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DIALECTICAL BEHAVIORAL THERAPY (DBT)JFKU
Mark Purcell, PsyD & Claire Coyne, LMFT
Different Types of Emotions
AngerSAD
LOVE
Panic
GUILT
Calm
JoyPainConfused
Worried
Embarassed
ESTATIC
DBT GoalsReduc
eTarget
Behaviors
Dysregulation
TOOLS:Diary Card
Behavior Chain
Increase
Skills
Emotional Stability
TOOLS:DBT Skills Group
4
RADICAL ACCEPTANCE
Grant me the serenity to ACCEPT the things I cannot change,
Courage to CHANGE the things I can, And WISDOM to know the difference.
DBT Program Overview
Weekly
Diary Cards
Target Behaviors
Individual
Therapy
Weekly
Skills Training
Youth & Coach
Skills Group Skills for
CopingAs Needed
Skills CoachBehavior CoachIndividual TherapistSkills Group Leaders
Skills Coachi
ng
Dialectics Finding Balance
Dialectics Involves integrating seemingly opposing views
Similar to Eastern Concepts of Non-Duality Use the word “And” instead of “But”
One Set of Needs or Wants
Opposing Needs or Wants
Acceptance Change
Trust Suspicion
Dependence Independence
Careful, Too Fearful Impulsive, Reckless
Surrender Protect/Fight
Focus on Self Focus on Others
Biosocial Theory
Invalidating Environme
nt
Behavioral Problems
Biological Vulnerabilit
y
I am Stupid.
..
There’s something wrong with me
I don’t deserv
e to live
You’re so
stupid!
I don’t understan
d why you’re so
upset
I wish you were
never born
Confusion about self; impulsivity; emotional instability;
interpersonal problems
Emotional Dysregulation
High Sensitivity Immediate reactions Reactions with only a little
provocation High Reactivity
Extreme reactions High arousal makes
thinking clearly difficult Slow return to baseline
Long-lasting reactions Higher sensitivity to next
emotional event
Difficulties with changing one’s own emotions
Difficulties with paying attention (e.g., in class) when emotions are felt
Difficulty in stopping from acting right away when emotions are felt
Biological Vulnerability to Emotions (Sensitive Wiring) Low Emotional
Modulation
Consequences of invalidating Environment
By not validating feelings, the environment does not teach the individual to:
Label feelings Effectively regulate emotions Trust feelings
By making problem solving seem easier than it is, the environment does not teach the individual to:
Effectively tolerate stress Form realistic goals and expectations
When communication of anger or sadness is punished and/or when only intense anger or sadness are responded to, the environment teaches the individual to:
Vary between having no emotions and having extreme emotions.
Types of Dysregulation
Emotional Interpersonal Self Behavioral Cognitive
DIALECTICAL BEHAVIOR THERAPYProblems(Behaviors to Decrease)
Skills(Behaviors to Increase)
Confusion about your self Mindfulness
Impulsivity Distress Tolerance
Emotional Instability Emotional Regulation
Interpersonal Problems Interpersonal Effectiveness
Parent-Youth Problems Middle Path
Validation
VALIDATION COMMUNICATES TO ANOTHER PERSON THAT HIS/HER FEELINGS, THOUGHTS, AND ACTIONS MAKE SENSE AND ARE UNDERSTANDABLE TO YOU IN A PARTICULAR SITUATION.
VALIDATION ≠ AGREEMENT
WHAT SHOULD WE VALIDATE? FEELINGS, THOUGHTS, AND BEHAVIORS IN:
OURSELVES OTHER PEOPLE
WHY SHOULD WE VALIDATE? IT IMPROVES RELATIONSHIPS VALIDATION CAN SHOW THAT:
WE ARE LISTENING WE UNDERSTAND WE ARE NOT BEING JUDGMENTAL WE CARE ABOUT THE RELATIONSHIP
CONFLICT IS POSSIBLE WITH DECREASED INTENSITY AND ANGER
Levels of Validation
Validation Level Goal of Interaction
One Listen Non-Judgmentally
Two Accurate Reflection
Three Articulate Unspoken Thoughts and Feelings
Four Understanding Historical Background of Behavior
FiveConfirming Thoughts, Behaviors and Feelings Based on Current Circumstances
Six Radical Genuineness & Authenticity
Interaction of Emotions, Thoughts, & Behaviors
Emotions
Thoughts
Action
Physical Sensatio
ns
Event
Matching Skills with Level of Dysregulation
Mindfulness
Interpersonal Effectiveness
Emotional Regulation
Distress Tolerance
EM
OT
ION
AL
DY
SR
EG
UL
AT
ION
Commitment Strategies
Selling it, evaluating pros and cons
Devil’s advocate
Foot-in-the-door technique
Freedom to choose in absence of alternatives
Shaping
Orientation Strategies Therapeutic Alliance
Connect problems to areas of dysregulation and skill development
Define problems as targets
Link long-term goals to targets
Introduce biosocial theory
Introduce tx format/characteristics
Introduce diary cards
Review agreements
Use commitment strategies
Pre-Treatment Goals
Agreement on Goals Commitment to change Initial targets of treatment
Agreement to Recommended Tx.Client agreementsTherapist agreements
Agreement to Therapist-Client Relationship
Treatment Goals
Level 1: Severe Behavioral Dyscontrol
Level 2: Quiet Desperation
Level 3: Problems in Living
Level 4: Incompleteness
Stage 1 Targets
Decrease Life-threatening/high-risk behaviors Therapy-interfering behaviors Quality of life interfering behaviors
Increase behavioral skills Mindfullness, distress tolerance, interpersonal
effectiveness, emotional regulation
Therapy-Interfering Behaviors
Client Non-compliance Non-collaborative Non-attending Behaviors that interfere with other clients Pushing therapists’ limits Reduce therapist’s motivation to treat
Therapy-Interfering BehaviorTherapist
Extreme acceptance or change Extreme flexibility to rigidity Extreme nurturing or withholding Extreme vulnerability or irreverence
Disrespectful Behaviors
Quality of Life Interfering Behaviors Incapacitating DSM Disorder
High risk sexual behavior
Extreme financial difficulties
Criminal behaviors
Severe interpersonal dysfuntion
Unemployment, severe school problems
Physical health, dysfunctional behaviors
Severe housing difficulties
Adol. Secondary Targets
Excessive leniency vs. authoritarian control
Normalizing pathological behaviors vs. pathologizing normative behaviors
Forcing autonomy vs. fostering dependence
Diary Cards
Track and observe behaviors in real time
Structure Session
Spring board to Chain and Solution Analysis
Integration of Skills
Diary Cards
Chain Analysis
vuVULNERABILIES
PROMTING EVENTS
PROBLEM BEHAVIOR
CONSEQUENCES
Solution Analysis
Identify goals, needs, desires
Generate solutions
Evaluate solutions
Choose a solution to implement
Troubleshoot solution
Responding to Problems
Solve the problem
Change emotional reaction to problem
Tolerate/accept the problem
Stay miserable
DBT Consultation Agreements To accept a dialectical philosophy
To consult with patient on how to interact with other therapists
Consistency of therapists is not expected
Observe own limits, without judgment
Consultation Agreements Con’t
Search for non-pejorative, empathic interpretation of client’s behavior
All therapists are fallible
DBT Team Responsibilities
Plan and trouble shoot treatment
Monitoring adherence to DBT
Progress towards DBT competence
Consult to the therapist
Support to therapist and team members