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ID Statement: Age, birth order/marital status, employment status, living situation
LTB = Life Threatening Behavior
*Suicide attempts
*Self Injury
*Suicidal ideation (pattern)
*SRA = Suicide Related Affects
*SRE = Suicide Related Expectancies
*RFL = Reasons for Living
TIB = Treatment Interfering Behavior
*Non-attendance - hospital habit
*Non-disclosure
*Non-adherence
QOL = Quality of Life Interfering
*Pts choice
DSM-5 Diagnosis
*Based on interview/collateral
*Standardized interviews
*Rating scales
Meds:
*Current
*Past (w responses)
Allergies:
Medical Hx:
Family Hx:
*ADHD, Autism, bipolar, schizophrenia
*medical conditions
ID Statement: 17 yo, youngest of three in an intact family, senior in public high school (w an IEP for social emotional), living with her family and accepted to college for next year
LTB = Life Threatening Behavior
*SA 3 previous low lethality, high rescue ODs
*SIB = cutting with a razor
*Suicidal ideation (pattern) = spikes quickly from a 3 to a 5 in context of interpersonal conflict
*SRA = Saddness, Shame, and Anger
*SRE = Escape distress
*RFL =Some hope for the future
TIB = Treatment Interfering Behavior
*Non-adherence - has difficulty following through with safety planning
QOL = Quality of Life Interfering
*Fear of public speaking
DSM-5 Diagnosis
*MDD
*Social Anxiety
Meds:
Current: Cymablta 90 mg daily
lamictal 100 mg daily
*Past trials of sertraline (partial benefit then faded, lexapro - unable to tolerate due to nightmares, but not full trial
Allergies: NKDA
Medical Hx:
1 previous concussion
Family Hx:
*Maternal Aunt with significant depression
*Maternal Cousin with depression/anxiety and inptatient admissions
*Set an agenda at the beginning of each session
*Focus on target hierarchy (life threatening behavior, therapy interfering behavior, quality of life interfering behavior)
*Target suicide attempts and self-injurious behavior with behavioral analysis
*Also an exercise in mindfulness and affect identification
*Do a behavioral analysis to identify barriers
*Modify the diary card to make it less annoying
*Start session with completing the diary card
Paradox: Therapists view suicide and self-injury as problems. Clients often view suicide and self-injury as solutions to the problems of living.
*Behavioral Analysis can be followed by a solutions analysis which helps presents alternative solutions to the clients problems
*The DBT alternative to suicide is a life worth living
*The DBT alternative to self-injury is distress tolerance
Pick one specific instance of the target behavior:
Consequences (Reinforcers)
Antecedents
(Emotional Vulnerability Factors)
Behavior Chain (Connect Thoughts, Feelings, and Behaviors)
1. To get a tangible object
2. To have a sensory experience
3. To get attention
4. To escape
Building a scale (0-5 or 0-10)
Emotion thermometer
Use multiple choice questions
Mad, sad, glad, hurt, scared, guilty, ashamed, disgusted
When the behavioral analysis is done, go back and do a solutions analysis
It's ok if this is a separate session
1. Solve the problem
2. Change how you feel about the problem
3. Accept the problem – wait for better times
4. Stay miserable
5. Make the problem worse
Behaviors can be operant or respondent
Clients may not be consciously aware of the functions of their behavior
Functional Analysis is the DBT equivalent of insight
Emotionally labile people in constant crisis often do not have the analytic skills to put life in order. Behavioral analysis teaches these skills.
Behavioral Analysis is a change strategy and also incorporates validation and mindfulness (observing, describing, and labeling emotions without trying to change them)
ID Statement: Age, birth order/marital status, employment status, living situation
DSM-5 Diagnosis
*Based on interview/collateral
*Standardized interviews
*Rating scales
Meds:
*Current
*Past (w responses)
Allergies:
Medical Hx:
Family Hx:
*ADHD, Autism, bipolar, schizophrenia
*medical conditions
LTB = Life Threatening Behavior
*Suicide attempts
*Self Injury
*Suicidal ideation (pattern)
*SRA = Suicide Related Affects
*SRE = Suicide Related Expectancies
*RFL = Reasons for Living
TIB = Treatment Interfering Behavior
*Non-attendance - hospital habit
*Non-disclosure
*Non-adherence
QOL = Quality of Life Interfering
*Pts choice
Pick one specific instance of the target behavior:
Consequences (Reinforcers)
Antecedents
(Emotional Vulnerability Factors)
Behavior Chain (Connect Thoughts, Feelings, and Behaviors)
*Use a diary card to set the session agenda
*Diary cards help a pt practice mindfulness and affect identification as well as track target behaviors
*Use behavioral analysis to target life threatening behavior
*Behavioral Analysis is a change strategy that teaches analytic skills (i.e. life goes in order and thoughts, feelings, and emotions are connected)
*The client may be unaware of the functions of their behavior
*Solutions analysis is a chance to highlight alternative decision points (skills)
Validation is the core acceptance strategy
Problem Solving is the core change strategy
Validation is a communication that a client's emotions and reactions make sense in the current life context.
Validation is NOT the same as praise, warmth, or agreement
You cannot validate what you do not understand
You can only validate the valid (and suicide is never valid)
You are only validating if you client feels validated
Functional Validation = Implicit Validation
– ex giving something, solving a problem, taking action
Explicit Validation is through words
V1 staying awake
V2 accurate reflection – similar to motivation interviewing
V3 mind reading – articulating unverbalized emotions, thoughts, or behavior patterns
V4 validation in terms of past learning or biologic dysfunction – understanding problems in context
V5 validation in terms of present circumstances or normative functioning – normalizing the normal
V6 radical genuineness
1. Calm an upset person who is too upset to problem solve
2. Repair a therapeutic error or rupture
3. Teach self validation – Non-pejorative self observation/descriptions
4. Learn about client’s current experiences
5. Provide validating (safe) context for change
Borderline Personality Disorder
Criteria
Deficit
Skill
Behavioral
Dysregulation
Distress Tolerance
Cognitive
Dysregulation
5 or more
1. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior inappropriate
2. Impulsivity in at least two areas that are potentially self-damaging
3. Transient, stress-related paranoid ideation or severe dissociative symptoms
4. Affective instability due to a marked reactivity of mood
5. Intense Anger
6. Unstable and intense interpersonal relationships (idealization and devaluation)
7. Frantic efforts to avoid loss
8. Unstable sense of self
9. Chronic feelings of emptiness
Emotion
Regulation
Emotion
Dysregulation
Interpersonal
Effectiveness
Interpersonal Dysregulation
Self
Dysregulation
Mindfulness
Alan Fruzzetti interview