dialectical behavior therapy paulette aasen, ph.d. director of psychology services west central...
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Dialectical Behavior Therapy
Paulette Aasen, Ph.D.
Director of Psychology ServicesWest Central Human Service Center• Bismarck, ND • (701) 328-8888
Badlands Human Service Center• Dickinson, ND• (701) 227-7500
February 10, 2014
Overview of DBTDeveloped by Marsha Linehan, Ph.D., in
1993 as treatment for clients struggling with severe & persistent emotional, behavioral, & thought difficulties, especially those diagnosed with Borderline Personality Disorder.
Dr. Linehan recently shared that she struggles with Borderline Personality Disorder.
The Goal of DBT: “Create a life worth living.”
Foundations of DBTDBT is a synthesis of three paradigms:
◦ Dialectics◦ Behaviorism◦ Mindfulness
Purpose:◦ Reducing dysfunctional behaviors◦ Increasing skillful behaviors◦ Building a life worth living
Client needs validating environment in which s/he is taught to regulate emotions, deal with interpersonal conflicts, tolerate distress, and find balance.
Swenson, Witterholt, & Bohus, 2007
Linehan Diagnosis forBorderline Personality Disorder
Emotion Dysregulation◦ Affective lability◦ Problems with anger
Interpersonal Dysregulation◦ Chaotic relationships◦ Fears of abandonment
Self Dysregulation◦ Identity disturbance – difficulties with sense of self◦ Sense of emptiness
Behavioral Dysregulation◦ Parasuicidal behavior◦ Impulsive behavior
Cognitive Dysregulation◦ Dissociation / paranoid ideation
(Linehan, 1993)
Bio-Social ModelBiological Sensitivity
AND Invalidating Environment = Dsyregulation Disorder Symptoms
Invalidating
Environment
Biology
Invalidating
Environment
Invalidating
Environment
Biology
Biology
Bio-Social Model (cont.)High SensitivityHigh ReactivitySlow Return to BaselineOften “Transactional” with the
Environment
Slow Return to Baseline
Series1
0
1
2
3
4
5
6
7
8
9
AverageDysregulatedThreshold
Em
oti
on
s
Dialectical ParadigmDialectics is the theory that opposites can co-exist.
• Hegel: “Process of change in which a concept or its realization passes over into and is preserved and fulfilled by its opposite.”
• Bohr: “The Universe is so constructed that the opposite of a true statement is a false statement, but the opposite of a profound truth is usually another profound truth.”
Dialectical Paradigm
From DBT Self Help at http://www.dbtselfhelp.com
Dialectics: A Model for Change
Movement Over Time
Thesis
Synthesis
Antithesis
Primary Dialectic in DBT
Acceptance
Change
Dialectical Dilemmas
Unrelenting Crisis
Social
Biological
Emotional Vulnerabili
ty
Apparent Competen
ce
Active Passivity
Self-Invalidation
Inhibited Experienci
ng
Dialectical StrategiesBalance Treatment
StrategiesEnter the paradoxMetaphorDevil’s AdvocateExtendingWise Mind“Lemonade out of lemons”Allowing natural changeDialectical Assessment
Behaviorism Paradigm
From DBT Self Help at http://www.dbtselfhelp.com
Behavior Therapy BasicsBehavioral Principles necessary to be
effective Behavior Therapy: a non-biological
form of therapy that developed from learning theory. The purpose is to change maladaptive patterns of behavior.
Shaping: Divide a behavior to be learned into a series of steps.
DBT: Harm reduction model so shape clients toward that
DBT Assumptions about ClientsClients are doing the best they
can.Clients want to improve.Clients need to do better, try
harder, and be more motivated to change.
Clients may not have caused all of their own problems, AND they need to solve them anyway.
Assumptions about Clients (cont.)
The lives of suicidal individuals with Borderline Personality Disorder are unbearable as they are currently being lived.
Clients must learn new behaviors in all relevant contexts.
Clients cannot fail in DBT.
Assumptions About TherapyThe most caring thing a therapist
can do is help clients change in ways that bring them closer to their own ultimate goals.
Clarity, precision, and compassion are of utmost importance in conducting DBT.
The therapeutic relationship is a real relationship between equals.
Hierarchy of TargetsIndividual Therapy
1. Life threatening behaviors2. Therapy interfering behaviors3. Quality of life interfering behaviors4. Increasing behavioral skills
Client Agreement
Client and Therapist BOTH sign the agreement to acknowledge what it is they are agreeing to in the therapy relationship.
Session StructureReview Diary CardAttention to Target HierarchyChain Analysis on highest
targeted behaviorWeave in Solution AnalysisContinue to move down hierarchy
until able to discuss skills related to current life situations or session time ends
Commitment StrategiesTherapist discusses PRO’s and CON’s
of commitment to changeUse the DEVIL’S ADVOCATE technique
to strengthen commitment and build sense of control
Highlight PRIOR COMMITMENTS consumer has made
Present consumer with CHOICE stressing the freedom to choose while presenting the consequences of choices clearly and directly
Commitment Strategies (cont.)
Therapist uses principles of SHAPING to elicit commitment
Therapist generates hope by CHEERLEADING
Therapist and client agree on HOMEWORK
Validation of ConsumerStay AwakeAccurate ReflectionArticulating unverbalized emotions,
thoughts, and behavior patternsValidation in terms of past learning
or biological dysfunctionValidation in terms of current
context or normative functioningRadical Genuineness
Self-Verification TheoryValidation = Self-VerificationInvalidation of Self-Construct
leads to AROUSAL!!! (Sense of out-of-control)
HIGH AROUSAL + OUT-OF-CONTROL leads to >>>>
Failure to process New Information =
NO NEW LEARNING!
Relationship StrategiesAccept the relationship as it is in
the current moment, use the relationship as therapy – YOU are the Key
Use problem solving on the relationship
Attend directly to generalization of behaviors learned in the relationship
Be honest about limitsBe consistently firmCombine Soothing, Validating, &
Problem Solving with Observing LimitsWarm Engagement:
◦Limits on Warmth◦Coping with anger/rage at the consumer◦Warm engagement and touch in
psychotherapyGenuineness
DBT Skills GroupScreening session1-year commitmentBoth client and therapist sign
agreementAgreement includes statements
regarding homework completion and attendance
Co-facilitators
Hierarchy of TargetsDBT Skills Group
1. Therapy destroying behavior2. Skills acquisition, strengthening,
and generalization3. Therapy interfering behaviors
Zen PracticeBe Mindful to the current momentSee reality as it is without delusionsAccept reality without judgment Focus on one’s own experiencing as
a means of understanding the worldLet go of attachments that obstruct
seeing and accepting reality as it isUse skillful meansFind the middle way
Mindfulness ParadigmMindfulness is at the core of
◦Emotion Regulation (emotions, thoughts, and behaviors).
◦Distress Tolerance (skills used to help us cope and survive during a crisis, distracting or soothing activities).
◦Interpersonal Effectiveness (skills which help us to attend to relationships, balance priorities versus demands, balance the “wants” and the “shoulds,” and build a sense of mastery and self-respect.
From DBT Self Help at http://www.dbtselfhelp.com
Mindfulness“Paying attention on purpose, in the
present moment, and nonjudgmentally to the unfolding of experiences moment by moment.” (Kabat-Zinn, 2003, p. 145).
Non-JudgmentPatienceBeginner’s Mind or Child’s MindTrustNon-StrivingAcceptanceLetting Go
Kabat-Zinn, 1990
5 Stages of Accomplishment
1. Denial
2. Uncertainty
3. Resistance
4. Panic
I can’t do it!
Maybe I can do
it!
There’s no way I can do it!
AAAARGH!What if I can’t do
it?!
5. Acceptance
CONGRATULATIONS!
ALL RIGHT!I DID IT!
LET’S PARTY!
References DBT Self-Help Website http://www.dbtselfhelp.com
Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Delacorte.
Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford.
Miller, A. L., Rathus, J. H., & Linehan, M. I. (2007). Dialectical Behavior Therapy for Suicidal Adolescents. New York: Guilford.
Swenson, C. R., Witterholt, S., & Bohus, M. (2007). Dialectical behavior therapy on inpatient units. In: L. Dimeff & K. Koerner (eds.). Dialectical Behavior Therapy in Clinical Practice. New York: Guilford.
DBT AssociatesChristine Kvidera, MSW, LICW
7362 University Ave. NE, Suite 101
Fridley, Minnesota 55432Phone & Fax: (763) 503-3981www.dbtassociates.comEmail: [email protected]