Paulette Aasen PhD Director of Psychology Services West Central Human Service Center Bismarck ND 701 3288888 Badlands Human Service Center Dickinson ND 701 2277500 February 10 2014 ID: 673895
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Slide1
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, 2014Slide2
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.”Slide3
Foundations of DBT
DBT is a synthesis of three paradigms:
Dialectics
Behaviorism
Mindfulness
Purpose:Reducing dysfunctional behaviorsIncreasing skillful behaviorsBuilding a life worth livingClient needs validating environment in which s/he is taught to regulate emotions, deal with interpersonal conflicts, tolerate distress, and find balance.
Swenson,
Witterholt
, &
Bohus
, 2007Slide4
Linehan
Diagnosis for
Borderline Personality Disorder
Emotion Dysregulation
Affective
labilityProblems with angerInterpersonal DysregulationChaotic relationships
Fears of abandonment
Self Dysregulation
Identity disturbance – difficulties with sense of selfSense of emptinessBehavioral DysregulationParasuicidal behaviorImpulsive behaviorCognitive DysregulationDissociation / paranoid ideation
(
Linehan
, 1993)Slide5
Bio-Social Model
Biological Sensitivity
AND
Invalidating Environment =
Dsyregulation
Disorder Symptoms
Invalidating
Environment
Biology
Invalidating
Environment
Invalidating
Environment
Biology
BiologySlide6
Bio-Social Model (cont.)
High Sensitivity
High Reactivity
Slow Return to Baseline
Often “Transactional” with the EnvironmentSlide7
Slow Return to Baseline
EmotionsSlide8
Dialectical Paradigm
Dialectics is the theory that opposites can co-exist.
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.”Slide9
Dialectical Paradigm
From DBT Self Help at http://www.dbtselfhelp.comSlide10
Dialectics: A Model for Change
Movement Over Time
Thesis
Synthesis
AntithesisSlide11
Primary Dialectic in DBT
Acceptance
ChangeSlide12
Dialectical Dilemmas
Unrelenting Crisis
Social
Biological
Emotional Vulnerability
Apparent Competence
Active Passivity
Self-Invalidation
Inhibited ExperiencingSlide13Slide14
Dialectical Strategies
Balance Treatment Strategies
Enter the paradox
Metaphor
Devil’s Advocate
ExtendingWise Mind“Lemonade out of lemons”Allowing natural changeDialectical AssessmentSlide15
Behaviorism Paradigm
From DBT Self Help at http://www.dbtselfhelp.comSlide16Slide17
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 thatSlide18
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.Slide19
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.Slide20
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.Slide21
Hierarchy of Targets
Individual Therapy
Life threatening behaviors
Therapy interfering behaviors
Quality of life interfering behaviors
Increasing behavioral skillsSlide22
Client Agreement
Client and Therapist BOTH sign the agreement to acknowledge what it is they are agreeing to in the therapy relationship.Slide23
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 endsSlide24
Commitment Strategies
Therapist discusses
PRO’s
and
CON’s
of commitment to changeUse the DEVIL’S ADVOCATE technique to strengthen commitment and build sense of controlHighlight PRIOR COMMITMENTS consumer has madePresent consumer with CHOICE stressing the freedom to choose while presenting the consequences of choices clearly and directlySlide25
Commitment Strategies (cont.)
Therapist uses principles of
SHAPING
to elicit commitment
Therapist generates hope by
CHEERLEADINGTherapist and client agree on HOMEWORKSlide26
Validation of Consumer
Stay Awake
Accurate Reflection
Articulating
unverbalized
emotions, thoughts, and behavior patternsValidation in terms of past learning or biological dysfunctionValidation in terms of current context or normative functioningRadical GenuinenessSlide27
Self-Verification Theory
Validation = Self-Verification
Invalidation of Self-Construct leads to
AROUSAL!!
! (Sense of out-of-control)
HIGH AROUSAL + OUT-OF-CONTROL leads to >>>>Failure to process New Information =NO NEW LEARNING!Slide28
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 relationshipSlide29
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 consumerWarm engagement and touch in psychotherapyGenuinenessSlide30
DBT Skills
Group
Screening session
1-year commitment
Both client and therapist sign agreement
Agreement includes statements regarding homework completion and attendanceCo-facilitatorsSlide31
Hierarchy of Targets
DBT Skills Group
Therapy destroying behavior
Skills acquisition, strengthening, and generalization
Therapy interfering behaviorsSlide32
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 isUse skillful meansFind the middle waySlide33
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.comSlide34
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-JudgmentPatienceBeginner’s Mind or Child’s MindTrustNon-Striving
Acceptance
Letting Go
Kabat-Zinn, 1990Slide35
5 Stages of Accomplishment
Denial
Uncertainty
Resistance
Panic
I can’t
do it!
Maybe I can do it!
There’s no way I can do it!
AAAARGH!
What if I can’t do it?!Slide36
5.
Acceptance
CONGRATULATIONS!
ALL RIGHT!
I DID IT!
LET’S PARTY!Slide37
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.Slide38
DBT Associates
Christine
Kvidera
, MSW, LICW
7362 University Ave. NE, Suite 101 Fridley, Minnesota 55432 Phone & Fax: (763) 503-3981 www.dbtassociates.com
Email: chrisco28@aol.com