DBT Training 2014Part 1

Fiona Kennedy for

Skills Development Service

Aims of the week

To enable participants to begin practising DBT with supervision as soon as they get home!

To give enough information to allow practitioners to be effective

To develop enough skills to allow practitioners to be effective

To provide sufficient support after the week to allow further learning and safe practice

How we plan to do this

Using the Kolb/Lewin model of adult learning

act

review

reflect

plan

What is DBT?

A mix of behaviour therapyvalidation andZen practicein context of dialectical thinking about change

How Dialectics views the world

Reality is interrelated and whole (don’t just look at parts look at whole)

Reality isn’t static but made up of internal opposing forces

THESIS ANTITHESIS

SYNTHESIS

Dialectical view of thinking

Both-and NOT either-orBlack and white and extreme thinking = not dialectical

Individual is unable to move to synthesis

Can be translated as ‘value opposites and find the middle way’

Emotional dysregulation

Low threshold

High intensity

Long recovery

BIOAspects affecting

development loosely categorised as

biological: e.g.genetics, epigenetics,

neural structures,hormonal influences,

nutrition

SOCIALAspects affecting

development loosely categorised as social environment: parenting, stimulation, friendships, traumatic events, abuse, neglect

theory

Biology (‘bio’)

Limbic system reactivity?Attentional control?Genetic links?Environment in the womb?Trauma modifying neurology?epigenetics

Social: Invalidating environments

Communication of private experiences is met by erratic, inappropriate and extreme responses

Expression of private emotion is punished/trivialised - Invalidated

Intolerant of expressed emotion ‘Perfect environments/perfect child’ Be happy,

never give in, there’s nothing you can’t do’ Behaviours attributed to manipulation/not

trying/hostility

Biosocial Theory

Component Parts of DBT

Skills Training GroupIndividual TherapySupport for generalisation of skills – telephone coaching

Consultation Meeting

Orienting client to treatment Building

commitment(strategies)

Testing motivation and ability

Individual therapySession agendaBehaviours to reduceCollaborative behavioural analysisAcceptanceChange

Skills groupLearn new skillsBehaviours to increaseMindfulnessInterpersonalEmotion regulationDistress tolerance

CoachingGive input at time neededClose to target behaviourUse relationshipContact also possible to repair relationship

Consult groupSupport and supervision for therapistsTherapist assumptionsRecursive values and techniquesRole play

ReviewTarget behavioursSkills acquiredClients perception

DischargePlanned endingRelapse planGoodbye letter?

Post dischargeStage 2 needed?If relapse?Gap between therapies?

DBT in a nutshell

Orienting client to treatment

Building commitment(strategies)

Testing motivation and ability

Commitment (pre-therapy) stage

Individual therapySession agendaBehaviours to reduceCollaborative behavioural analysisAcceptanceChange

Skills groupLearn new skillsBehaviours to increaseMindfulnessInterpersonalEmotion regulationDistress tolerance

CoachingGive input at time neededClose to target behaviourUse relationshipContact also possible to repair relationship

Consult groupSupport and supervision for therapistsTherapist assumptionsRecursive values and techniquesRole play

Therapy Stage: 4 aspects

Review

Target behavioursSkills acquiredClients perception

Discharge

Planned endingRelapse planGoodbye letter?

Post dischargeStage 2 needed?If relapse?Gap between therapies?

Ending DBT therapy

Twin Tasks of DBT

INCREASE skills

DECREASE problematic &

unskilful behaviour

Individual therapy

◦ Target behaviours list◦ Create a context of validation rather

than blaming◦ Block or extinguish maladaptive

behaviours◦ Drag out effective behaviours◦ Make the effective behaviours so

reinforcing that the client stops using the maladaptive ones!

Further work

(Linehan)Stage 2: PTSDStage 3: achieve self-validation and self-respect

problem-solving

validation

client therapist

Validation (acceptance)

1. Find the nugget of wisdom somewhere in what the client says/does!

2. Observe and believe in client’s ability to get out of the misery that is her life and build a life worth living

Play to client’s strengths, not her fragility

Problem solving (change)

Analyse target behaviours (chain analysis)Solution analysesOrient client to solutionGet commitment to engageDo it!

irreverent reciprocal

Interpersonal styles

Consultation to the client

Strong bias towards client being her own case manager

Therapist coaches client how to solve problems herself

Inappropriate behaviour of professionals regarded as learning opportunity

Consultation to the environment

Interventions by DBT therapists to change the environment, solve problems, co-ordinate professional treatment are used when

1. It is important2. Client clearly is not capable of producing

the outcome

Treating the therapist

SupervisionCase consultationConsult groupStay in DBT frameTreatment of the therapist is integral to

the therapy

Telephone consultation

Inhibition of asking for helpAsking for help abusively, demandinglyPhone provides practice in changing these

patternsGeneralisation of skillsRepair of relationship

DBT assumptions

Clients are doing the best they can

Clients want to improve

Clients need to do better, try harder

Clients may not have caused all their problems but have to solve them anyway

DBT assumptions

Suicidal clients’ lives are unbearable as currently lived

Clients must learn new behaviours in all relevant contexts

Clients cannot fail in therapy

DBT therapist assumptions

Therapists treating clients with BPD need support

Therapists should show:

Warm empathyPersistent focusEndless hopeDialectical viewNon-judgmental stance

Practice DBT on themselves and each other

Skills Training in DBT

To learn and refine skills in changing behavioural, emotional and thinking patterns associated with problems in

living that are causing misery and distress.

Core Mindfulness

WHATObserveDescribeParticipate

HOWNon-judgmental

stanceFocus on one

thing in-the-moment

Being effective: do what works

DISTRESS TOLERANCE

DistractingSelf-soothingImproving the momentRadical acceptance (turning the mind, willingness)

EMOTION REGULATION

Identify and label affectObstacles to changeReducing vulnerability to emotional mind

Mindfulness to emotionOpposite action

INTERPERSONAL EFFECTIVENESS

Asking and saying noCoping with conflictObtaining desired changes while keeping the relationship and one’s own self-respect

Increasing behavioural skills-SELF-MANAGEMENT

NOT A MODULEKnowing principles of behaviour changeRealistic goal-settingBehavioural analysis skillsContingency management skillsEnvironmental controlRelapse preventionTolerating limited progress

Consult Groups

Read and sign therapist consultation agreements

Set any other rules you feel necessary for working as a team

Discuss how you will manage lateness/non-attendance

Read and discuss case study-how would you usually approach this case?