The Relevance of DBT to - PowerPoint Presentation

The Relevance of DBT to Trauma WorkDAY 2 Two-Day Training withDeborah Barrett, PhD, LCSW&Robin Sansing, MSW, LCSW UNC Chapel Hill School of Social Work Clinical Institute

Day 2 Agenda9:00  Welcome & Mindfulness9:10 I. Case conceptualization10:15 BREAK10:30 II. Q & A and case consultation12:00 LUNCH1:00 III. DBT skills2:30 Break2:45 IV. DBT Skills4:00 V. Summation, discussion, resources4:30 END

Mindfulness Nonjudgmental Stance

Questions from yesterday?

I. Case conceptualization (case formulation)

Elements of Case FormulationDemographic history & thorough symptom assessmentPrimary targets – according to stage of treatmentSecondary targetsAssessment of skills and skills deficitsUncovering “controlling variables”Case conceptualization should be revised regularly

dialectical dilemmasUnrelenting crisisEmotional vulnerability Apparent competence Inhibited griefSelf-invalidationActive passivitySecondary targets

Adolescent secondary targetsNormalizing pathological behavior Excessive leniencyFostering dependence Pathologizing normative behaviorAuthoritarian controlForcing autonomy

Case formulation Based on repeated BCAs and in-session observationsIdentify controlling variables and typical patterns that set off, lead to or maintain the problem behavior.  Include operating hypotheses – “What’s getting in way?”EXAMPLES: secondary targets, skill deficits, invalidation, problematic cognition, contingency/reinforcement patterns “controlling variables” Opportunity to see what you don’t yet knowFormal case formulation and “ mini-case-formulations” (do often, include date) *Guides your treatment plan . . .

Samantha developing aCase Formulation

Conceptualization comes through finding common links through repeated chains

Samantha – BCA of NSSIB Vulnerabilities Tired, food deficit, invalidated by motherTriggering event Friend left Links: “I’m all alone” “My friend might die” Scared, sad, hopeless Noticed urge to cut Stared at razor Couldn’t think of alternative “Fuck it” Consequences: Felt relief Exhaustion Didn’t want to wake up Cutting forearm Skills? Relationship with emotions? Contingencies & reinforcement?

Samantha – BCA (therapy interfering behavior) Vulnerabilities Hurting,TiredTriggering event Spoke about car accident in therapy Links: “I don’t want to be doing this” Felt raw, exposed, guilt, shame, self-disgust Held it together until end of session Trouble breathing “I can’t stand it” Stepped into traffice Consequences : Felt relief about giving up Later t herapist helped me calm down Called to quit therapy Skills? Relationship with emotions? Contingencies & reinforcement?

Case formulation: SamanthaFactors that control targeted problem:Skill deficit? Teach relevant skill. 2. What else is getting in the way?Secondary targets: Mindfulness Distress toleranceEmotion Regulation Interpersonal effectivenessActive passivityEmotion reactivityUnrelenting crisis Apparent competenceSelf-invalidation Inhibited grieving

Your TurnIn Pairs:Fill out your own case conceptualization Select a current (or past) client of yours

II. Q & ACase conceptualization?Linking to treatment planning?DBT treatment in general?Case consultation?

III. DBT SkillsCore Mindfulness & Interpersonal Effectives

Core Mindfulness

Goals of module: To learn to observe one’s thoughts, feelings, and sensations without reacting to themTo increase control of one’s experienceTo cultivate a non-judgmental stanceTo participate in life with awareness (rather than impulsive or mood-dependent behaviors)To experience reality as it is

Core Mindfulness – States of mindReason MindEmotionMind BodyMindWiseMindBalanced point of viewintersection of reason and emotion states Embraces dialecticsensation = sensationCultivate “Wise Mind” Awareness of each “mind state” sensation = sensation

How:NonjudgmentallyOne-mindfullyEffectively What to do:ObserveDescribe ParticipateCore Mindfulness – What and How Skills

Interpersonal Effectiveness

Interpersonal Effectiveness →What is the goal of the communication? Objective EffectivenessWhat is my objective – What do I need to get out of this interaction? Relationship EffectivenessHow do I want the other person to feel about me after our interaction? Self-respect EffectivenessHow do I want to feel about myself after our interaction? *Walk the Middle Path – Maintaining balance in relationships*

Objective EffectivenessDEAR Describe the current situationExpress feelings and opinionsAssert or by asking or saying noReinforce(WO)MANWise mind placeOne mindfullyMindful of objectivesAppear confidentNegotiate alternative solutions WhatHow

Relationship EffectivenessGentle mannerInterested in the other personValidate the other person without judgingEasy manner with humor

Self-respect EffectivenessFASTbe Fairno ApologiesStick to valuesbe Truthful

In pairs: Practice your DEAR (WO)MANYour turn

IV. DBT SkillsEmotion Regulation & Distress Tolerance

Emotion Regulation

Emotion Regulation Skills Understanding & Naming Emotions Changing Unwanted Emotions Reducing Vulnerability to Emotion Mind Managing Extreme Emotions

Emotion Regulation Start with → All emotions are VALID* May or may not be justified/warrantedPractice NAMING emotions

Components of Emotions

Components of Emotions or “the WaveSeth Axelrod

Changing unwanted emotions → Opposite ActionFEAR ………………ANGER ……………ENVY ………………LOVE ………………SADNESS ………….SHAME/GUILT ……Approach Gently avoid/Be kindGratitudeAvoid/DistractGet active/Avoid avoidingMake public/Repeat

Distress Tolerance

The ability to tolerate and survive crises without making things worse

Holding an Open Heart Towards What Is.Pain+ Non-acceptance = Suffering & Being StuckPain + Acceptance = Ordinary Pain & the Possibility of Moving Forward

Distress Tolerance SkillsCrisis Survival Skills Reality Acceptance SkillsSkills when the crisis is addiction

Crisis survival skills with DistractionWise Mind ACCEPTSActivitiesContributeComparisonsChange your EmotionsPush away thoughtsThink of other things SensationsIMPROVE the moment with cognitive techniques:ImageryMeaningPrayerRelaxationOne-thing-in-the-momentVacationEncouragement

Distress Tolerance Skills: Self soothe (with five senses)

Crisis survival withPros & Cons

Reality Acceptance skills: - Radical Acceptance- Willingness- Turning the mind

Distress Tolerance: Willingness practicesSmall smileWilling hands, posture Willingness is saying yes to the mystery of being alive in each moment. Willfulness is saying no, or perhaps more commonly, “yes, but . . . ” Source: Gerald May, 1982, in Care of Mind-Care of Spirit: Psychiatric Dimensions of Spiritual Direction, San Francisco: Harper and Row, p.6.

Skills Modules:Q & A

Summary

Stages of therapy: IV. Incompleteness  Capacity for sustained joyIII. Problems in living  Ordinary happiness & unhappinessII. Quiet desperation  Emotional experiencingI. Severe Behavioral Dysregulation  ControlDBT ReviewSession structure:Review Diary CardAttention to target hierarchy Chain Analysis on highest target Weave in Solution Analysis Move down hierarchy → current life situations Components of treatment Individual therapy Skills group (CM, IPE, ER, DT) Phone skills coaching Consult team Primary Targets (hierarchy -levels) Life-threatening behaviors (SI, NSSI) Therapy-interfering behaviors (TIB) Quality of life behaviors (QL) Skills acquisition Ways to approach any problem Solve the problem Change your perception of the problem Radically accept the problem Stay miserable

Dialectical approach: Acceptance (validation) & Change (problem solving)Synthesis (and/both)Transactional (person & environment)Secondary targets (dialectical dilemmas): Unrelenting crisis Emotional vulnerability Apparent competence   Inhibited grief Self-invalidation Active passivity Nurturing Oriented to change Benevolent demanding Compassionate flexibility Unwavering centeredness Oriented to acceptance Therapist characteristics DBT Review ( cont . )

Assumptions about patients People are doing the best they can.People want to improvePeople must learn new behaviors both in therapy and in the context of day-to-day life.People cannot fail in DBTPeople may not have caused all of their problems, but they have to solve them anyway.People need to do better, try harder and be more motivated to change.The lives of people who are suicidal are unbearable as they are currently being lived. Assumptions about therapists The most caring thing a therapist or treatment provider can do is help people change in ways that bring them closer to their own ultimate goals. Clarity, precision and compassion are of the utmost importance. The treatment relationship is a real relationship between equals. Principles of behavior are universal, affecting clinicians no less than clients. Treatment providers need support Treatment providers can fail. DBT Review ( cont.)

Behaviors to DecreaseInterpersonal chaos Labile emotions and moodsImpulsivenessConfusion about self and cognitive dysregulationQuality-of-life interfering behaviorsChange Strategies:Contingency managementSkillsExposure Cognitive Modification Dialectical Strategies: Entering the paradox Metaphor Devil’s advocate Extending Skills / behaviors to increase: Core mindfulness Interpersonal effectiveness Emotion regulation Distress tolerance Self-management and life skills Core Strategies = Validation + Problem Solving DBT Review ( cont ) Activating Wise Mind Making lemonade Allowing natural change Dialectical assessment

Levels of Validation:Being Present Accurate ReflectionReading Cues HistoryNormalizingRadical genuineness Core Strategies = Validation + Problem Solvinghttps://www.youtube.com/watch?v=-4EDhdAHrOgValidation Strategies Emotional validationBehavioral validationCognitive validationCheerleading  

States of Mind“What” skillsObserveDescribeParticipateCore Mindfulness “How” skillsOne-mindfullyNon-judgmentallyEffectivelyLoving kindness

Emotion Regulation Mindfulness of current emotionUnderstanding & naming emotionsEmotion mythsDescribing emotionsCheck the factsProblem solving Opposite actionABC PLEASE Identifying skills breakdown

Distress ToleranceSTOPPros & ConsTIPWise mind ACCEPTSSelf-sootheBody scanIMPROVE the momentRadical AcceptanceHalf smile & willing handsTurning the mind/Mindfulness of current thoughts

Interpersonal EffectivenessFactors reducing effectiveness: Myths & CheerleadingObjective Effectiveness – DEAR (WO)MANRelationship Effectiveness – GIVESelf-respect Effectiveness - FASTIntensity of need (The dime game)

Using DBT with a variety of populations

Case explorationsWhat stage of treatment are they in?Primary target behaviors?Secondary targets? Life worth living goals? Acceptance, change, dialectical strategies?Skill areas to target?Consultation?

Resources Articles on DBT & TraumaTexts and websitesLocal resourcesCertification:

DBT Kahoot!

https://dbt-lbc.org/

Closing awareness & From Debbie & Robin Thank you !