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DBT 101:

Getting Started

Formulation

Integrated Formulation

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

Case Example: Louise B.

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

Diary Cards (Tracking)

Use Diary Cards to Set the Agenda

*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

What is a diary card?

Louise B:

Jean B:

Tina B:

What if my patient won't do a diary card?

*Do a behavioral analysis to identify barriers

*Modify the diary card to make it less annoying

*Start session with completing the diary card

Behavioral Analysis

Behavioral/Solutions Analysis

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

Behavioral Analysis

Pick one specific instance of the target behavior:

Consequences (Reinforcers)

Antecedents

(Emotional Vulnerability Factors)

Behavior Chain (Connect Thoughts, Feelings, and Behaviors)

Functions of Any Behavior

1. To get a tangible object

2. To have a sensory experience

3. To get attention

4. To escape

Behavioral Analysis Tools

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

Options for Responding to Any Problem

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

A few points!

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.

The Acceptance in Change

Behavioral Analysis is a change strategy and also incorporates validation and mindfulness (observing, describing, and labeling emotions without trying to change them)

Role Play

Integrated Formulation

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

Behavioral Analysis

Pick one specific instance of the target behavior:

Consequences (Reinforcers)

Antecedents

(Emotional Vulnerability Factors)

Behavior Chain (Connect Thoughts, Feelings, and Behaviors)

Recap

Take Home Points

*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

Acceptance vs. Change

Validation is the core acceptance strategy

Problem Solving is the core change strategy

What is Validation?

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

Types of Validation

Functional Validation = Implicit Validation

– ex giving something, solving a problem, taking action

Explicit Validation is through words

Levels of Explicit Validation

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

Goals of Validation

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

Skills Overview

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

Video

Alan Fruzzetti interview

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