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Linehan, et al., 2001Linehan, et al., 2001Linehan, et al., 2001Linehan, et al., 2001
Dialectical Behavior Therapy:Dialectical Behavior Therapy:Clinical Outcomes Clinical Outcomes and Essential Characteristics and Essential Characteristics
Marsha M. LinehanMarsha M. LinehanUniversity of WashingtonUniversity of Washington
Dialectical Behavior Therapy:Dialectical Behavior Therapy:Clinical Outcomes Clinical Outcomes and Essential Characteristics and Essential Characteristics
Marsha M. LinehanMarsha M. LinehanUniversity of WashingtonUniversity of Washington
DBT is a DBT is a cognitive-behavioral therapycognitive-behavioral therapydesigned for the designed for the severe and severe and
chronic multi-diagnosticchronic multi-diagnostic, difficult-, difficult-to-treat patientto-treat patient
with both Axis I with both Axis I and Axis IIand Axis II disorders disorders
DBT is a DBT is a cognitive-behavioral therapycognitive-behavioral therapydesigned for the designed for the severe and severe and
chronic multi-diagnosticchronic multi-diagnostic, difficult-, difficult-to-treat patientto-treat patient
with both Axis I with both Axis I and Axis IIand Axis II disorders disorders
Borderline Personality DisorderDisorder (Re-organized)
Borderline Personality DisorderDisorder (Re-organized)
Emotion Dysregulation Affective lability & Problems with angerInterpersonal Dysregulation Chaotic relationships & Fears of abandonmentSelf Dysregulation Identity disturbance/confused sense of self Sense of emptinessBehavioral Dysregulation Parasuicidal behavior & Impulsive behaviorCognitive Dysregulation Dissociative responses &/or paranoid ideation
Emotion Dysregulation Affective lability & Problems with angerInterpersonal Dysregulation Chaotic relationships & Fears of abandonmentSelf Dysregulation Identity disturbance/confused sense of self Sense of emptinessBehavioral Dysregulation Parasuicidal behavior & Impulsive behaviorCognitive Dysregulation Dissociative responses &/or paranoid ideation
Randomized Clinical Trials (Randomized Clinical Trials (6 with BPD)6 with BPD)Randomized Clinical Trials (Randomized Clinical Trials (6 with BPD)6 with BPD)
DBT Superior to Comparison TreatmentsDBT Superior to Comparison Treatments
Reducing:Reducing:• Suicide attemptsSuicide attempts and self-injury and self-injury• Premature Premature drop-outdrop-out• InpatientInpatient/ER admissions and days/ER admissions and days• Drug abuseDrug abuse• Depression, hopelessnessDepression, hopelessness, anger, anger• ImpulsivenessImpulsiveness
Increasing:Increasing:• Global adjustmentGlobal adjustment• Social adjustmentSocial adjustment
(See Lieb, K., Zanarini, M., Linehan, M.M. (See Lieb, K., Zanarini, M., Linehan, M.M. and Bohus, M. Seminar Section: and Bohus, M. Seminar Section: Borderline Personality Disorder. The Borderline Personality Disorder. The Lancet 2004;364:453-61.) Lancet 2004;364:453-61.)
DBT grew out of DBT grew out of an iterative attempt (1971- ) an iterative attempt (1971- )
to apply behavioral principles andto apply behavioral principles andstandard cognitive behavior therapy standard cognitive behavior therapy
to to highly suicidal patients with highly suicidal patients with
Borderline Personality DisorderBorderline Personality Disorder
DBT grew out of DBT grew out of an iterative attempt (1971- ) an iterative attempt (1971- )
to apply behavioral principles andto apply behavioral principles andstandard cognitive behavior therapy standard cognitive behavior therapy
to to highly suicidal patients with highly suicidal patients with
Borderline Personality DisorderBorderline Personality Disorder
Workshop goalsWorkshop goalsWorkshop goalsWorkshop goals
• Learn the essential characteristics Learn the essential characteristics of DBTof DBT
• Assess whether DBT (in whole or Assess whether DBT (in whole or in part) may be useful in your in part) may be useful in your practicepractice
• Decide if you are interested in Decide if you are interested in further training in DBTfurther training in DBT
• Learn the essential characteristics Learn the essential characteristics of DBTof DBT
• Assess whether DBT (in whole or Assess whether DBT (in whole or in part) may be useful in your in part) may be useful in your practicepractice
• Decide if you are interested in Decide if you are interested in further training in DBTfurther training in DBT
Problem 1
Impaired Cognitive ProcessingImpaired Cognitive Processing ++
Intense Effort to ControlIntense Effort to Control
FOCUS ON CHANGEFOCUS ON CHANGE
!!AROUSAL!!!!AROUSAL!!SENSE OF SENSE OF
OUT-OF-CONTROLOUT-OF-CONTROL
The ClientThe ClientThe ClientThe Client
Shut Down, Withdrew, QuitShut Down, Withdrew, Quitoror
Shut Down, Withdrew, QuitShut Down, Withdrew, Quitoror
INVALIDATIONINVALIDATION
OF OF SUFFERINGSUFFERING
The ProblemFurther
FOCUS ON FOCUS ON ACCEPTANCEACCEPTANCE !!AROUSAL!!!!AROUSAL!!
SENSE OFSENSE OF OUT-OF-CONTROLOUT-OF-CONTROL
Solution Was to Apply Solution Was to Apply A Dialectical Approach A Dialectical Approach
BalancingBalancing
Solution Was to Apply Solution Was to Apply A Dialectical Approach A Dialectical Approach
BalancingBalancing
AcceptanceAcceptanceStrategiesStrategies
ChangeChangeStrategies Strategies
Problem 2:Problem 2:Problem 2:Problem 2:
ProblemBehavior 1Problem
Behavior 1ProblemBehavior
2
ProblemBehavior
2ProblemBehavior
i
ProblemBehavior
i
Percent Axis I Diagnoses: BPD Chronically Suicidal PatientsBPD Chronically Suicidal Patients Diagnosis Lifetime Current
Major depression 96.7% 75.0%Dysthymic disorder N/A 14.3%Substance abuse 15.2% 5.4%Substance dependence 56.5% 26.1%PTSD 56.5% 51.1%Social phobia 21.7% 16.3%Panic disorder 52.2% 40.2%OCD 23.9% 19.8%Eating disorder 41.3% 23.9%
Linehan et al., 2004 APA presentationLinehan et al., 2004 APA presentation
Problem 2:Problem 2:Problem 2:Problem 2:
ProblemBehavior 1Problem
Behavior 1ProblemBehavior
2
ProblemBehavior
2ProblemBehavior
i
ProblemBehavior
i
LOW Distress LOW Distress ToleranceTolerance
ProblemBehavior 2Problem
Behavior 2
Problem
Behavior 2
Problem
Behavior 2
Problem Behaviors
4,5….
Correlation between a measure of distress Correlation between a measure of distress tolerance (PASAT) and BPD (BSL)tolerance (PASAT) and BPD (BSL)
Correlation between a measure of distress Correlation between a measure of distress tolerance (PASAT) and BPD (BSL)tolerance (PASAT) and BPD (BSL)
0
60
120
180
240
300
360
420
0 0.5 1 1.5 2 2.5 3
BSL Total Score
PA
SA
T D
ura
tio
n (
se
co
nd
s)
< ½ SD below BPD patient mean
Lejuez, Daughters, Wolf, Kosson, & Lynch.(under review).
Female Inner City Residential Treatment
Seeking Drug Users
Solution Was to Teach Solution Was to Teach Two Sets of New Behaviors Two Sets of New Behaviors
Solution Was to Teach Solution Was to Teach Two Sets of New Behaviors Two Sets of New Behaviors
AcceptanceAcceptanceSkillsSkills
ChangeChangeSkills Skills
Solution Was to Apply Solution Was to Apply A Dialectical Approach A Dialectical Approach
BalancingBalancing
Solution Was to Apply Solution Was to Apply A Dialectical Approach A Dialectical Approach
BalancingBalancing
Acceptance Acceptance ValidationValidation
Change Change Problem SolvingProblem Solving
DialecticsDialectics
Definition of Dialectics:Definition of Dialectics:Definition of Dialectics:Definition of Dialectics:
1““worldview…worldview…
2““debate…establishing truths on both debate…establishing truths on both sides rather than disproving one sides rather than disproving one argument”argument”
Encarta World, English Dictionary, North American EditionEncarta World, English Dictionary, North American Edition
1““worldview…worldview…
2““debate…establishing truths on both debate…establishing truths on both sides rather than disproving one sides rather than disproving one argument”argument”
Encarta World, English Dictionary, North American EditionEncarta World, English Dictionary, North American Edition
Dialectical World ViewDialectical World View Dialectical World ViewDialectical World View
–Holistic, connected, and in relationshipHolistic, connected, and in relationship
–Complex, oppositional, and in polarityComplex, oppositional, and in polarity
–Change is continualChange is continual
–Change is transactionalChange is transactional
–Identity is relational and in continuous Identity is relational and in continuous changechange
–Holistic, connected, and in relationshipHolistic, connected, and in relationship
–Complex, oppositional, and in polarityComplex, oppositional, and in polarity
–Change is continualChange is continual
–Change is transactionalChange is transactional
–Identity is relational and in continuous Identity is relational and in continuous changechange
BPD is a Systemic Emotion BPD is a Systemic Emotion Regulation Disorder Regulation Disorder
BPD is a Systemic Emotion BPD is a Systemic Emotion Regulation Disorder Regulation Disorder
BPD criterion behaviors function to BPD criterion behaviors function to regulate emotions orregulate emotions or
are a natural consequence of are a natural consequence of emotion dysregulationemotion dysregulation
BPD criterion behaviors function to BPD criterion behaviors function to regulate emotions orregulate emotions or
are a natural consequence of are a natural consequence of emotion dysregulationemotion dysregulation
Emotion DysregulationEmotion DysregulationEmotion DysregulationEmotion Dysregulation
Emotional VulnerabilityEmotional Vulnerability
Inability to Modulate EmotionsInability to Modulate Emotions
Emotional VulnerabilityEmotional Vulnerability
Inability to Modulate EmotionsInability to Modulate Emotions
BPD results from BPD results from transactiontransaction of of biological vulnerability with invalidation biological vulnerability with invalidation
over timeover time
BPD results from BPD results from transactiontransaction of of biological vulnerability with invalidation biological vulnerability with invalidation
over timeover time
A1A1 B1B1
A2A2 B2B2
AAii
A1A1 B1B1
A2A2 B2B2
AAii BPDBPD
Invalidating EnvironmentInvalidating EnvironmentInvalidating EnvironmentInvalidating Environment
Invalidates (punishes, ignores) Invalidates (punishes, ignores)
behavior independent of the behavior independent of the
actual validity of the behavioractual validity of the behavior
Invalidates (punishes, ignores) Invalidates (punishes, ignores)
behavior independent of the behavior independent of the
actual validity of the behavioractual validity of the behavior
Characteristics ofCharacteristics ofan Invalidating Environmentan Invalidating Environment
Characteristics ofCharacteristics ofan Invalidating Environmentan Invalidating Environment
1.1. INDISCRIMINATELY REJECTS INDISCRIMINATELY REJECTS communication of private experiences and communication of private experiences and self-generated behaviors self-generated behaviors
2.2. PUNISHES PUNISHES emotional displaysemotional displays andand INTERMITTENTLY REINFORCES INTERMITTENTLY REINFORCES emotional emotional escalationescalation
3.3. OVER-SIMPLIFIES OVER-SIMPLIFIES ease of problem solving ease of problem solving and meeting goalsand meeting goals
1.1. INDISCRIMINATELY REJECTS INDISCRIMINATELY REJECTS communication of private experiences and communication of private experiences and self-generated behaviors self-generated behaviors
2.2. PUNISHES PUNISHES emotional displaysemotional displays andand INTERMITTENTLY REINFORCES INTERMITTENTLY REINFORCES emotional emotional escalationescalation
3.3. OVER-SIMPLIFIES OVER-SIMPLIFIES ease of problem solving ease of problem solving and meeting goalsand meeting goals
STANDARD DBT isSTANDARD DBT is....STANDARD DBT isSTANDARD DBT is....
FLEXIBLEFLEXIBLE
COMPREHENSIVECOMPREHENSIVE
PRINCIPLE-DRIVENPRINCIPLE-DRIVEN
FLEXIBLEFLEXIBLE
COMPREHENSIVECOMPREHENSIVE
PRINCIPLE-DRIVENPRINCIPLE-DRIVEN
Standard DBT ModesStandard DBT ModesStandard DBT ModesStandard DBT Modes
• Outpatient Individual PsychotherapyOutpatient Individual Psychotherapy
• Outpatient Group Skills TrainingOutpatient Group Skills Training
• Telephone ConsultationTelephone Consultation
• Therapists’ Consultation MeetingTherapists’ Consultation Meeting
• Uncontrolled Ancillary TreatmentsUncontrolled Ancillary Treatments
– PharmacotherapyPharmacotherapy
– Acute-InpatientAcute-Inpatient PsychiatricPsychiatric
• Outpatient Individual PsychotherapyOutpatient Individual Psychotherapy
• Outpatient Group Skills TrainingOutpatient Group Skills Training
• Telephone ConsultationTelephone Consultation
• Therapists’ Consultation MeetingTherapists’ Consultation Meeting
• Uncontrolled Ancillary TreatmentsUncontrolled Ancillary Treatments
– PharmacotherapyPharmacotherapy
– Acute-InpatientAcute-Inpatient PsychiatricPsychiatric
5 Functions of All5 Functions of AllComprehensive TreatmentsComprehensive Treatments
5 Functions of All5 Functions of AllComprehensive TreatmentsComprehensive Treatments
1.1. Enhance capabilities Enhance capabilities
2.2. Improve motivationalImprove motivationalfactorsfactors
3.3. Assure generalization to natural Assure generalization to natural environmentenvironment
4.4. Structure the environment Structure the environment
5.5. Enhance therapist capabilities and Enhance therapist capabilities and motivation to treat effectively motivation to treat effectively
1.1. Enhance capabilities Enhance capabilities
2.2. Improve motivationalImprove motivationalfactorsfactors
3.3. Assure generalization to natural Assure generalization to natural environmentenvironment
4.4. Structure the environment Structure the environment
5.5. Enhance therapist capabilities and Enhance therapist capabilities and motivation to treat effectively motivation to treat effectively
Stages of TreatmentStages of TreatmentStages of TreatmentStages of Treatment
Pre-Treatment:Pre-Treatment:
Stage 1: Severe Behavioral DyscontrolStage 1: Severe Behavioral Dyscontrol Behavioral ControlBehavioral Control
Stage 2: Quiet DesperationStage 2: Quiet Desperation Emotional ExperiencingEmotional Experiencing
Stage 3: Problems in LivingStage 3: Problems in Living
Ordinary Happiness /UnhappinessOrdinary Happiness /Unhappiness
Stage 4: IncompletenessStage 4: Incompleteness Capacity for Joy and FreedomCapacity for Joy and Freedom
Pre-Treatment:Pre-Treatment:
Stage 1: Severe Behavioral DyscontrolStage 1: Severe Behavioral Dyscontrol Behavioral ControlBehavioral Control
Stage 2: Quiet DesperationStage 2: Quiet Desperation Emotional ExperiencingEmotional Experiencing
Stage 3: Problems in LivingStage 3: Problems in Living
Ordinary Happiness /UnhappinessOrdinary Happiness /Unhappiness
Stage 4: IncompletenessStage 4: Incompleteness Capacity for Joy and FreedomCapacity for Joy and Freedom
Commitment and Commitment and AgreementAgreement
Commitment and Commitment and AgreementAgreement
• DecreaseDecrease–Life-threatening behaviorsLife-threatening behaviors–Therapy-interfering behaviorsTherapy-interfering behaviors–Quality-of-life interfering behaviorsQuality-of-life interfering behaviors
• IncreaseIncrease behavioral skillsbehavioral skills
MindfulnessMindfulness Distress ToleranceDistress Tolerance Interpersonal EffectivenessInterpersonal Effectiveness EmotionEmotion RegulationRegulation
• DecreaseDecrease–Life-threatening behaviorsLife-threatening behaviors–Therapy-interfering behaviorsTherapy-interfering behaviors–Quality-of-life interfering behaviorsQuality-of-life interfering behaviors
• IncreaseIncrease behavioral skillsbehavioral skills
MindfulnessMindfulness Distress ToleranceDistress Tolerance Interpersonal EffectivenessInterpersonal Effectiveness EmotionEmotion RegulationRegulation
Stage 1 Primary TargetsStage 1 Primary TargetsDialectical SynthesisDialectical Synthesis
Stage 1 Primary TargetsStage 1 Primary TargetsDialectical SynthesisDialectical Synthesis
Pre-Treatment:Pre-Treatment: Commitment & Commitment & AgreementAgreement
Commitment & Commitment & AgreementAgreement
Dialectical SynthesisDialectical Synthesis- the “middle path” -- the “middle path” -
Dialectical SynthesisDialectical Synthesis- the “middle path” -- the “middle path” -
Dialectical AnalysesDialectical Analyses
Truth is sought through efforts to discover what Truth is sought through efforts to discover what is left out of current ways of ordering eventsis left out of current ways of ordering events
Dialectical Lifestyle:Dialectical Lifestyle:Balanced Behavior PatternsBalanced Behavior Patterns
Balanced actionsBalanced actions
Balanced emotionsBalanced emotions Balanced cognitionBalanced cognition
Dialectical AnalysesDialectical Analyses
Truth is sought through efforts to discover what Truth is sought through efforts to discover what is left out of current ways of ordering eventsis left out of current ways of ordering events
Dialectical Lifestyle:Dialectical Lifestyle:Balanced Behavior PatternsBalanced Behavior Patterns
Balanced actionsBalanced actions
Balanced emotionsBalanced emotions Balanced cognitionBalanced cognition
DBT Targets for Skills TrainingDBT Targets for Skills TrainingDBT Targets for Skills TrainingDBT Targets for Skills Training
• Decrease behaviors likely to destroy Decrease behaviors likely to destroy therapytherapy
• IncreaseIncrease skill acquisition/ skill acquisition/ strengthen skillsstrengthen skills
• Decrease treatment interfering Decrease treatment interfering behaviorsbehaviors
• Decrease behaviors likely to destroy Decrease behaviors likely to destroy therapytherapy
• IncreaseIncrease skill acquisition/ skill acquisition/ strengthen skillsstrengthen skills
• Decrease treatment interfering Decrease treatment interfering behaviorsbehaviors
DBT Targets for Phone CallsDBT Targets for Phone CallsDBT Targets for Phone CallsDBT Targets for Phone Calls
• For the Individual TherapistFor the Individual Therapist–DECREASE DECREASE suicide crises behaviorssuicide crises behaviors
– INCREASE INCREASE generalization of DBT generalization of DBT behavioral skillsbehavioral skills
–DECREASE DECREASE sense of conflict, sense of conflict, alienation, distance with therapistalienation, distance with therapist
• For the Individual TherapistFor the Individual Therapist–DECREASE DECREASE suicide crises behaviorssuicide crises behaviors
– INCREASE INCREASE generalization of DBT generalization of DBT behavioral skillsbehavioral skills
–DECREASE DECREASE sense of conflict, sense of conflict, alienation, distance with therapistalienation, distance with therapist
DBT Therapists OBSERVE DBT Therapists OBSERVE Their Own LimitsTheir Own Limits
DBT Therapists OBSERVE DBT Therapists OBSERVE Their Own LimitsTheir Own Limits
Basic Behavioral ParadigmBasic Behavioral ParadigmBasic Behavioral ParadigmBasic Behavioral Paradigm
CueCue
Problem BehaviorProblem Behavior
Consequences
Consequences
Basic DBT ParadigmBasic DBT ParadigmBasic DBT ParadigmBasic DBT Paradigm
CueCue
Emotion Dysregulation
Emotion Dysregulation
Problem BehaviorProblem Behavior
Consequences
Consequences
DBT Problem SolvingDBT Problem SolvingDBT Problem SolvingDBT Problem SolvingBehavioral AnalysisBehavioral Analysis
InsightInsightSolution AnalysisSolution Analysis
DidacticDidacticOrientingOrienting
CommitmentCommitment
Behavioral AnalysisBehavioral AnalysisInsightInsight
Solution AnalysisSolution Analysis
DidacticDidacticOrientingOrienting
CommitmentCommitment
SKILLS TRAININGSKILLS TRAINING
CONTINGENCIESCONTINGENCIES
EXPOSUREEXPOSURE
COGNITIVE MODIFICATIONCOGNITIVE MODIFICATION
SS
TT
AA
NN
DD
AA
RR
DD
CC
BB
TT
11stst Figure out the problem: Figure out the problem:
Conduct a Conduct a Behavioral AnalysisBehavioral Analysis
11stst Figure out the problem: Figure out the problem:
Conduct a Conduct a Behavioral AnalysisBehavioral Analysis
Analyze the chain of events Analyze the chain of events moment-to-moment overtimemoment-to-moment overtimeAnalyze the chain of events Analyze the chain of events moment-to-moment overtimemoment-to-moment overtime
PROMPTINGEVENT
VULNERABILITY PROBLEMBEHAVIOR
CONSEQUENCES
LINKS
22ndnd
Figure out what to do:Figure out what to do:
Generate solutions and Generate solutions and new behaviorsnew behaviors
22ndnd
Figure out what to do:Figure out what to do:
Generate solutions and Generate solutions and new behaviorsnew behaviors
Possible SolutionsPossible SolutionsPossible SolutionsPossible Solutions
1.1. Solve the problemSolve the problem
2.2. Change emotional reaction to the problemChange emotional reaction to the problem
3.3. Radically Accept and Tolerate the Radically Accept and Tolerate the problemproblem
4.4. Stay miserableStay miserable
1.1. Solve the problemSolve the problem
2.2. Change emotional reaction to the problemChange emotional reaction to the problem
3.3. Radically Accept and Tolerate the Radically Accept and Tolerate the problemproblem
4.4. Stay miserableStay miserable
33rdrd Address factors getting in the Address factors getting in the
way of new behaviors:way of new behaviors:
33rdrd Address factors getting in the Address factors getting in the
way of new behaviors:way of new behaviors:
1.1. Apply ContingenciesApply Contingencies
2.2. Teach New Skills Teach New Skills
3.3. Break Maladaptive AssociationsBreak Maladaptive Associations
4.4. Modify Cognitions Modify Cognitions
Consequence Consequence
-Add Reinforcer-Add Reinforcer
-Remove Aversive -Remove Aversive
-Withhold Reinforcer-Withhold Reinforcer
-Maintain Aversive-Maintain Aversive
-Add Aversive-Add Aversive-Remove Positive-Remove Positive
Consequence Consequence
-Add Reinforcer-Add Reinforcer
-Remove Aversive -Remove Aversive
-Withhold Reinforcer-Withhold Reinforcer
-Maintain Aversive-Maintain Aversive
-Add Aversive-Add Aversive-Remove Positive-Remove Positive
Goal Goal
StrengthenStrengthenBehaviorBehavior
WeakenWeakenBehaviorBehavior
SuppressSuppressBehaviorBehavior
Goal Goal
StrengthenStrengthenBehaviorBehavior
WeakenWeakenBehaviorBehavior
SuppressSuppressBehaviorBehavior
Contingency ManagementContingency Management
Contingency Management Contingency Management Changes the Hierarchy of BehaviorChanges the Hierarchy of Behavior
Contingency Management Contingency Management Changes the Hierarchy of BehaviorChanges the Hierarchy of Behavior
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
00.10.20.30.40.50.60.70.80.9
1 highhigh
lowlow
STRENGTH OF BEHAVIORSTRENGTH OF BEHAVIORSTRENGTH OF BEHAVIORSTRENGTH OF BEHAVIOR
Adaptive BehaviorAdaptive Behavior
Maladaptive Behavior
REINFORCE
Punish/Punish/ExtinguishExtinguishPunish/Punish/ExtinguishExtinguish
SKILLS TRAININGSKILLS TRAINING
Mindfulness Mindfulness
Distress Tolerance Interpersonal Distress Tolerance Interpersonal Effectiveness Effectiveness
Emotion RegulationEmotion Regulation
SKILLS TRAININGSKILLS TRAINING
Mindfulness Mindfulness
Distress Tolerance Interpersonal Distress Tolerance Interpersonal Effectiveness Effectiveness
Emotion RegulationEmotion Regulation
44thth
Give needed information:Give needed information:
Do PsychoeducationDo Psychoeducation(DBT Didactic Strategies)(DBT Didactic Strategies)
44thth
Give needed information:Give needed information:
Do PsychoeducationDo Psychoeducation(DBT Didactic Strategies)(DBT Didactic Strategies)
55thth
Explain the rationale: Explain the rationale: Orienting to TreatmentOrienting to Treatment
55thth
Explain the rationale: Explain the rationale: Orienting to TreatmentOrienting to Treatment
• Describe the general taskDescribe the general task
• Link to C’s goals (rationale)Link to C’s goals (rationale)
• Link to specific expectations and Link to specific expectations and
behaviorsbehaviors
• Rehearse new expectationsRehearse new expectations
• Describe the general taskDescribe the general task
• Link to C’s goals (rationale)Link to C’s goals (rationale)
• Link to specific expectations and Link to specific expectations and
behaviorsbehaviors
• Rehearse new expectationsRehearse new expectations
66thth
Get a commitment: Get a commitment:
Strengthen it, get it again, strengthen it, Strengthen it, get it again, strengthen it,
get it again….get it again….
66thth
Get a commitment: Get a commitment:
Strengthen it, get it again, strengthen it, Strengthen it, get it again, strengthen it,
get it again….get it again….
Core StrategyCore StrategyCore StrategyCore Strategy
Validation DefinedValidation Defined"The action of validating or making valid…a
strengthening, reinforcement, confirming; an establishing or ratifying" as valid
SynonymsTo Confirm
To Authenticate
To Corroborate
To Substantiate
To Verify
"The action of validating or making valid…a strengthening, reinforcement, confirming;
an establishing or ratifying" as valid
SynonymsTo Confirm
To Authenticate
To Corroborate
To Substantiate
To Verify
Levels of ValidationLevels of ValidationLevels of ValidationLevels of Validation
1.1. Staying Awake: UnbiasedStaying Awake: Unbiasedlistening and observinglistening and observing
2.2. Accurate reflectionAccurate reflection
3.3. Articulating the unverbalized emotions, Articulating the unverbalized emotions, thoughts, or behavior patternsthoughts, or behavior patterns
4.4. Validation in terms of pastValidation in terms of pastlearning or biological dysfunctionlearning or biological dysfunction
5.5. Validation in terms of present context or Validation in terms of present context or normative functioningnormative functioning
6.6. Radical GenuinenessRadical Genuineness
1.1. Staying Awake: UnbiasedStaying Awake: Unbiasedlistening and observinglistening and observing
2.2. Accurate reflectionAccurate reflection
3.3. Articulating the unverbalized emotions, Articulating the unverbalized emotions, thoughts, or behavior patternsthoughts, or behavior patterns
4.4. Validation in terms of pastValidation in terms of pastlearning or biological dysfunctionlearning or biological dysfunction
5.5. Validation in terms of present context or Validation in terms of present context or normative functioningnormative functioning
6.6. Radical GenuinenessRadical Genuineness
Core StrategyCore StrategyCore StrategyCore Strategy
Acceptance Acceptance
ValidationValidation
Dialectics: Step by StepDialectics: Step by StepDialectics: Step by StepDialectics: Step by Step
Step 1:Step 1: Adopt and model a dialectical Adopt and model a dialectical world view world view
Step 2:Step 2: Balance treatment strategies and Balance treatment strategies and therapeutic positions. therapeutic positions.
Step 3:Step 3: When polarization occurs, work When polarization occurs, work for a synthesis. for a synthesis.
Step 4:Step 4: When one dialectical strategy When one dialectical strategy doesn’t work, try anotherdoesn’t work, try another
Step 1:Step 1: Adopt and model a dialectical Adopt and model a dialectical world view world view
Step 2:Step 2: Balance treatment strategies and Balance treatment strategies and therapeutic positions. therapeutic positions.
Step 3:Step 3: When polarization occurs, work When polarization occurs, work for a synthesis. for a synthesis.
Step 4:Step 4: When one dialectical strategy When one dialectical strategy doesn’t work, try anotherdoesn’t work, try another
1. Model a 1. Model a Dialectical World ViewDialectical World View1. Model a 1. Model a Dialectical World ViewDialectical World View
• Teach biosocial theory of etiology.Teach biosocial theory of etiology.– Development and maintenance of Development and maintenance of
disorder is transactional.disorder is transactional.– Disorder is systemic.Disorder is systemic.
• Search for “what is left out.”Search for “what is left out.”– Disorder occurs when focus is on Disorder occurs when focus is on
part without reference to wholepart without reference to whole..
• Allow natural change.Allow natural change.
• Teach biosocial theory of etiology.Teach biosocial theory of etiology.– Development and maintenance of Development and maintenance of
disorder is transactional.disorder is transactional.– Disorder is systemic.Disorder is systemic.
• Search for “what is left out.”Search for “what is left out.”– Disorder occurs when focus is on Disorder occurs when focus is on
part without reference to wholepart without reference to whole..
• Allow natural change.Allow natural change.
Change AcceptanceChange Acceptance
CoreCore
Problem Solving
Problem Solving
IrreverenceIrreverence
ValidationValidation
Team Consultation
Team Consultation
ReciprocityReciprocity
Environmental Intervention
Environmental Intervention
Consultation-to-the-PatientConsultation-to-the-Patient
2. Balance Treatment Strategies2. Balance Treatment Strategies2. Balance Treatment Strategies2. Balance Treatment Strategies
3. When Polarization Occurs3. When Polarization Occurs3. When Polarization Occurs3. When Polarization Occurs
Search for The SynthesisSearch for The SynthesisSearch for The SynthesisSearch for The Synthesis
Invoke “WISE MIND”Invoke “WISE MIND”
4. When one dialectical strategy 4. When one dialectical strategy doesn’t work, try anotherdoesn’t work, try another
4. When one dialectical strategy 4. When one dialectical strategy doesn’t work, try anotherdoesn’t work, try another
• Magnify the tension between oppositesMagnify the tension between opposites–Devil’s AdvocateDevil’s Advocate
–ExtendingExtending
• Enter the paradoxEnter the paradox–And versus ButAnd versus But
–Making Lemonade out of lemonsMaking Lemonade out of lemons
• Develop MetaphorsDevelop Metaphors–StoriesStories
–AnalogiesAnalogies
• Magnify the tension between oppositesMagnify the tension between opposites–Devil’s AdvocateDevil’s Advocate
–ExtendingExtending
• Enter the paradoxEnter the paradox–And versus ButAnd versus But
–Making Lemonade out of lemonsMaking Lemonade out of lemons
• Develop MetaphorsDevelop Metaphors–StoriesStories
–AnalogiesAnalogies
50.20
In DBT, The Therapist Acting from In DBT, The Therapist Acting from Wise Mind...Wise Mind...In DBT, The Therapist Acting from In DBT, The Therapist Acting from Wise Mind...Wise Mind...
practicespractices• Observing (Observing (Just NoticesJust Notices))
– Describing (Describing (Puts Words OnPuts Words On))
– Participating (Participating (Acts Intuitively from Wise MindActs Intuitively from Wise Mind))
and isand is
– Non-Judgmental (Non-Judgmental (Neither Good nor BadNeither Good nor Bad))– One-Mindful (One-Mindful (In-the-MomentIn-the-Moment))– Effective (Effective (Focus on What WorksFocus on What Works))
practicespractices• Observing (Observing (Just NoticesJust Notices))
– Describing (Describing (Puts Words OnPuts Words On))
– Participating (Participating (Acts Intuitively from Wise MindActs Intuitively from Wise Mind))
and isand is
– Non-Judgmental (Non-Judgmental (Neither Good nor BadNeither Good nor Bad))– One-Mindful (One-Mindful (In-the-MomentIn-the-Moment))– Effective (Effective (Focus on What WorksFocus on What Works))
You canYou can
do do
this!this!
You canYou can
do do
this!this!