Dialectical Behavior Therapy Paulette Aasen Ph D Director

Dialectical Behavior Therapy Paulette Aasen, Ph. D. Director of Psychology Services West Central Human Service Center • • Bismarck, ND (701) 328 -8888 Badlands Human Service Center • • 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 Environme nt 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 Average 4 Dysregulated 3 2 1 0 Threshold

Dialectical Paradigm Dialectics is theory that opposites can coexist. • 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 Acceptanc e Change

Dialectical Dilemmas Emotional Vulnerability Active Passivity Unrelenting Crisis Biological Social Apparent Competence Inhibited Experiencin g Self-Invalidation

Dialectical Strategies �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 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 �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 Kabat-Zinn, 1990 Go

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: chrisco 28@aol. com