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Dialectical Behavior Therapy & Mindfulness

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on 31 May 2015

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Transcript of Dialectical Behavior Therapy & Mindfulness

Dialectical Behavior Therapy & Mindfulness
Created by Dr. Marsha Linehan as therapists struggled to a find an effective treatment for those who attempted suicide
DBT as a modification of the standard CBT model
“Dialectic" through the use of acceptance and change strategies
DBT Offers Coping Skill to Address:
Characteristics of DBT

Support-oriented:
Helps client identify their strengths and build on them
Cognitive-based:
Identifies negative thoughts, beliefs, and assumptions, and helps the client learn different ways of thinking to improve their life
Collaborative:
Therapist, Client, Group Members, Family, Friends, and other Social Relationships

DBT is usually implemented as combination of individual weekly psychotherapy session, and weekly group therapy sessions
Homework exercises are used regularly
The 4 Stages of DBT
Skills & Techniques of Mindfulness
Adelle, Kara, Keeley, Emmalys
History and Origin
Target Populations
Moving from Being Out of Control of One’s Behavior to Being in Control
Stage 1 Continued...
Moving from Being
Emotionally Shut Down to Experiencing Emotions Fully
Skills & Techniques of
Interpersonal Effectiveness
Our Media Case
From the TV show: Girls
Skills & Techniques of
Emotion Regulation
Skills & Techniques of Distress Tolerance
Roleplay
P & L
Treat Physical Illness
E
Eating
A
Altering Drugs (no drugs unless it is medication to be taken as prescribed by your doctor)
S
Sleep
E
Exercise
Roleplay
Critique
Strengths
Areas in need of
Improvement
Discussion
1. As a social worker do you feel that this theory appeals to you?



If yes, what key concepts speak to you and why?

If no, what about the theory makes you apprehensive to utilize the principles?
2. Although DBT is recognized as an empirically sound theory, it is often more associated by its clinical skill set. What do you think?
Additional Resources
3. Do you feel that there are techniques, values or principles that can be generically applied to clients with other diagnoses, other than one's typically used in DBT ie. suicide ideation?

If yes, what particular techniques do you think can be broadly applied and how so?

P & L
Treat Physical Illness
E
eating
A
Altering Drugs
S
Sleep
E
Exercise
Social Worker
A
Activities
C
Contributing
C
Comparisons
E
Emotions
P
Pushing Away
T
Thoughts
S
Sensations


I
Imagery
M
Meaning
P
Prayer
R
Relaxation
O
One Thing at a Time
V
Vacation
E
Encouragement

Using Self Soothe with five senses:


What is DBT?
combines elements of cognitive-behavioural therapy with Zen mindfulness philosophies
provides coping skills for managing distressing emotions and improving interpersonal relationships
painful, intense, and controlling emotions
quickly shifting from one emotion to another
problems with anger
difficulties in interpersonal relationships
feelings of emptiness and confusion surrounding self-identity
impulsive behaviours
self-harm
suicidal thoughts and behaviours
confused and fearful thinking
borderline personality disorder
suicidal thinking and behaviour
substance abuse
depression in older adults
eating disorders
domestic violence
The Purpose of DBT
DBT interventions address behaviours in the following order of priority:

Decreasing any behaviours that are life threatening (suicidal, parasuicidal, and imminently life-threatening)

Decreasing any behaviours that will interfere with therapy

Decreasing those behaviours (as defined by DBT) that will impact negatively on the client’s quality of life



the most important of the overall goals of DBT is helping clients create
"lives worth living"

Reduce and then eliminate life-threatening behaviors (suicide attempts, suicidal thinking, intentional self-harm).

Reduce and then eliminate behaviors that interfere with treatment (behavior that “burns out” people who try to help, non-attendance of sessions, non-collaboration with therapists, etc.).

Decreasing behaviors that destroy the quality of life (depression, phobias, non-attendance at work or school, lack of money, substandard housing, lack of friends, etc.) and increasing behaviors that make a life worth living.

(Sanderson, 2008)

"What"

Skills
1. Observe
2. Describe
3. Participate
"How"
Skills
1. Non-Judgementally
2. One-Mindfully
3. Effectively
Learn skills that help people do the following:

Control their attention, so they stop worrying about the future or obsessing about the past. Also, increase awareness of the “present moment” so they learn more and more about what makes them feel good or feel bad.

Start new relationships, improve current relationships, or terminate bad relationships.

Understand what emotions are, how they function, and how to experience them in a way that is not overwhelming.

Tolerate emotional pain without resorting to self-harm or self-destructive behaviors.

(Sanderson, 2008)

The main target of this stage is to help clients experience feelings without having to shut down by dissociating, avoiding life, or having symptoms of post-traumatic stress disorder.

We want to ensure that the client is not experiencing “quiet desperation” not just demonstrating external control of their behaviors – the goal of treatment is not to teach one to suffer in silence.

In this stage, the therapist works with the client to treat PTSD and/or teaches the client to experience all of his or her emotions without shutting the emotions down and letting the emotions take the driver’s seat.

(Sanderson, 2008)

In Stage 3, clients work on ordinary problems like marital or partner conflict, job dissatisfaction, career goals, etc.

Some clients choose to continue with the same therapist to accomplish these goals.

Some may take a long break from therapy and work on these goals independently without therapeutic intervention.

Some decide to take a break and then work with a different therapist in a different type of therapy

(Sanderson, 2008)

Most people may struggle with “existential” problems despite having completed therapy at the end of stage 3.
Even if they have the lives they wanted, they may feel somewhat empty or incomplete. Some people refer to this as “spiritual dryness” or “an empty feeling inside.”

Stage 4 was a DBT addition by creator Marsha Linehan after realizing that many clients go on to seek meaning through spiritual paths, churches, synagogues, or temples.

Clients have also been known to change career paths or relationships.

(Sanderson, 2008)

Shoshanna
A
Activities
C
Contributing
C
Comparisons
E
Emotions - use opposite
P
Pushing Away
T
Thoughts
S
Sensations
Social Worker
Shoshanna
Dialectical Behavioral Skills:
Theory to Practice
Mindfulness:
Are skills that help the client experience the present moment.
Interpersonal Effectiveness:

Are skills that help the client set limits and negotiate solutions.
Emotions Regulation:
Are skills that help the client recognize and regulate their own feelings.
Distress Tolerance
:
Are skills that help the client cope with painful events or circumstances.

References
Building Mastery
Taste
Smell
See
Hear
Touch
Association for Natural Psychology (2012). Dialectical Behavior Therapy: History and Development, Use for Borderline Personality Disorder, Controversies. Retrieved from http://www.winmentalhealth.com/dialectical_behavior_therapy.php

Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical psychology: Science and practice, 10(2), 125-143.

Bray, S. (2013). Interpersonal Effectiveness in Dialectical Behavior Therapy. Retrieved from http://www.goodtherapy.org/blog/interpersonal-effectiveness-dialectical-behavior-therapy-dbt-0416134

CAMH: Centre for Addiction and Mental Health. (2014) An Introduction to Dialectical Behavioural Therapy. Centre for Addiction and Mental Health. Retrieved on March 16, 2015, from http://www.camh.ca/en/education/about/AZCourses/Pages/dbt_part_a.aspx

Compassion kindness metta. (2012). Living Well. Retrieved March 22, 2015, from http://www.livingwell.org.au/mindfulness-exercises-3/10-compassion-mindfulness/

Distress Tolerance: Crisis Survival Strategies. (2014). In DBT Self Help: Life Skills for Emotional Health. Retrieved March 21, 2015, from http://www.dbtselfhelp.com/html/overview1.html

Dietz, L. (2012). DBT self help: life skills for emotional health. Retrieved from http://dbtselfhelp.com/index.html

Dimeff, L., & Lineham, M.M. (2001). Dialectical behaviour therapy in a nutshell. The California Psychologist, 34, 10-13.

Fink, C. (2010). Mindfulness over matter: dbt in the treatment of bipolar disorder? Psych Central. Retrieved from http://blogs.psychcentral.com/bipolar/2010/07/dbt-bipola/

Fulton State Hospital (2004). Dialectical Behavior Therapy: Skills Handbook Retrieved from http://www.bipolarsjuk.se/pdf/Handbook%20in%20DBT%20Group.pdf

Huxter. M. (1999). Dialectical behaviour therapy: a critique and evaluation retrieved from file:///Users/emmalysmulder/Downloads/DBT%20review.pdf

Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

Linehan, M.M., Tutek, D.A., Heard, H.L., & Armstrong, H.E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. Am J Psychiatry, 151, 1771-1776.

Sanderson, C (2008). Dialectical Behavior Therapy Frequently Asked Questions . Retrieved from http://behavioraltech.org/downloads/dbtFaq_Cons.pdf

Psych Central. (2007). An Overview of Dialectical Behavior Therapy. Psych Central. Retrieved on March 16, 2015, from http://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy/0001096

UCL (2015), Dialectical Behavioral Therapy for Borderline Personality Disorder. University College London. Retrieved March 21, 2015, from http://www.ucl.ac.uk/




(Association for Natural Psychology, 2012; Sanderson, 2008).
(Association for Natural Psychology, 2012; Dietz, 2012)
Why Use these Skills?
1. To quiet the body
2. To quiet behavior
3. So that Wise Mind is easier to find
4. To be more effective in meeting goals
5. To improve self-respect


Identifying and labeling emotions
Identifying obstacles to changing
Reducing vulnerability to emotion mind
Increasing positive emotional events
Increasing mindfulness to current emotions
The
"Wise"
Mind
1. Mindfulness
originated in Eastern Buddhist meditation practices
bringing one's complete attention to the present experience on a moment-to-moment basis
key component:
non-judgemental acceptance
shown effective in reducing pain, stress, anxiety, depressive relapse, disordered eating
Mindfulness Activity
Dialects:
balancing change procedures with acceptance strategies
Building an Ordinary Life, Solving Ordinary Life Problems
Moving from Incompleteness to Completeness/Connection
Provides patients a better understanding of themselves in the moment and an opportunity to talk in an accepting environment
Teaches skills that clients can use outside of therapeutic settings
Studies have suggested that DBT is effective for its target populations (i.e. BPD, suicidal behavior, self- harm, etc.)
Decreased
: feelings of hopelessness, anger, hostility, suicidal behaviour, self-injurious behaviour, psychiatric hospitalization, anger, and medication usage
Increased:
client retention, level of functioning, social adjustment and employment performance
(Linehan et al., 1991)
Evidence that DBT in addition to medication may produce even better results than DBT alone
DBT is not a miracle cure
Some studies have shown that it does not relieve depression or makes clients happier
DBT is appropriate only for patients who acknowledge their illness, want to learn about it
DBT is demanding and requires the client to be fully committed to the process
DBT is not always accessible in different communities
It can be costly
Some argue that professionals are unsure whether it is the skills training itself or simply the high level of support which leads to the reduction in self-harm
Objectiveness Effectiveness:
Dear Man

D
escribe

E
xpress

A
ssert

R
einforce

M
indful

A
ppear Confident

N
egotiate

Self-respect Effectiveness:
FAST

F
air

A
pologies (no apologies)

S
tick to value

T
ruthful

Relationship Effectiveness:
GIVE

G
entle

I
nterested

V
alidate

E
asy Manner

http://www.dbt-app.com/
https://play.google.com/store/apps/details?id=se.cognitus.dbtapp&hl=en
https://itunes.apple.com/ca/app/id479013889?mt=8

http://www.bipolarsjuk.se/pdf/Handbook%20in%20DBT%20Group.pdf
http://practicegroundprojects.wikifoundry.com/page/DBT+Handouts,+Protocols+%26+Client+Learning+Activities
DBT Skills Handbook and Worksheets
DBT Apps
DBT Podcast
https://archive.org/details/APeerIntroductionToDbtSkills-PodcastWithRachelGill
(Psych Central, 2007; CAMH, 2004)
(Dimeff, 2001)
(Dimeff, 2001)
(UCL, 2015)
Social Work Podcast: Johnathan B. Singer
Episode 26 Dialectical Behavior Therapy
(Linehan, 1993)
(Linehan, 1993; Baer, 2003)
(Baer, 2003)
(Linehan,1993; Baer,2003)
(Living Well, 2012)
(Fink, 2010; Huxter, 1999)
3. Emotion Regulation
2. Interpersonal Effectiveness
4. Distress Tolerance
Please Master Skill
Are skills that help the client recognize and regulate their own feelings.
(Fulton State Hospital, 2004)
Healthy Perspectives on Emotions
1. Emotions are neither good or bad
2.There is a difference between having an emotion acting on the emotion.
3. Emotions don’t last forever.
4. You do not have to act on your feeling.
5. Emotions are not facts
6. You cannot get rid of emotions

used when we are unable, unwilling, or it would be inappropriate to change a situation
concerned with coping, tolerating and surviving crises and with accepting life as it is in the moment.
goal is to become capable of calmly recognizing negative situations and their impact
Four sets of crisis survival strategies:
1.Distracting
2. Self-soothing
3. Improving the moment
4. Thinking of pros and cons
Objectiveness Effectiveness:
getting the “thing” you want
Self-Respect Effectiveness:
keeping or improving self-respect and liking for yourself
Relationship Effectiveness:
getting and keeping a good relationship

· Using these skills increases the likelihood of positive outcomes in all areas of interpersonal functioning

· Interpersonal effectiveness skills are intended to maximize the chances a person’s needs/requests will be met, while not damaging either the relationship or the person’s self-respect
(Linehan,1993)
(Psych Central, 2007; Bray, 2013)
(DBT Self Help, 2014)
Full transcript