DIALECTICAL BEHAVIOUR THERAPY

AND

COMMUNICATION

Expressive Therapy Clinic

ORIGINAL DBT • Developed and researched for Borderline

Personality Disorder Sufferers

• Now researched further to benefit adolescents, children, multi-disorder diagnosis such as addiction, depression, anxiety, eating disorders, the aged

• Any people who have difficulty managing their emotional responses

Biosocial Theory of BPD The main tenet of the biosocial theory is that the core disorder in BPD is emotional dysregulation. Emotional regulation is viewed as a joint outcome of biological disposition, environmental context and the transaction between the two during development. 1.Very high sensitivity to emotional stimuli 2.Very intense response 3.Slow return to emotional baseline after arousal 4. Likely to have suffered repeated invalidation

BPD sufferers often present with maladaptive emotion regulation ? - Parasuicide can be highly effective as an emotional strategy, overdosing usually leads to long periods of sleep, or admission to a hospital. - BPD patients self report that self injury/mutilation gives them relief from anxiety and other intense negative emotional states after acting out on these urges. -Parasuicide behaviour often recruits an environmental response therefore alleviating a sense of desperate aloneness and also sets up dependency on relationships and systems.

- Emotional consistency and predictability, across time are prerequisites of identity development.

- Emotional regulation difficulties interfere with a stable sense of self and with normal expression of emotion.

- Controlling negative emotions and impulsive behaviours is extremely difficult for this client group. Consequences of not being able to do so wreak havoc on many of their relationships and their ability to function normally

CLIENTS ARE OFTEN STUCK IN THREE MAJOR POLARITIES. First Polarity:

The need for the patient to accept herself and the need to change

Second Polarity:

The patient getting what she needs and losing what she doesn’t need if she

becomes more competent. Pretending skills don’t help when she is using them

all the time.

Third Polarity:

The patient needs to maintain personal integrity and validate her own

difficulties versus learning new skills to help ease her suffering. She gains

integrity in the knowledge that she was not manipulating her environment, she

just didn’t have the skills to cope with her environment in the first place.

Individuals with Borderline Personality Disorder

8-10% commit suicide Up to 75% attempt suicide

69-80% self-mutilate

Dialectical Behaviour Therapy • Sufferers of Bi Polar, Borderline Personality (BPD), Post Traumatic Stress ,

Eating and Addiction disorders, Anxiety and Depression can be assisted by the skills and strategies of DBT. The symptoms of emotional dysregulation and co-morbid behaviour are similar in most disorders.

• Dialectical Behaviour Therapy(DBT) was developed by Marsha M. Linehan, Ph.D., at the University of Washington in the late 1970’s. She added validation, dialectics and acceptance strategies to cognitive-behavioural treatment for borderline personality disorder (BPD) especially for individuals with chronic patterns of suicidal or other severe dysfunctional behaviours and named the therapy DBT.

• It’s important to note that DBT is an “empirically-supported treatment.” It has been researched in clinical trials. While the research on DBT was conducted initially with women who were diagnosed with BPD, DBT is now being used for many other disorders and focuses on mindfulness to urges to use impulsive behaviour to manage emotions.

• Most approaches to addictions and mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for and tolerating the distress of situations that arise. The premise that changing the way you think or understanding why you have the belief system you have, is seen to be invalidating for BPD Clients.

•Balancing acceptance and change strategies, DBT calls on the patient and the therapist to accept reality while maintaining a strong and conscious commitment to change, over and over again.

•Acceptance of reality is not equivalent to approval of reality.

•DBT skills are extremely useful for people in assisting in the management of impulsive behaviours, emotional dysregulation, anxiety, depression and urges to use substances, food, gambling etc. to avoid or get rid of uncomfortable or intense emotions. It gives them strategies.

Researched Model of DBT

Everyone Works for the Client and Reports to the Primary Therapist:

Skills Individual Phone Therapists Psychiatrist

Training Psychotherapy Coaching Consult Team Pharmacotherapy

(Primary)

CLIENT

After 12 months of DBT

• 77% decrease in hospital days used

• 76% decrease in inpatient stays

• 56% decrease in crisis beds

• 80% decrease in arrive at Emergency Departments

When working in the DBT Frame

5 Functions of Treatment • Enhance Capabilities of client

• Improve Motivational Factors towards change

• Assure generalization to natural environment

• Structure the environment

• Enhance Case co-ordinator’s capabilities and motivation to assist client effectively

HOW WE USE DIALECTICS

Change Acceptance

Validation

Mindfulness Skills

Distress Tolerance Skills

Skills Training

Behavioural Analysis

Problem Solving

WALKING THE MIDDLE PATH • Dialectics – Balancing opposites while entering

the paradox of “Yes” and “No”, “true and “not true” at the very same time

• Validation • Including the valid and understandable in

ourselves and others • Recognize black and white thinking – there can

not be a middle path if there is polarization

Dialectical thinking Black and White thinking causes problems, always search

out for what is missing the “grey”, the “space in between”. Truth becomes absolute in the eye of the beholder. Truth (Validating these truths is important) Truth

Thesis (Black) Antithesis(White)

I want this Job I can’t catch I have to get to public transport

the interview too many people Synthesis (New Truth)

I can ask for help to get transport support or save for a taxi. I could arrange a less crowded time for the interview

Dialectics: Working Step by Step

• Step 1: When polarization occurs, work for a synthesis – a middle path

• Step 2: When one dialectical strategy doesn’t work try another

• Step 3: Always converse with flexibility being the aim

• Step 4: The aim is to move the person from a fixed position, there are always alternatives

Functions of Validation (To Authenticate)

• To strengthen relationship

• To help people gain strength to self-validate

• As feedback

• To help people feel more confident

Validation: What does it mean AND how it is used

The Worker needs to make validation: • Immediately relevant and meaningful - To the current circumstances • Well grounded or justifiable

- In terms of being factual - Logically correct or linked to a generally accepted view, making

situation more ‘normal’

• Appropriate and specific to the end in view - i.e., effective for reaching the individual’s ultimate goals

Levels of Validation 1. Staying Awake: Unbiased listening and observing 2. Accurate reflection 3. Describing what you see (not what you are judging you see) the

unverbalised emotions, thoughts, or behaviour patterns, closely observing the clients presentation

4. Validation in terms of past learning or biological dysfunction 5. Validation in terms of present situation or the idea that this is

normal reaction. 6. Radical Genuineness – open real frank conversation

Validate thoughts

• Find the ‘kernel of truth’

• Acknowledge that in the circumstances the person is feeling anxiety and frustration

• Respect others values even if it is not how you would behave, everyone behaves differently

VALIDATE VULNERABILITIES

• ? Am I tired

• ?Am I in pain

• ?Do I have too high expectations

• ?Did I have nightmares or memories

• ?Am I feeling sensitive today

Strategies of Encouragement

• Assume the client has done the best they can

• Encourage

• Focus on strengths

• Contradict/modulate external criticism

• Be realistic

Genuineness • Responding to the individual as he or she actually

is • Seeing and responding to the strengths of the

individual while also understanding the difficulties

• Responding to the client on equal level • Being without role or facade • Humility

Other strategies Responsiveness • ‘Being awake’, ‘actively listening’ • Taking the person’s agenda seriously • Responding to the ‘content’ of the person’s

communications Warm interaction Genuineness

How to work with clients who have difficulty managing emotional responses

• Use Dialectical conversation – teaching them how to reach ‘the middle path’

• Use Validation – Often validation connects people, they realize they are being listened to

• Use Acceptance- Learning how to accept where they are right now is the only way to move towards change

Commitment to changes in behaviour

• Selling commitment: weighing up the pros and cons of emotional disturbance in the setting

• Becoming the devil’s advocate, if behaviour doesn’t moderate, as a worker you have to follow guidelines of setting

• Commitment to moderate behaviour helps trust and relationships improve

Workers’ Role • Make every effort to conduct calm, competent and

effective interaction. • Abide by ethical and professional guidelines of

workplace • Provide assistance in a timely manner if possible • Respect the integrity and rights of the person • Maintain confidentiality • Obtain assistance when needed

INCREASE •Moderation of Emotions

•Self-Validation

•Realistic-Judgment

•Problem solving strategies

•Authentic, accurate expression

DECREASE •Emotional Reactivity

•Self-Invalidation

•Behaviours generating crises

Where things can go wrong • Behaviours of the worker that cause an

imbalance in the Extremes of: Acceptance or change Flexibility or rigidity Nurturing or withholding Vulnerability or inappropriate irreverence

• Behaviours that are disrespectful

When interaction has halted

• No collaboration

• Intense effort to control by everyone

• Invalidating responses

• High arousal – sense of out of control

• Failure to process information

• No new learning

How to Manage the Moment: • I notice you appear to be upset, body tense, breathing

fast, agitated movements. How can I help you? • Listen quietly to person, and validate their reactions

and feelings given the circumstances they are in. • Try to help them find an approach that would be a

more effective solution. • Suggest they seek support from people who can help

them as it is not allowed for you as a worker to offer counselling.

FIRST RULE OF DBT

• If you can solve the problem ‘SOLVE IT’

• If you can’t ‘SURVIVE IT WITHOUT MAKING IT WORSE’

Possible Solutions

• Solve the problem

• Change emotional reaction to the problem

• Tolerate the problem

• Stay miserable

Learning to bear pain skilfully

• Pain and distress are a part of life;

Avoiding this fact itself leads to increased pain and suffering.

• Distress tolerance, is part and parcel of any attempt to change oneself.

The goal is to interrupt the building of the distress curve with skills to

lower emotion stimuli

Emotional stimuli

increases Reactions of people who

can moderate emotional stimuli well

Interrupt with DBT skills

__________________________

Trigger

Prompting Event

Distress Overload Usual behaviours to manage uncomfortable emotions can be: -Impulsivity -Substance Abuse -Isolation/Avoidance -Self-harm -Suicide Ideation -Intense Anger -Dissociation

Practicing DBT skills often, a client can learn to regulate their emotional

responses to stimuli. Gradual improvement in this, changes behaviours and builds confidence and self-esteem

Distress Overload Emotional stimuli

increases

Interrupt with DBT skills

Trigger

Prompting Event

WHEN Environmental Intervention is Mandatory

• When the person is unable to act on her own and outcome is crucial

• When environment is in high power and intransigent

• To save the life of the patient or the safety of others

• When it will cause no harm and is humane • When the person is a minor

Environment Intervention Strategies

• Contact and provide information to others independent of the person

• Advocacy for the person if appropriate in your workplace

• Core Mindfulness Skills – observation of one’s reactions allowing more choices

• Distress Tolerance – learning how to survive crisis without making things worse, manage urges

• Interpersonal Effectiveness skills – learning to increase effectiveness in communications improving relationships

• Emotional Regulation – understanding emotions and their functions, learning how to increase positive emotions

THE FOUR SKILLS OF DBT

STOP SKILL – Distress

Tolerance Skill S - Do not just react. Stop! Freeze! Don’t move a

muscle, stay in control

T - Take a step back, Take a break. Let go breathe. Do not act impulsively

O – Observe, notice what the situation is. What am I feeling? What are others doing?

P – Proceed Mindfully with awareness. Consider and decide how to act wisely

TIPP SKILL – Distress

Tolerance Skill T – Changing my body Temperature Using Cold

water to change emotions 30 seconds

I - Intense exercise – To calm your body down

P - Paced Breathing, In breath for 5 Out breath for 7

P - Paired Muscle Relation – Breathing in Tense muscle, Breathe out, relax muscle

I Wise

Mind

Emotion

Mind

A Hot Place Good for: passion

Creativity, Motivation,

Spontaneity, Empathy,

Feels: Exhilarating,

Unstable, Intense, reactive

Extended time in Emotion

Mind:

Exhausting,Drowning

Nothing to hold on to

Erratic, Chaotic,

Unreliable, Unpredictable

Empty

(See attachment 18)

Reason

Mind

How to find Wise Mind

G

Wise

Mind

A Knowing

Place

Intuitive

Rounded

Balanced

Helpful for: self care,

responding, making

decisions, increasing

choices, confidence.

Reason

Mind

A Cold Place Good for: Analysing,

Control, Grounded,

Planning, Learnng,

Organizing

Feels: Slower, Paced,

Controlled, Mechanical

Extended time in Reason

Mind:

Boring, Clinical,

predictable, Reduces

choices, goals and joy,

Not motivated

Empty

Cortisol Levels Individuals suffering symptoms of PTSD, Complex PTSD (BPD) Extremely High levels of stress hormone Cortisol Individuals suffering from the symptoms of High Anxiety and Panic Moderately High levels of Cortisol People who have learnt to manage their emotional responses well Low Levels which Cortisol levels which can fluctuate when under stress

Wise Mind ‘ Accepts’ Distracting – reduces emotional stimuli, changes part of emotional

response

A Activities SELF SOOTHE

C Contributing Vision

C Make Comparisons Taste

E Emotional Change Touch

P Push Away Smell

T Thoughts Hearing

S Sensations

Improve the Moment • Imagine • Meaning • Prayer/Performance • Relaxation • One thing in the Moment • Vacation • Encouragement

DISTRESS TOLERANCE Reality Acceptance – There is a cause and

an effect Why do people suffer:

Pain + Acceptance = Pain Pain + Non-acceptance = Suffering

“Turn the Mind” Towards Radical Acceptance, ‘there is a cause and there is an effect’ and I can only do my best in the moment I am in.

Coping Ahead

• Check the facts beforehand, describe impending situation in your head – name likely emotions

• What coping strategies could you use, practice

• Imagine the situation right now

• Rehearse coping well step by step

• Practice relaxation after you have rehearsed

Gaining Mastery

• Plan on doing one thing a day to build confidence

• Plan for success-Do something difficult but possible

• If a task is too difficult do something a little easier

• Look for a challenge

and Coping Ahead

INTERPERSONAL EFFECTIVENESS Goals

• Objective Effectiveness What do I want? • Relationship Effectiveness How do I want the other person to feel about me

after the conversation? • Self-Respect Effectiveness How do I want to feel about myself after the

conversation?

Getting What you Want

• Describe • Express • Assert • Reinforce • Mindful • Appear Confident • Negotiate

Keeping The Relationship

•Gentle

• Interested

•Validate

•Easy Manner

Keeping Your Self-Respect

•Fair

•Apologies (None)

•Stick to your Values

•Truthful

PHONE CALLS – 10 Minutes • Short time • Location – Where are they? • Validate distress – How in the past have you got through

moments like these? • Can you contact support? • Workplace policy to direct distressed people to focussed

care by other agencies. Have numbers to give them • If distress keeps elevating .......(no alternative but to

contact authorities) • Seek debriefing with Manager around how to take care

of yourself

BOUNDARIES PHYSICAL

EMOTIONAL

INTELLECTUAL

SPIRITUAL

DeBriefing and Surviving in your role • Use your fellow workmates as a Team • Support each other and describe your achievements as well as your

mistakes • Check in with each other that you are validating and using dialectics

with clients • Notice when it makes a difference-congratulate yourselves • If it is possible to seek change in your workplace to assist you, seek

help from Managers • Always seek outside help, refer on, when situation is not within

your job description • At the end of each day use ‘Radical Acceptance’