abandonment � Self-dysregulation (identity confusion) � Identity Disturbance/difficulties with sense of self � Sense of emptiness � Behavioral Dysregulation � Para suicidal behavior � Impulsive behavior -- may benefit from DBT

Post-Acute Withdrawal Signs of Alcoholism/Addiction: �Difficulty thinking clearly �Difficulty managing feelings �Difficulty remembering things �Difficulty with physical coordination and balance �Difficulty sleeping restfully �Difficulty managing stress �Difficulty staying in touch with reality from Gorski, Staying Sober: Relapse Prevention Therapy

Linehan’s Biosocial Theory explains how an individual develops Emotional Dysregulation

A PERSON WHO EXPERIENCES High Sensitivity + High Reactivity + Slow Return to Baseline EMOTIONAL VULNERABILITY

Problem symptom patterns emerge when: �Person is emotionally vulnerable �Person is in an invalidating environment Increased self-invalidation

Is this also what happens to a person as the addiction progresses?

Causes? Effects? �There are biological preconditions for addiction and for many serious mental illnesses �The biology may cause the sensitivity – AND the brain changes which occur in the addict/alcoholic heighten emotional sensitivity �Reactions of others to changes in the addict are often critical, invalidating �And the addict becomes either more sensitive to or more denying of the criticism/invalidation (worsening the symptoms) �This process leads to confusion about “real self”, and the “self” which is acceptable to others

Dialectics in DBT and in Addiction Treatment

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

Addictive Behaviors Defined “Addiction. . . includes any repetitive behavior than an individual is unable to stop, despite the negative consequences of the behavior and the person’s best efforts to stop. . . Some people say that when they engage in addictive behaviors, they feel “normal” again. In these cases, a behavior that may have started with positive reinforcement (gives pleasure) comes to be maintained by negative reinforcement (stops unbearable distress)” (Linehan, 2015)

Recovery Demands Living in the Paradox. . . �We are powerless �Egomaniac �Surrender. . . �It’s not my fault; I have a disease �We are responsible �With inferiority complex �To win �It’s all my fault; I have done terrible things

DBT demands attention to 3 “polarities”: The client must. . . 1. 2. 3. Accept herself as she is in the moment Validate her own view of her difficulties Pursue getting what she needs While also. . . Changing her thinking and behavior 2. Validating another person’s view that she may surmount these difficulties 3. Losing old ways of getting what she needs as she becomes more competent 1.

From Hegel: Thesis + Antithesis = Synthesis “An event or idea (thesis) generates its opposite (antithesis), leading to a reconciliation of the opposites (synthesis)”

Reasons to Approach Emotions, Thoughts, and Value Conflicts Dialectically �Allows you to: �Become aware of conflicts �Notice third, less damaging possibility �Make conscious, “intentional decisions, rather than act automatically �Compromise, because you see what you are “giving up” in order to “get” �Make skillful, “wise mind” choices (not at the extremes)

Reasonable Mind Wise mind Wise Mind Emotional Mind

DBT -- Skillful Living Assumptions 1. People are doing the best that they can; and people need to do better, try harder, be more motivated to change 2. People may not have caused all their problems; people have to solve their own problems, anyway. 3. The lives of emotionally dysregulated individuals are painful as they are currently being lived. 4. Emotionally dysregulated people must learn new behaviors in many of the most important life situations.

More Skillful Living Assumptions 5. There is no absolute truth. 6. People can take feedback as well-meaning rather than assuming harsh criticism. 7. People generally want to improve. 8. People cannot fail in DBT.

DBT Skills Training �Teaches clients to “Accept” the situation and the feelings evoked until they know what to do. �By using mindfulness skills �By using distress tolerance skills �Teaches clients an array of actions they can take to “Change” (improve) the situation. �By using emotion regulation skills �By using interpersonal effectiveness skills

DBT Acceptance Skills �Mindfulness �“What” Skills �“How” Skills �Distress Tolerance �Distraction skills �Improve the moment skills �Radical Acceptance

DBT Change Skills �Emotion Regulation �Emotion Identification skills �Decreasing Vulnerability to Emotion Mind skills �Decreasing Intensity of Emotion skills �Interpersonal Effectiveness � Requests and Refusals � Maintaining relationship skills (validating others) � Keeping self-respect skills (validating self) � Choosing intensity of communication based on the situation, not just on emotion � Starting healthy relationships and ending destructive ones.

DIALECTICAL ABSTINENCE: A Relapse Prevention Model

Synthesis of: �Absolute abstinence whenever one is abstinent even for a moment AND �Harm reduction following every slip even when it is very small

To the Addict: “ The dialectical tension here is that, on the one hand, you have agreed that you value living up to your potential and building a life worth living, and that your addictive behavior is incompatible with this goal. On the other hand, even with this commitment, you accept that you might have a lapse and once again engage in the addictive behavior. Thus you need a harm reduction plan. ” (Linehan, 2014)

“Clear Mind” as a replacement for “Addict Mind” and “Clean Mind” (Linehan, 2014) “When in “Clear Mind, ” make a firm verbal commitment to abstinence” ADDICT MIND CLEAN MIND CLEAR MIND

Mindfulness for Abstinence “Urge Surfing”

A plan for abstinence: 1. 2. 3. 4. 5. 6. 7. Enjoy your success, but with a clear mind; plan for temptations to relapse. Spend time or touch base with people who will reinforce you for abstinence. Plan reinforcing activities to do instead of addictive behaviors Burn bridges: Avoid cues and high-risk situations for addictive behaviors. Build new bridges: images, smells, and mental activities (urge surfing) to compete with information associated with craving. Find alternative ways to rebel. Publicly announce abstinence; deny any idea of lapsing to addiction.

Maintain abstinence with “Alternate Rebellion” When addictive behaviors are a way to rebel against • authority and the boredom • on not breaking the rules, • • try alternate rebellion. • • Replace destructive • rebellion and keep yourself • on the recovery path. • Shave your head Wear crazy underwear Wear unmatched shoes Express unpopular views Do random acts of kindness Dye your hair a wild color Print a slogan on a T-shirt Write a letter saying exactly what you want to Etc.

Prepare a Harm Reduction Plan To put into action immediately after a lapse – “fight with all your might the “abstinence violation effect. ” Might include: 1. Call your therapist, sponsor, or mentor for skills coaching; 2. Get in contact with other effective people who can help 3. Get rid of temptations; surround yourself with cues for effective behaviors; 4. Review skills and handouts from your treatment; 5. Practice opposite action for shame. Make your lapse public among people who will not reject you once they know. 6. Build mastery and cope ahead

Harm Reduction Plan, cont’d. 7. Use Interpersonal Skills to ask for help 8. Conduct a Chain Analysis to analyze what prompted the lapse. 9. Use Problem Solving right away to “get back on the wagon” and repair any damage you have done. 10. Distract yourself, self-soothe, and IMPROVE the moment. 11. Cheerlead yourself. 12. Do a pros & cons chart of stopping addictive behaviors or continuing addictive behaviors. 13. Stay away from extreme (all or nothing) thinking. 14. Keep a list of all your harm reduction behaviors with you all the time, ready if needed.

Pros & Cons for Distress Tolerance CHOICES PROS CONS Acting on urges Pros of acting on urges, giving in, giving up, avoiding what needs to be done Cons of acting on impulsive urges, giving in, giving up, avoiding what needs to be done ____________________ ____________________ Pros of resisting impulsive urges, doing what needs to be done, and not giving up. Cons of resisting impulsive urges, doing what needs to be done, and not giving up. Resisting urges ________________ ________________

Maintain Abstinence with Adaptive Denial When your mind can’t tolerate craving for addictive behaviors, try adaptive denial. 1. Give logic a break when you are doing this. Don’t argue with yourself. 2. When urges hit, deny that you want the problem behavior or substance. Convince yourself you want something else. Be adamant with yourself in your denial and engage in the alternative behavior. 3. Put off addictive behavior – for 5 minutes, then another 5 minutes, and so on. By telling yourself you will be abstinent “just for today, ” you are saying “I don’t know about forever, but I can stand this right now. ”

Specific Therapist Approaches for Early Recovery Treatment: �Commitment: to absolute abstinence (be it only for 20 minutes !) �Coping ahead �When relapses occur – promote “failing well” �Validate effort – avoid shaming �Hold clients accountable for pushing ahead toward positive change “Simultaneously prompting for acceptance and prompting for change” Therapist needs the wisdom to know the difference

David Berenson on AA Paradoxes You must. . . While also. . . Put your own sobriety 1. above everything else 2. Do it totally for yourself, 2. independent of the bottle and addictive relationships 3. Understand addiction is not 3. a moral failing 1. Caring for others Accepting the help of the group and/or a personal Higher Power Taking your moral inventory, healing character defects, making amends

Holding the Opposites Until Synthesis Occurs! �Addicts are not helpless �Everyone is “another Bozo on the bus” �Willingness replaces willfulness �It’s an addict’s job to arrest the disease, and he needs and deserves help to do this. By following “Good Orderly Direction, ” we gain “a new Freedom and a new Happiness”

Radical Acceptance of our Addiction means “learning to love the dandelions…”

Bibliography for DBT Presentation, Tuerk Conference, 2015 (Betsy F. Amey, LCSW-C , Katharine Blakeslee, LCSW-C) 1. Berenson, David. (1987) “Alcoholics Anonymous – from surrender to transformation. ” Family Therapy Networker, July/August 1987. pp. 25 -31. 2. Daley, D. C. & Marlatt, G. A. (2006) Overcoming your Alcohol or Drug Problem: Effective Recovery Strategies (pp. 27 -33). New York: Oxford University Press. 3. Dimeff, Linda A. and Koerner, Kelly, ed. (2007) Dialectical Behavior Therapy in Clinical Practice. New York: Guilford Press. 4. Dimeff, Linda A. and Linehan, Marsha M. (2008)“Dialectical Behavior Therapy for Substance Abusers. ” Addiction Research, June. 5. Goldstein, Eda D. “ Substance abusers with borderline disorders. ” In S. L. A. Straussner (Ed. ), (2004) Clinical Work with Substance Abusing Clients (pp. 370 -391). New York: Guilford Press. 6. Gorski, Terence. (1992) Staying Sober: A Relapse Prevention Therapy. Independence, MO: Herald House. 7. Kabat-Zinn, Jon. (1994) Wherever You Go, There You are: Mindfulness Meditation in Everyday Life. New York: Hyperion.

Bibliography (p. 2) 8. 9. 10. 11. 12. 13. Linehan, M. M (2014) DBT Skills Training Manual, Second Edition. New York: Guilford Press. Najavits, L. M. (2006). Seeking safety: Therapy for post-traumatic stress disorder and substance use disorder. In V. M. Follette & J. I. Ruzek (Eds. ), Cognitive-Behavioral Therapies for Trauma (pp. 228257). New York: Guilford Press. Orlin, L. , O’Neill, M. & Davis, J. (2004). Assessment and intervention with clients who have coexisting psychiatric and substance-related disorders. In S. L. A. Straussner (Ed. ), Clinical Work with Substance Abusing Clients (pp. 103 -124). New York: Guilford Press. Pederson, L. (2013) DBT Skills Training for Integrated Dual Disorder Treatment Settings. Eau Claire, WI: PESI. Tolliver, B. K. (2006). Highlights of the 17 th Annual Meeting of the American Academy of Addiction Psychiatry. Medscape Psychiatry & Mental Health. http: //www. medscape. com/viewarticle/551332. Van den Bosch, L. M. C. & Verheul, R. (2007). Patients with Addiction and Personality Disorder: Treatment Outcomes and Clinical Implications. Current Opinions in Psychiatry, 20(1): 67 -71.