DIALECTICAL BEHAVIORAL THERAPY (DBT)JFKU

Mark Purcell, PsyD & Claire Coyne, LMFT

Different Types of Emotions

AngerSAD

LOVE

Panic

GUILT

Calm

JoyPainConfused

Worried

Embarassed

ESTATIC

DBT GoalsReduc

eTarget

Behaviors

Dysregulation

TOOLS:Diary Card

Behavior Chain

Increase

Skills

Emotional Stability

TOOLS:DBT Skills Group

4

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. 

DBT Program Overview

Weekly

Diary Cards

Target Behaviors

Individual

Therapy

Weekly

Skills Training

Youth & Coach

Skills Group Skills for

CopingAs Needed

Skills CoachBehavior CoachIndividual TherapistSkills Group Leaders

Skills Coachi

ng

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 Wants

Opposing Needs or Wants

Acceptance Change

Trust Suspicion

Dependence Independence

Careful, Too Fearful Impulsive, Reckless

Surrender Protect/Fight

Focus on Self Focus on Others

Biosocial Theory

Invalidating Environme

nt

Behavioral Problems

Biological Vulnerabilit

y

I am Stupid.

..

There’s something wrong with me

I don’t deserv

e to live

You’re so

stupid!

I don’t understan

d 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

DIALECTICAL BEHAVIOR THERAPYProblems(Behaviors to Decrease)

Skills(Behaviors to Increase)

Confusion about your self Mindfulness

Impulsivity Distress Tolerance

Emotional Instability Emotional Regulation

Interpersonal Problems Interpersonal Effectiveness

Parent-Youth Problems Middle Path

Validation

VALIDATION COMMUNICATES TO ANOTHER PERSON THAT HIS/HER FEELINGS, THOUGHTS, AND ACTIONS MAKE SENSE AND ARE UNDERSTANDABLE TO YOU IN A PARTICULAR SITUATION.

VALIDATION ≠ AGREEMENT 

WHAT SHOULD WE VALIDATE? FEELINGS, THOUGHTS, AND BEHAVIORS IN:

OURSELVES OTHER PEOPLE

 

WHY SHOULD WE VALIDATE? IT IMPROVES RELATIONSHIPS VALIDATION CAN SHOW THAT:

WE ARE LISTENING WE UNDERSTAND WE ARE NOT BEING JUDGMENTAL WE CARE ABOUT THE RELATIONSHIP

CONFLICT IS POSSIBLE WITH DECREASED INTENSITY AND ANGER

Levels of Validation

Validation Level Goal of Interaction

One Listen Non-Judgmentally

Two Accurate Reflection

Three Articulate Unspoken Thoughts and Feelings

Four Understanding Historical Background of Behavior

FiveConfirming Thoughts, Behaviors and Feelings Based on Current Circumstances

Six Radical Genuineness & Authenticity

Interaction of Emotions, Thoughts, & Behaviors

Emotions

Thoughts

Action

Physical Sensatio

ns

Event

Matching Skills with Level of Dysregulation

Mindfulness

Interpersonal Effectiveness

Emotional Regulation

Distress Tolerance

EM

OT

ION

AL

DY

SR

EG

UL

AT

ION

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 agreementsTherapist 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 BehaviorTherapist

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

vuVULNERABILIES

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