1. Fiona Kennedy www.greenwoodmentors.com drkennedy@greenwoodmentors.com copyright Fiona C Kennedy 2012 2. Programme for the day Overview of DBT Commitment Structuring the therapy Validation Skills Training Group Behaviour analysis Dialectical strategies Mindfulness Questions & Evaluations copyright Fiona C Kennedy 2012 3. DBT was Developed by Marsha Linehan For women with Borderline Personality Disorder who also harm themselves Unrelenting crises of BPD meant that ordinary therapy was impractical copyright Fiona C Kennedy 2012 4. DBT vs CBT DBT CBT Dialectical thinking Therapeutic relationship essential working with commitment and therapy interfering behaviours Radical acceptance Wrong thinking Therapeutic relationship needed to do work Collaborative stance with willing client change copyright Fiona C Kennedy 2012 5. Evidence Base DBT has recently been conceptualized as a treatment with utility for intervening with difficult-to-treat & multiply-disordered clients not just BPD (Linehan, Bohus, & Lynch, 2007; Lynch et al., 2006). copyright Fiona C Kennedy 2012 6. Theoretical & Principle Bases of DBT Dialectical Philosophy copyright Fiona C Kennedy 2012 7. DBT in a nutshell commitment Orienting, commitment strategies, testing ability, contract therapy Individual & group sessions, telephone coaching, target behaviours discharge Review, relapse planning, fading, discharge, Stage 2? copyright Fiona C Kennedy 2012 8. Component Parts of DBT Skills Training Group Individual Therapy Support for generalisation of skills telephone coaching Consultation Meeting copyright Fiona C Kennedy 2012 9. Orienting client to treatment Building commitment (strategies) Testing motivation and ability Individual work Session agenda Behaviours to reduce Collaborative behavioural analysis Acceptance Change Skills group Learn new skills Behaviours to increase Mindfulness Interpersonal Emotion regulation Distress tolerance Coaching Give input at time needed Close to target behaviour Use relationship Contact also possible to repair relationship Consult group Support and supervision for therapists Therapist assumptions Recursive values and techniques Role play Review Target behaviours Skills acquired Clients perception Discharge Planned ending Relapse plan Goodbye letter? Post discharge Stage 2 needed? If relapse? Gap between therapies? DBT in a nutshell copyright Fiona C Kennedy 2012 10. Orienting client to treatment Building commitment (strategies) Testing motivation and ability Commitment (pre-therapy) stage 11. Individual therapy Session agenda Behaviours to reduce Collaborative behavioural analysis Acceptance Change Skills group Learn new skills Behaviours to increase Mindfulness Interperson al skills Emotion regulation Distress tolerance Coaching Give input at time needed Close to target behaviour Use relationship Contact also possible to repair relationship Consult group Support and supervision for therapists Therapist assumptions Recursive values and techniques Role play Therapy Stage: 4 aspects 12. Review Target behaviours Skills acquired Clients perception Discharge Planned ending Relapse plan Goodbye letter? Post discharge Stage 2 needed? If relapse? Gap between therapies? Ending DBT therapy 13. acceptance change copyright Fiona C Kennedy 2012 14. Acceptance Validation Mindfulness Collaboration Client can comment on therapist behaviour too! Behaviour Analysis done together copyright Fiona C Kennedy 2012 15. Change INCREASE skills DECREASE problematic & unskilful behaviour copyright Fiona C Kennedy 2012 16. Change Behaviour analysis Problem solving Exposure Planning Skills development copyright Fiona C Kennedy 2012 17. Dialectics=Accept and Change For when youre stuck! copyright Fiona C Kennedy 2012 18. Commitment work For clients with Problems of motivation copyright Fiona C Kennedy 2012 19. Commitment work Orienting client to treatment Building commitment (strategies) Testing motivation and ability copyright Fiona C Kennedy 2012 20. Commitment strategies Pros and Cons Foot in the Door, Door in the Face Door in the Face Foot in the Door Shaping Devils advocate Linking to past commitment Cheerleadingcopyright Fiona C Kennedy 2012 21. Values and Goals Why does your client want therapy? What would she be able to do/how would she be if she was fine? Goals: e.g. I want my children back from Soc Services Values work: e.g. In my relationship I want to be................ copyright Fiona C Kennedy 2012 22. Life-threatening Therapy-interfering Quality-of-life interfering STRUCTURING THE TREATMENT- target behaviours to reduce copyright Fiona C Kennedy 2012 23. Suicidal behaviours e.g. overdosing Self harm behaviours e.g. cutting Harm to others e.g. Punching husband Includes threats and urges 1 Risky/Life-threatening behaviours copyright Fiona C Kennedy 2012 24. Patient behaviours E.g. Therapist behaviours E.g. Therapy-interfering behaviours copyright Fiona C Kennedy 2012 25. Substance abuse High risk sex Criminal stuff Dysfunctional interpersonal Employment Illness-related Housing-related Mental-health related Mental-disorder- related dysfunctional patterns Quality of Life-interfering behaviours copyright Fiona C Kennedy 2012 26. Behaviours to Increase Mindfulness Emotion Regulation Plus any other specific skills needed by client Distress tolerance Interpersonal Skills Self- management copyright Fiona C Kennedy 2012 27. Contract Length of therapy Frequency of meeting Coaching?? Consequences of non attendance Unacceptable behaviours Values and Goals Target behaviours to increase and decrease How will we know when were done? copyright Fiona C Kennedy 2012 28. Structuring a Session Agenda for session Homework review Diary/thought record/observations review Target behaviours to reduce Chain analyse Problem solve Trouble shoot End copyright Fiona C Kennedy 2012 29. Find the nugget of wisdom somewhere in what the client says/does! Observe and believe in clients ability to get out of the misery that is her life and build a life worth living Play to clients strengths, not her fragility Validation (Acceptance) copyright Fiona C Kennedy 2012 30. Clients responses make sense and are understandable in the context in which they occur- within the clients current life situation Search for, recognise, reflect the validity in her response to events Validation copyright Fiona C Kennedy 2012 31. 1. Stay awake , look and listen, Dont judge 2. Reflect back to the person what they have said to you 3. Saying what the person might have felt/thought/wanted to do (articulate) 4. Its Normal and understandable (Past) 5. Its normal and understandable (Present) 6. Radical genuineness Levels of Validation copyright Fiona C Kennedy 2012 32. Define the behaviour to reduce: describe it exactly Chain Analyse target behaviours Generate ideas about what is keeping behaviour going CHANGE BEHAVIOURAL ANALYSIS copyright Fiona C Kennedy 2012 33. CHAIN ANALYSE TARGET BEHAVIOUR Choose specific instance Links: where to start? Filling in the links Where to stop? Analyse in-session behaviours Watch out for therapist and client avoidance!! copyright Fiona C Kennedy 2012 34. copyright Fiona C Kennedy 2012 35. Example chain analysis copyright Fiona C Kennedy 2012 36. Reinforcement Strengthens behaviour Positive (reward) Negative (escape) copyright Fiona C Kennedy 2012 37. Supermarket copyright Fiona C Kennedy 2012 38. Supermarket copyright Fiona C Kennedy 2012 39. Problem solving Once you have decided what the rewards and escape/avoidance are: Think of other things to do: make a plan Commit to plan copyright Fiona C Kennedy 2012 40. Troubleshoot Ask what might go wrong with this plan copyright Fiona C Kennedy 2012 41. Coaching Offer to be on the end of the phone to help put the plan into practice copyright Fiona C Kennedy 2012 42. copyright Fiona C Kennedy 2012 43. Skills Modules Interpersonal Effectiveness Emotion Regulation Distress Tolerance Mindfulness copyright Fiona C Kennedy 2012 44. Skills Group Delivery Interpersonal effectiveness (6 weeks) Mindfulnes s (2 weeks) Distress Tolerance (6 weeks) Mindfulness (2 weeks) Mindfulness (2 weeks) Emotion Regulation (6 weeks) copyright Fiona C Kennedy 2012 45. Mindfulness WHAT Observe Describe Participate HOW Non-judgmental stance Focus on one thing in-the- moment Being effective: do what works copyright Fiona C Kennedy 2012 46. Interpersonal Effectiveness Asking and saying no Coping with conflict Obtaining desired changes while keeping the relationship and ones own self-respect copyright Fiona C Kennedy 2012 47. Emotion Regulation Identify and label affect Obstacles to change Reducing vulnerability to emotional mind Mindfulness to emotion Opposite to emotion action copyright Fiona C Kennedy 2012 48. Distress Tolerance Distracting Self-soothing Improving the moment Radical acceptance (turning the mind, willingness) copyright Fiona C Kennedy 2012 49. Acceptance & change: DIALECTICAL strategies copyright Fiona C Kennedy 2012 50. Acceptance & change: DIALECTICAL strategies Balance acceptance and change; teach client to be dialectical 1 therapeutic relationship: be aware of dialectical tensions 2 in all interactions, teach and model dialectical behaviour patterns copyright Fiona C Kennedy 2012 51. E.g. Using metaphor Stories are easier to remember Metaphors can communicate difficult stuff-e.g. the effect of clients behaviour on others Useful metaphors: Red-hot coals, therapy-as swimming Keep a metaphor book Dialectical strategies copyright Fiona C Kennedy 2012 52. Dialectical Strategies E.g. Making lemonade out of lemons Did you do your homework? Was it hard? Great, now we know you can do hard things. You got the sack? Now we can really practice distress tolerance! copyright Fiona C Kennedy 2012 53. Dialectical Strategies E.g. Entering the paradox: both-and not either-or Yes its true you feel better when you drink Yes its also true drink is bad for you If you get better you will be independent And...If you get better your husband will stop looking after you copyright Fiona C Kennedy 2012 54. Ending DBT Have we got better? Contract Target behaviours Skills Life goals and values Start saying good bye at the beginning copyright Fiona C Kennedy 2012 55. A quick note: DBT Special Interest Group BABCP (British Association of Behavioural and Cognitive Psychotherapists) Please join us if youre a BABCP member copyright Fiona C Kennedy 2012