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Dialectical Behavior Therapy(DBT) Basics20203

Presenter Matthew Rynkiewicz, LCSW Master of Social Work (2007) Experienced in direct clinical care as well as mentalhealth program coordination DBT group facilitator since 2013 Received 65 hours of intensive DBT training Beacon Quality Management Specialist since 20174

Learning Objectives Identify the elements of comprehensive Dialectical Behavior Therapy (DBT) programs Describe the history and philosophy of DBT Explain how the functions of DBT treatment and modes of therapy are used to createsuccessful clinical interventions Demonstrate how DBT skills training works through demonstration of techniques5

Chapter01What isDialecticalBehaviorTherapy?8

What is Dialectical Behavior Therapy (DBT)? DBT is a type of cognitive behavioral therapy Focuses on increasing an individual’s ability tocope with intense emotions in healthy ways “Emotional Sensitivity” Transactional theoryoInvalidating environments9

History of DBT Developed by Marsha Linehan in the1980s & early 1990s Treatment manual published in 1993 Originally intended to treat BorderlinePersonality Disorder Dr. Linehan and her team addedtechniques and developed a treatmentthat would meet the unique needs ofthese patients.Photo from University of Washington10

What are Dialectics? DBT incorporates a philosophical processcalled dialectics Everything is composed of opposites Change occurs when there is a "dialogue"between opposing forces Dialectics makes three basic assumptions All things are interconnected Change is constant and inevitable Opposites can be integrated to form acloser approximation of the truth12

Wise Mind Practice Think of something bothering you in your life that is unresolved.13

Goals of DBTCope with stress in healthy waysLearn to regulate emotionsImprove interpersonal relationshipsLive in the moment14

What makes a good DBT candidate? DBT is intended to treat high risk, multiplediagnosis individuals with pervasive, severeemotion dysregulation Individuals with high emotional reactivity, engagingin problem behaviors Commitment to change is not a prerequisitePhoto from WestSide DBT15

DBT is Effective for the Following ConditionsBorderlinePersonalityDisorderCluster BPersonalityDisordersSuicide andSelf-harmingBehaviorADHDSubstance UseDisordersPTSDMood DisordersEating disorders(Binge andBulimia)16

DBT Effective in onCostsDepression& SuicidalBehavior17

18Photo from Behavioral Tech 2019

Who can perform DBT?TherapistsCounselorsSocial WorkersCase ManagersTraining:Milieu Staff 2 week intensive courses on clinical teams Certification available via Behavioral Tech19

Chapter02How does DBTWork?20

DBT Basics Individual takes ownership oftheir recovery, - self-sufficiency. Homework Tracking emotions, urges, &behaviors Individual and therapist worktogether to: Resolve the apparentcontradiction between selfacceptance Skills Training - encouragepositive behaviorsPhoto from Allure.com 10/23/1921

DBT AssumptionsIndividuals are doing the best they canIndividuals want to improveIndividuals need to do better, try harder, and be more motivated to changeAll behavior is causedIndividuals may not have caused their problems, but it is up to them to solve them anywayFiguring out and changing the causes of behavior is more effective than judging and blamingNew behavior needs to be learned in all relevant contexts22

Behavioral Skills Training DBT assumes that the problems exhibited byindividuals are caused by skills deficits. Failure to use effective behavior is often a resultof not knowing skillful behavior, or when / how touse it Skills Trainings teaches the individual a set ofbehavioral skills to strengthen their ability to usethose skills in their everyday livesooooMindfulnessEmotion RegulationInterpersonal EffectivenessDistress Tolerance23Photo from Psychiatric Times, 2016

Stylistic ApproachesValidation Acknowledging the truth in an individual’s experienceIrreverence Challenging patterns in the individuals perceptions & behaviors to get “unstuck”Dialectics Synthesizing opposites to get closer to the truthUse of Metaphor Using stories & symbols to illustrate conceptsObserving Limits vs. Setting Boundaries Within the therapeutic relationship; accepting what we can & can’t tolerate24

Stages of DBTPre-treatmentStabilization Orientation to DBT 1:1 meeting withtherapist EstablishingcommitmentTargets: Life ThreateningBehavior Therapy InterferingBehavior Quality of LifeInterfering BehaviorInterventions: 1:1 Therapy Skills Training Phone coaching Consultation Team Ancillary TreatmentsSymptomReductionProblems inlivingTargets: Reduce SymptomsTargets: Improve self-worth Problem solving Utilize supportsInterventions: 1:1 Therapy Skills Training Phone coaching Consultation Team Ancillary TreatmentsInterventions: 1:1 Therapy Skills generalizationIncompletenessTargets: Increasing capacityfor joy and freedomInterventions: 1:1 Therapy Pursuing meaningand purpose25

Secondary Targets for Borderline PersonalityEmotional Vulnerability vs. Self-InvalidationDialecticalTensionsUnrelenting Crisis vs. Inhibited ExperiencingActive Passivity vs. Apparent Competence26

Chapter03Components andModalities ofDialecticalBehaviorTherapy27

Two Main Treatment SettingsIndividual TherapySkills Group (Group Sessions) Consists of one-on-one contact with atrained therapist Group led by one trained therapist Therapist helps individual: Group meets weekly for 6 monthsostay motivatedoapply DBT skills within daily lifeoaddress obstacles that might ariseover the course of treatment. Each session lasts 2 hours Group members share experiences /provide mutual support Assigned homework or exercises Groups can be shorter/ longer –depends group members’ needs28

Modes of DBTIndividualTherapySkillsTraining BehavioralTargets Diary Cards Behavioral ChainAnalysis DevelopingCommitment Mindfulness Skills InterpersonalEffectiveness DistressTolerance EmotionRegulationCoachingPhoneCalls SkillsGeneralization Behavioral ChainAnalysis Crisis InterventionTherapistConsultation Therapy for thetherapist Problems intherapy Cheerleading ProvidingDialectical BalanceAncillaryTreatments MedicationManagement CaseManagement Group Therapy Vocational &EducationalAssistance29

IndividualTherapySkillsTrainingCoachingPhone CallsTherapistConsultationAncillaryTreatments Behavioral Targets Diary Cards Behavioral Chain Analysis Developing Commitment30

IndividualTherapyBehavioral Targets (Stage 1)Pre-treatmentStabilization Orientation to DBT 1:1 meeting withtherapist EstablishingcommitmentInterventions: 1:1 Therapy Skills Training Phone coaching Consultation Team Ancillary TreatmentsTargets:Threatening1 LifeBehaviorInterfering2 TherapyBehaviorof Life3 QualityInterfering BehaviorSymptomReductionProblems inlivingInterventions: 1:1 Therapy Skills Training Phone coaching Consultation Team Ancillary TreatmentsInterventions: 1:1 Therapy Skills generalizationTargets: Reduce SymptomsTargets: Improve self-worth Problem solving Utilize supportsIncompletenessInterventions: 1:1 Therapy Pursuing meaningand purposeTargets: Increasing capacityfor joy and freedom31

IndividualTherapyBehavioral Chain AnalysisDBT requires evaluation of the Behavior How is the behavior conditioned?oClassically conditioned – cue is paired with the behavioroOperantly conditioned - reward/ punishment following behavior Behavior Chain AnalysisLinksVulnerabilities FactorsprecedingproblembehaviorTriggeringEvent Cuespreceding thebehavior Identifyactions, bodysensation,cognitions,events ers Following theproblembehavior32

Diary CardsIndividualTracksIndividualTherapyIncidents of behavioral targets, urges to engage in thebehavior (scale of 1-5)Incidents of substance and alcohol useConsistency with medication regimenPractice of skills over the last weekReviewonly inIndividualtherapyReview inIndividual therapy& Skills Training33

Diary Card ExampleIndividualTherapy34

Developing commitmentIndividualTherapy IndividualsoCommit to making changes to cues, practicing skills, using interpersonal skills with others TherapistsoDo not assume commitment, and do not assume that commitment to change will be uniformacross treatment Strategies including are used at the end of sessions to ensure commitmentoPros & ConsoFoot in the Door35

IndividualTherapySkillsTrainingCoachingPhone CallsTherapistConsultationAncillaryTreatments Mindfulness Skills Interpersonal Effectiveness Distress Tolerance Emotion Regulation36

Mindfulness SkillsSkillsTraining Wise Mind “What” SkillsoObserveo“Teflon mind”oDescribeoParticipate “How” Skills – Non-Judgmentally,One Mindfully, EffectivelyPhoto from Psychology Compass37

Interpersonal Effectiveness SkillsImprove ability to Clearly communicate with others Say “no”Objectives Observe limitsEffectiveness Head off conflictSelf Respect Attend to sSkillsTraining DEARMAN FAST GIVE38

SkillsTrainingTools for Interpersonal MindfulAppear ConfidentG GentleI InterestedV ValidateE Easy MannerFASTFairApologiesStick to ValuesTruthfulNegotiate39

Distress ToleranceSkillsTraining Tolerating distressing situations without engaging in problem behaviorsCrisisSurvivalSTOP skillPros and consTIPDistractionSelf-soothingImproving the momentRealityAcceptanceSkillsRadical acceptanceTurning the mindHalf-smileWilling handsWillingness versus willfulnessMindfulness of current thought40

PRACTICE: Radical AcceptanceSkillsTraining Think back to the problem you used earlieroIs there anything about the problem – about yourself, someone else, the world aroundyou that you might be fighting?oAnything you’re resisting, or makes you feel tense about the situation?oGet comfortable and relax and open yourself to acceptance of the situation. Did you feel any different?41

Emotion RegulationSkillsTraining Reducing the intensity of emotion statesthat can cue engagement in problembehaviors Steps involvedoObserving emotionsoChanging emotional responsesoReduce emotional vulnerability— Examples – ABC, PLEASE42

IndividualTherapySkillsTrainingCoachingPhone CallsTherapistConsultationAncillaryTreatments Skills Generalization Behavioral Chain Analysis Crisis Intervention43

CoachingPhone CallsSkills Generalization Behavior needs to be learned across allenvironments Phone coachingoIncreases the likelihood that individuals will beable to apply newly learned skills in all contextsoProvides in the moment reinforcement of skills44

Behavioral Chain Analysis (Via Phone)CoachingPhone Calls In the moment evaluation of current cues, urges, emotions and reinforcers Therapist evaluates when the member began to experience urges Therapist coaches through the identification and execution of skillful means to preventengagement in problem behaviors Contingency management (if all else fails .) Needs to happen BEFORE the problem behavior has occurred, not after- otherwisehaving your therapist on the phone becomes reinforcement of behavior (24 hour rule)45

Crisis Intervention (as needed)CoachingPhone Calls Engagement of suicide assessmentprotocols/ safety protocols as needed Assisting by using skills to return tobehavioral chain analysis, and avoidproblem behaviors (ie. distress tolerance) Last Resort - Hospitalization and use ofemergency roomsIllustration by Brittany England via healthline.com46

IndividualTherapySkillsTrainingCoachingPhone CallsTherapistConsultationAncillaryTreatments Therapy for the therapist Problems in therapy Cheerleading Providing DialecticalBalance47

TherapistConsultationTherapy for thetherapist(weekly)Problems age from vectorstock.com48

IndividualTherapySkillsTrainingCoachingPhone CallsTherapistConsultationAncillaryTreatments Medication Management Case Management Group Therapy Vocational & Educational49

entGroup TherapyVocational &Educational50

Chapter04In Summary51