1/31/2015 1 DBT & Adaption of DBT in Treatment for S uicidal - PDF document

1/31/2015 1 DBT & Adaption of DBT in Treatment for S uicidal Adolescents Amy Marzulla LMSW Carol Hartford LMS W ACS W Ann Arbor DBT Center Materials Authored by: Marsha Linehan, Jill Rathus, and Alec Miller 2 Goals for Presentation  Define DBT  Features of BPD  Biosocial Theory  Mindfulness  Introduction to Standard Skills Modules  Adaptation to S uicidal Teens  Walking the Middle Path  Chain Analysis 3 What is Dialectical Behavior Therapy?  Multi-disciplinary, cognitive behavioral treatment designed specifically for individuals with suicidal and intentional self harm behaviors.  DBT emphasizes basic behavioral principles and Eastern Meditative practices. 1

1/31/2015 4 DBT Outcomes  Reduces: S uicidal behaviors, intentional self inj ury, depression, hopelessness, anger, eating disorders, substance dependency and impulsiveness  Increases: Adj ustment (general and social), positive self esteem. 5 The Overarching DBT Goal is… “ Having a life worth living” 6 Borderline Personality Disorder  BPD is a pervasive disorder of the Emotion Modulation S ystem  BPD criterion behaviors function to regulation emotions  The behaviors are a natural consequence of emotion dysregulation 2

1/31/2015 BPD Characteristics 7  Emotion Dysregulation: Affectively labile & Problems with anger.  Interpersonal Dysregulation: Chaotic relations and Fears of abandonment.  S elf Dysregulation: Identity disturbance/ confused sense of S elf, sense of emptiness.  Behavioral Dysregulation: Intentional self harm behavior, impulsive behavior.  Cognitive Dysregulation: Dissociative responses, and/ or paranoid ideation. 8 The Bio S ocial Theory of Borderline Personality Disorder  Transactional interaction between the Individual and the Environment  What is the Biological Component?  What is the Environmental Component? 9 Biosocial Theory of BPD Biological Dysfunction in the Emotion Regulation S ystem Invalidating Environment P ervasive Emotion Dysregulation 3

1/31/2015 10 BPD and Biological Dysfunction  High S ensitivity: High level of emotional arousal, Low threshold for emotional reaction  High Reactivity: Extreme reactions  Impairs cognitive processing  S low return to baseline: Long lasting reactions  Adds sensitivity to next situation 11 Tasks of Emotion Modulation S ystem  Decreases or increases physiological arousal associated with emotion  Re-orients attention  Inhibits mood dependent behavior  Organizes behavior in the service of external non-mood dependent goals 12 Invalidating Environment Pervasively negates or dismisses behavior independent of the actual validity of the behavior 4

1/31/2015 13 Characteristic of an Invalidating Environment  Indiscriminately rej ects communication of private experience and self generated behaviors.  Punishes emotional displays and intermittently reinforces emotional escalation.  Over-simplifies the ease of problem solving and meeting goals. 14 Invalidating Environment Teaches the Person to:  Actively self invalidate and search environment for cues on how to respond.  Oscillate between emotional inhibition and extreme emotional styles.  Form unrealistic goals and expectations. 15 Assumptions about BPD Patients and Therapy  Patients are doing the best they can.  Patients want to improve.  Patients need to do better, try harder and be more motivated to change.  Patients may not have caused their problems but they have to solve them.  The lives of suicidal individuals , with BPD are unbearable.  Patients cannot fail in DBT .  DBT patients need to learn new behaviors in all relevant contexts.  Therapist Treating BPD patients need support. 5

1/31/2015 16 S tandard DBT Modes  Individual Psychotherapy  Group S kills Training  Telephone Consultation  Team Consultation Meeting 17 S tages of DBT  Pretreatment Orientation and agreements on goals  First S tage targets: S uicidal behavior, therapy interfering behavior, quality of life interfering behavior, increasing behavioral skills  S econd S tage targets: Decreasing posttraumatic stress  Third S tage target: increase self respect, goal achievement 18 Pre-treatment S tage in DBT Reduces early t erminat ion  Orientation to therapy  Managing clients expectations about therapy  24 hour rule, 4 miss rule  Homework  Assessment  Discuss clients commitment to therapy  Arrive at an agreement to work together on helping the client make changes 6

1/31/2015 19 First S tage: Primary Targets Severe Behavior Dyscontrol Behavior Control •Decrease •Life-threatening behaviors (suicidal and parasuicidal) •Therapy-interfering behaviors •Quality-of-life interfering behaviors •Increase behavior skills Core Mindfulness Emotion Regulation Distress Tolerance Self Management Interpersonal Effectiveness 20 Validation  We teach it  We practice it  Validation in the therapy experience is intended to resolve the dialectic of the invalidating environment  Validation is calming and helps the client to regulate their emotion 21 Levels of Validation  Level 1: Be Fully Present, Actively Listen  Level 2: Reflective Listening  Level 3: Express the Unspoken Emotions, Thoughts or Behavior Patterns  Level 4: Validation in Terms of Previous Behavior or Learning  Level 5: Validation in Terms of Present S ituation and Normal Behavior  Level 6: Radical Genuineness 7

1/31/2015 22 Mindfulness Learning to be in Control of your Own mind, instead Of letting your MIND be in control Of you. 23 Mindfulness S tates of Mind Reasonable Emotional Wise Mind Mind Mind 24 Mindfulness Taking Hold of Y our Mind: “ What S kills”  OBS ERVE  Just notice the experience with out getting caught  Having a “ TEFLON MIND” letting go of… ..  Control your attention but not what you see  Be like a guard at the palace gate: Alert  DES CRIBE  Put words on your experience  P ARTICIP ATE  Enter FULLY into & BECOME ONE WITH YOUR EXPERIENCE  Act INTUITIVELY from WIS E MIND  Activity PRACTICE skills as you learn them  Keep an eye on your obj ectives in the situation 8

1/31/2015 25 Mindfulness Taking Hold of Y our Mind: “ How S kills”  NON JUDGMENTALL Y  S ee but DON’ T EVALUATE  UNGLUE your opinions from the facts  Acknowledge the wholesome & the harmful, but don’ t j udge it  DON’ T JUDGE YOU JUDGING  ONE MINDFULL Y  Do ONE THING AT A TIME  LET GO OF DIS TRACTIONS return to what you were doing again & again  CONCENTRATE YOUR MIND  EFFECTIVEL Y  FOCUS ON WHAT WORKS  PLA Y BY THE RULES  Keep your eye on YOUR OBJECTIVES  Act as S KILLFULLY as you can 26 27 Distress Tolerance  Crisis S urvival S trategies  Guidelines for Accepting Reality 9

1/31/2015 28 Distress Tolerance Crisis S urvival S trategies  Distract (Wise Mind ACCEPTS )  S elf-S oothe  IMPROVE the Moment  Pros and Cons 29 Distress Tolerance IMPROVE t he Moment Imagery Meaning Prayer Relaxation One Thing at a time Vacation Encouragement 30 Distress Tolerance Principles of Accept ing Realit y  Radical Acceptance  Turning the Mind  Willingness versus Willfulness 10

1/31/2015 31 32 Emotion Regulation Goals of Emot ion Regulat ion Module  Understand emotions  Reduce emotional vulnerability  Decrease emotional suffering  Change by acting opposite to painful emotions  Apply Mindfulness Observe & Describe S kills to Emotions  Understand Function of Emotions 33 Emotion Regulation Reducing Vulnerabilit y To Negat ive Emot ions “PLEASE”  Treat Physical Illness  Balance Eating  Avoid mood-Altering Drugs  Balance S leep  Get Exercise  Build Mastery 11

1/31/2015 34 Emotion Regulation S t eps for Increasing Posit ive Emot ions  S hort Term  Increase pleasant events that prompt positive emotions  DO ONE THING each day from adult pleasant events list  Long Term  Work toward goals: ACCUMULATE POS ITIVES  Make list of positive events you want  List small steps towards your goal  Take first step  Attend to relationships  Repair old: reach out to new, work on current relationships  Avoid Avoiding 35 Emotion Regulation Be MINDFUL of Posit ive Experience  Focus attention on positive events that happen  Refocus when mind wanders to the negative Be UNMINDFUL of Worries  Distract from  Thinking when positive experience will end  Thinking about whether you deserve it or not  Thinking about how much more might be expected of you 36 Emotion Regulation Change by Acting Opposite t o Painful Emot ions  When afraid: approach  When ashamed: continue behavior openly  When depressed: get active  When angry: gently avoid/ be kind 12

1/31/2015 37 38 Goals for Interpersonal Effectiveness Obj ectives Effectiveness (DEAR MAN) Getting your obj ectives or goals in a sit uat ion Relat ionship Effect iveness (GIVE) Get t ing/ Keeping a good relat ionship S elf-Respect Effectiveness (F AS T) Keeping/ Improving self-respect while achieving your obj ect ive 39 Factors Interfering with Interpersonal Effectiveness  Lack of S kill  Worry Thoughts  Emotions  Indecision  Environment 13