DIALECTICAL BEHAVIORAL THERAPY (DBT) JFKU Mark Purcell, PsyD & Claire Coyne, LMFT

Different Types of Emotions

DBT Goals Reduce Target Behaviors Dysregulation TOOLS: Diary Card Behavior Chain Increase Skills Emotional Stability TOOLS: DBT Skills Group

RADICAL ACCEPTANCE  Grant me the serenity to ACCEPT the things I cannot change,  Courage to CHANGE the things I can,  And WISDOM to know the difference. 4

DBT Program Overview Weekly Diary Cards Target Behaviors Individual Therapy Weekly Skills Training Youth & Coach Skills Group Skills for Coping As Needed Skills Coach Behavior Coach Individual Therapist Skills Group Leaders Skills Coaching

Dialectics Finding Balance  Dialectics Involves integrating seemingly opposing views  Similar to Eastern Concepts of Non-Duality  Use the word “And” instead of “But” One Set of Needs or WantsOpposing Needs or Wants AcceptanceChange TrustSuspicion DependenceIndependence Careful, Too FearfulImpulsive, Reckless SurrenderProtect/Fight Focus on SelfFocus on Others

Biosocial Theory Invalidating Environment Behavioral Problems Biological Vulnerability I am Stupid... There’s something wrong with me I don’t deserve to live You’re so stupid! I don’t understand why you’re so upset I wish you were never born Confusion about self; impulsivity; emotional instability; interpersonal problems

Emotional Dysregulation  High Sensitivity  Immediate reactions  Reactions with only a little provocation  High Reactivity  Extreme reactions  High arousal makes thinking clearly difficult  Slow return to baseline  Long-lasting reactions  Higher sensitivity to next emotional event  Difficulties with changing one’s own emotions  Difficulties with paying attention (e.g., in class) when emotions are felt  Difficulty in stopping from acting right away when emotions are felt Biological Vulnerability to Emotions (Sensitive Wiring) Low Emotional Modulation

Consequences of invalidating Environment By not validating feelings, the environment does not teach the individual to:  Label feelings  Effectively regulate emotions  Trust feelings By making problem solving seem easier than it is, the environment does not teach the individual to:  Effectively tolerate stress  Form realistic goals and expectations When communication of anger or sadness is punished and/or when only intense anger or sadness are responded to, the environment teaches the individual to:  Vary between having no emotions and having extreme emotions.

Types of Dysregulation  Emotional  Interpersonal  Self  Behavioral  Cognitive

D IALECTICAL B EHAVIOR T HERAPY Problems (Behaviors to Decrease) Skills (Behaviors to Increase) Confusion about your selfMindfulness ImpulsivityDistress Tolerance Emotional InstabilityEmotional Regulation Interpersonal ProblemsInterpersonal Effectiveness Parent-Youth ProblemsMiddle Path

Validation V ALIDATION COMMUNICATES TO ANOTHER PERSON THAT HIS / HER FEELINGS, THOUGHTS, AND ACTIONS MAKE SENSE AND ARE UNDERSTANDABLE TO YOU IN A PARTICULAR SITUATION. V ALIDATION ≠ A GREEMENT WHAT SHOULD WE VALIDATE ?  F EELINGS, THOUGHTS, AND BEHAVIORS IN :  O URSELVES  O THER P EOPLE WHY SHOULD WE VALIDATE ?  I T IMPROVES RELATIONSHIPS  V ALIDATION CAN SHOW THAT :  W E ARE LISTENING  W E UNDERSTAND  W E ARE NOT BEING JUDGMENTAL  W E CARE ABOUT THE RELATIONSHIP  C ONFLICT IS POSSIBLE WITH DECREASED INTENSITY AND ANGER

Levels of Validation

Interaction of Emotions, Thoughts, & Behaviors Emotions Thoughts Action Physical Sensations Event

Matching Skills with Level of Dysregulation Mindfulness Interpersonal Effectiveness Emotional Regulation Distress Tolerance EMOTIONAL DYSREGULATION

Commitment Strategies  Selling it, evaluating pros and cons  Devil’s advocate  Foot-in-the-door technique  Freedom to choose in absence of alternatives  Shaping

Orientation Strategies  Therapeutic Alliance  Connect problems to areas of dysregulation and skill development  Define problems as targets  Link long-term goals to targets  Introduce biosocial theory  Introduce tx format/characteristics  Introduce diary cards  Review agreements  Use commitment strategies

Pre-Treatment Goals  Agreement on Goals  Commitment to change  Initial targets of treatment Agreement to Recommended Tx. Client agreements Therapist agreements Agreement to Therapist-Client Relationship

Treatment Goals Level 1: Severe Behavioral Dyscontrol Level 2: Quiet Desperation Level 3: Problems in Living Level 4: Incompleteness

Stage 1 Targets  Decrease  Life-threatening/high-risk behaviors  Therapy-interfering behaviors  Quality of life interfering behaviors  Increase behavioral skills Mindfullness, distress tolerance, interpersonal effectiveness, emotional regulation

Therapy-Interfering Behaviors Client Non-compliance Non-collaborative Non-attending Behaviors that interfere with other clients Pushing therapists’ limits Reduce therapist’s motivation to treat

Therapy-Interfering Behavior Therapist  Extreme acceptance or change  Extreme flexibility to rigidity  Extreme nurturing or withholding  Extreme vulnerability or irreverence Disrespectful Behaviors

Quality of Life Interfering Behaviors  Incapacitating DSM Disorder  High risk sexual behavior  Extreme financial difficulties  Criminal behaviors  Severe interpersonal dysfuntion  Unemployment, severe school problems  Physical health, dysfunctional behaviors  Severe housing difficulties

Adol. Secondary Targets  Excessive leniency vs. authoritarian control  Normalizing pathological behaviors vs. pathologizing normative behaviors  Forcing autonomy vs. fostering dependence

Diary Cards  Track and observe behaviors in real time  Structure Session  Spring board to Chain and Solution Analysis  Integration of Skills

Diary Cards

Chain Analysis vu VULNERABILIES PROMTING EVENTS PROBLEM BEHAVIOR CONSEQUENCES

Solution Analysis  Identify goals, needs, desires  Generate solutions  Evaluate solutions  Choose a solution to implement  Troubleshoot solution

Responding to Problems  Solve the problem  Change emotional reaction to problem  Tolerate/accept the problem  Stay miserable

DBT Consultation Agreements  To accept a dialectical philosophy  To consult with patient on how to interact with other therapists  Consistency of therapists is not expected  Observe own limits, without judgment

Consultation Agreements Con’t  Search for non-pejorative, empathic interpretation of client’s behavior  All therapists are fallible

DBT Team Responsibilities  Plan and trouble shoot treatment  Monitoring adherence to DBT  Progress towards DBT competence  Consult to the therapist  Support to therapist and team members