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Intro to DBT

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Betsy Lindeland

on 14 June 2013

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Transcript of Intro to DBT

Betsy Lindeland, M.S.
An Introduction to
Dialectical Behavior Therapy

What comes to mind?
borderline personality disorder
Developed by Marsha Linehan in 1993
Considered part of the third-wave
Initially created to treat clients with BPD
Standard CBT deemed ineffective
Too change-focused (invalidating)
Ineffective interventions reinforced
Effective interventions were punished
Crisis management vs. growth work
High therapist burnout
Generalizable to multiple populations and settings
DBT's Theoretical Influences
Zen principals
Biosocial Theory of BPD
Biological influences
...So, what is it already?!
June 14, 2014
Marsha Linehan
third wave
phone coaching
Learning Objectives
Increase awareness about the theoretical foundations
Gain understanding of the structure of DBT
Identify how aspects of DBT can be implemented in a college counseling setting
•Enhancing the client’s capabilities
Objectives of DBT
Social Influences
abuse & dependency
Eating Disorders
Interpersonal Difficulties
(Swales & Heard, 2009)
Biological Influences
Increased sensitivity to emotional stimuli
Intense reactivity to emotional stimuli
Slow return to baseline
Social Influences
Invalidating environment, "one which communication of private experiences is met by erratic, inappropriate, and extreme responses." (Linehan, 1993)
Behavior and communications are rejected as invalid
Emotional displays are punished
Oversimplification of problems and solutions
(Linehan, 1993)
Theoretical foundation for change strategies
Learning theory
Operant and classical conditioning principals
Emphasis on behavioral aspects
Thinking, emoting, acting are ALL behaviors
“the successful reduction or removal of the behaviors that constitute the diagnosis removes the diagnosis itself” – (Swales & Heard, 2008)
The CBT in DBT
Provides an emphasis on acceptance and validation to balance the emphasis on change
“The world is perfect in the sense that it is the best that it can be in this moment. It cannot be any different than it is because it is created or cause by what has preceded it”
First noble truth- “life is suffering”
Suffering results from attachments or insatiable desires for reality to be a certain way
Avoidance of suffering leads to worse suffering
Radical acceptance: “the fully open experience of what is without distortion, adding judgment of good/bad, clinging or pushing away.”
Zen Influences
The art of holding things in balance that seem to be in conflict, mismatched, contradictory, while being real or true
Conflict between polarities bring about tension that is necessary for change
BPD is full of dialectics in itself
Are doing the best they can, yet they need to learn how to be more effective
Client’s behavior is valid, and also problematic
Did not cause all of their problems, but they have to solve them
Don’t want to be told what to do, but cannot figure out their own solutions
Any others come to mind?
What are some dialectics in your life?
Two change strategies: being able to sit with emotions without responding, and learning how to reduce them
Individual counseling
Phone coaching
Consultation team
Skills group
Individual Counseling
Weekly (-ish), one-year agreement
Intensive focus on therapeutic contract at onset
4 Stages:
1. Achieving behavioral stability
Life threatening behaviors targeted first
Therapy-interfering behaviors second
Quality-of-life-interfering behaviors third
2. Emotionally processing the past
3. Returning to ordinary levels of happiness
4. Enhancing capacity for joy/meaning
Variety of CBT, Zen-influenced tools utilized
Therapeutic Interventions in Individual Mode
Problem acceptance and solution generation
Validation, validation, validation!
Chain analysis
Therapist modeling
Skills coaching and generalization
Exposure techniques
Between-session diary cards
Phone Coaching
Therapist is on-call between sessions should client need them
Promotes appropriate help-seeking behavior
Helps clients maintain skill practice and generalization should they get stuck
Allows clients the opportunity to address a perceived rupture in alliance following conflict
Often individual therapist is in the phone coach role, unless contraindicated
Consultation Group
DBT therapists need support, or they will BURN OUT!
Weekly consultation meetings are crucial
Entire treatment team meets together
Identification of therapist's therapy-interfering behaviors
Ensures therapist maintains competency
Allows treatment team to work through inconsistencies in conceptualizations and feedback
Therapists get support and validation
Decreases likelihood of therapist splitting
Skills training group
One year, 2-2.5 hours per session
Two co-leaders
Open or closed
First half of meeting is check in, reviewing diary cards
Second-half of meeting, new skill is taught and then wind-down
Four modules, 8 weeks each
Interpersonal effectiveness
Emotion Regulation
Distress Tolerance
Three primary states of mind:
Emotion mind
Reasonable mind
Wise mind- Goal of module
Wise mind is achieved by "what" and "how" skills
"What": developing a lifestyle of participation with awareness
"How": how to do the what
Nonjudgmental stance
Focusing on one thing in the moment
Being effective
Interpersonal Effectiveness
Premature termination of relationships among clients with BPD
Acquisition of basic interpersonal skills
Identification of factors that enhance or inhibit healthy relationships
Explore what considerations are necessary before making a request, stating an opinion, or saying no
Objective effectiveness: DEAR MAN (or WOMAN)
Relationship effectiveness: GIVE
Self-respect effectiveness: FAST
Emotion Regulation
"Many emotions that clients with BPD feel are secondary emotions in reaction to primary ones that have been invalidated by their environment" (Linehan, 1993)
Explore function and nature of emotions- validate primary emotions
Identifying and naming of emotions
Increase mindfulness of current emotional states
Identifying obstacles to changing emotions
Reducing vulnerability to emotion mind
PLEASE MASTER (Linehan, 1993), MEDDSS (Moonshine, 2008)
Increasing positive emotional experiences
Pleasant events schedule
Taking opposite action
Distress Tolerance
Pain and distress are a part of life
If we don't learn how to cope, we cannot grow
First step: Radical acceptance of reality
Willingness vs. willfulness
Four skill sets
Distraction: ACCEPTS skills help reduce contact with negative emotions
Improving the moment
Thinking of pros and cons
Of tolerating the distress at hand
Of resorting to old behaviors
So... What do y'all think?
Are there any components of DBT that you might consider using?
Are there any that you would never, in a million years consider using?
How might some aspects of DBT be modified to fit a brief model like we use at CS?
Why/when is our emotion mind useful?
Hidden Question!
When isn't it?
Why/when is our rational mind useful?
When isn't it?
Hidden Question!
What do you all think about Linehan's Biosocial Theory?
Is it missing anything?
Cultural Competence and DBT
Ethical and Legal Considerations in DBT
"Because of its emphasis on client values and goals, DBT is easily applicable to all clients regardless of race, ethnicity, or gender. DBT helps clients achieve their individual goals without imposing social expectations of the dominant culture" (Neacisu et al., 2013)
Skills often modified to various groups
Harned, Salsman, Secrist, Comotois, & Linehan (2006): Ethnicity, education, age, and marital status did not predict change in remission, dropout, self-injury, or suicide attempts following DBT treatment.
Paucity of research on DBT and diverse populations
Pure DBT is expensive
Individuals with strong religious backgrounds may take issue with Buddhist influences.
Duty to warn
Duty to protect
Mandated reporting of abuse
High rates of childhood abuse
Boundaries & maintenance
Multiple relationships
Informed consent
Confidentiality and its limits
Sharing information with outside parties
Sexual intimacies with clients
Interruption of therapy
Termination of therapy
Very detailed therapeutic contract established at onset of treatment
What legal and ethical issues might come up?
Recommended Readings:
Cognitive-Behavioral Treatment of Borderline Personality Disorder (Linehan, M. 1993)
Skills Training Manual for Treating Borderline Personality Disorer (Linehan, M. 1993)
Dialectical Behaviour Therapy (Swales & Heard, 2009)
Acquiring Competency and Achieving Proficiency with Dialectical Behavior Therapy, Vols. 1 & 2 (Moonshine, 2008)

•Enhance and maintain client’s motivation for change
•Ensure that clients learned abilities are generalizable

•Support treating clinicians

•Structure environment so change can take place
Full transcript