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: Purpose: 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 Environment Invalidating Environment Invalidating Environment Biology Biology Biology

Bio-Social Model (cont.) High Sensitivity High Reactivity Slow Return to Baseline Often “Transactional” with the Environment

Slow Return to Baseline Emotions

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.”

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 Acceptance Change

Emotional Vulnerability Inhibited Experiencing Dialectical Dilemmas Emotional Vulnerability Active Passivity Unrelenting Crisis Biological Social Apparent Competence Inhibited Experiencing 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 Life threatening behaviors Therapy interfering behaviors Quality of life interfering behaviors Increasing behavioral skills

Client Agreement Client and Therapist BOTH sign the agreement to acknowledge what it is they are agreeing to in the 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-OF- CONTROL 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

Combine Soothing, Validating, & Problem Solving with Observing Limits 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 Therapy destroying behavior Skills acquisition, strengthening, and generalization Therapy interfering behaviors HIERARCHY??

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 Go Kabat-Zinn, 1990

5 Stages of Accomplishment I can’t do it! Denial Uncertainty Resistance Panic Maybe I can do it! 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: chrisco28@aol.com