Dialectical Behavior Therapy Part 4, Las Vegas 2020 Alan E. - PDF document

DBT Part 4, NPA Las Vegas July 2020 Comprehensive Training in Dialectical Behavior Therapy Part 4, Las Vegas 2020 Alan E. Fruzzetti, Ph.D. 1 Adherence Pyramid Adherence Mindful/Team Dialectics Acceptance & Validation Change and Behavior Therapy Assessment of Targets Theory, Program & Therapy Structure, & Case Conceptualization 2 Revisit Dialectics in DBT (c) Alan E. Fruzzetti 2020 1

DBT Part 4, NPA Las Vegas July 2020 Balance Communication • Reciprocal communication • Irreverent communication • Dialectically balanced: speed, movement in the service of behavioral self- management and reduced suffering • Dialectics: strong reciprocal and strong irreverent communication 4 Balance Consultation Strategy With Intervening in the Environment Consultation with the Patient: • Teach the patient to be effective on his/her own behalf with – Social network – Professional network Environmental Intervention: • Intervene on her/his behalf when the short-term gain is greater than the short-term loss + long-term loss 5 Environmental Intervention Necessary when: • The patient cannot do what is needed on her/his own behalf (or the environment will not accept it from the patient) and the outcome is very important • The life of the patient or another is at stake • The patient is a minor (legal/ethical) • It is humane to do so and unlikely to cause harm to the patient 6 (c) Alan E. Fruzzetti 2020 2

DBT Part 4, NPA Las Vegas July 2020 Dialectical Opportunities • Integrate/synthesize acceptance & change • Use metaphors and stories • Balance acceptance & change as solutions (targets and matched skills) • Dialectical targets (both/and, polarizations) • Wise mind • Communication strategies • Consultation-to-the patient/ environmental intervention • Consultation team (structure & process) 7 Dialectical opportunities, continued • Lemonade out of lemons • Dialectical assessment: What am I (or, are we) missing? • Allow natural change • Notice or enter the paradox • Play devil’s advocate • Omnipotence and impotence • Dialectics of behavior therapy (ABCs?) • Movement, speed and flow (jazz, dance) 8 Dialectics is participation (mindfulness) for the therapist. “As in the training of the samurai, the student needs a number of years to achieve expertise and many more to achieve spontaneity.” - Salvador Minuchin, famous DBT supervisor (c) Alan E. Fruzzetti 2020 3

DBT Part 4, NPA Las Vegas July 2020 Basic DBT Family Interventions How People Transact in Healthy Relationships: Two-Steps 2.Validating 1.Accurate Responses Expression 11 Transactional Model of Emotion Dysregulation Individual Emotion Invalidating Vulnerability & Responses Emotion Dysregulation 12 (c) Alan E. Fruzzetti 2020 4

DBT Part 4, NPA Las Vegas July 2020 Judgments High emotional arousal & dysregulation Inaccurate self-expression Misunderstanding Judgments, reactivity Invalidating responses Parent Responses to Adolescent Children (~BPD) 5 Parents of Clinic 4.5 Children 4 Parents of Non- 3.5 Clinic Children 3 2.5 2 1.5 1 Validation* Invalidation* Shenk & Fruzzetti, 2014 *p<.05 14 Judgements and anger get in the way, and are corrosive in relationships even when justified. And, anger always hides other, often more important emotions, in close relationships. http://www.mindfuls c hools .org/graduate -s tories /jus t-breathe-ju lie-bay er-s alz man/ (c) Alan E. Fruzzetti 2020 5

DBT Part 4, NPA Las Vegas July 2020 Steps Toward a Accurate Expression Identify Manage Emotion, Relationship Accurate Emotions Want, Mindfulness Experession Goals, etc. What is my Describe: Your Mindfulness: Mindfulness: relationship with primary emotions, Observe emotion Bring attention to Non-judgmental your sensations, this person? what you want, your Remember I care goals, sensations, Be effective, not right what happened De-escalate emotions (event), identify about him/her and opinions, how you Let go: judgments primary emotion that she/he cares want to try to solve about me. Is this a a problem ets. Anger as a signal What do you Accept/allow want? What do good time for Stay descriptive. communication? Change: Problem you care about? Is the other solve, opposite action, exposure person open? 16 Steps Toward a Validating Response Relationship Mindfulness Mindfulness Validatin g Understand (manage (bring Response emotions)) attention to another) Manage attention Validate the valid Mindfulness: Relationship Observe emotion Mindfulness: Be curious Don’t invalidate Describe Bring mindfulness Be kind valid things Manage own Don’t validate Participate to the other, your Non-judgmental relationship emotions to invalid things Be effective, not right Remember this is understand the Invalidate the De-escalate a person you love, other person: invalid only emotions what kind of What would get a occasionally… person to do this? Let go: judgments relationship you Anger as a signal want What would get me to do this? 17 Open your mind before you open your mouth. (c) Alan E. Fruzzetti 2020 6

DBT Part 4, NPA Las Vegas July 2020 Interventions • Family Psychoeducation – Understanding emotion dysregulation – Transactional model → reciprocity – No judgments, no blame • Individual DBT Skills (self-management) • Family DBT Skills – Emotion Regulation + Mindfulness → Accurate Expression – Emotion Regulation + Relationship Mindfulness → Validation 19 Overall Intervention Program: 1. Establish safety 2. Assess/orient/commit to treatment 3. Build skills (ongoing) 4. Identify and reduce invalidation 5. Rebuild relationships 6. Accurate expression 7. Increase validation 8. Problem management 9. Transform conflict into closeness via acceptance & engagement 20 Treatment Modes are Flexible Parent, couple, family groups (with or without the identified patient) or Family therapy (c) Alan E. Fruzzetti 2020 7

DBT Part 4, NPA Las Vegas July 2020 Session Management Strategies • Revolving door • Relationship mindfulness • Speaking “for” (expressing accurately, or validating) the partner • Involve others • Blocking, blocking, blocking… 22 More therapeutic issues • Finding a way to like the client(s) – Allows early blocking, while still liking him/her – Allows playfulness, irreverence • Be able to “see” the chain leading to the present, or problem, behavior • Understand dysfunctional behavior IN the model…don’t be judgmental or reactive • Make the partner or parent look good; don’t undermine or show him or her up – Speaking for the partner or parent can help – Validating the family member, his/her wise mind 23 Validation Increases Positive Affect and Decreases Negative Affect 24 (c) Alan E. Fruzzetti 2020 8

DBT Part 4, NPA Las Vegas July 2020 Mindfulness, description Lowered emotional arousal Accurate expression Relationship mindfulness Understanding, low reactivity Validating responses Validating & Invalidating Responses Validating Invalidating 1. Pay attention; relationship 1. Not paying attention; mindfulness closed 2. Acknowledge & describe; 2. Judgmental, minimizing; reflect disregarding reality 3. Ask questions; mind reading 3. Closed mind 4. Benefit of the doubt/ valid 4. Assume the worst; due to learning or biology criticize vulnerabilities 5. Normalize (“of course”) the 5. Invalidate the normative normatively valid 6. Respectful, not 6. Condescending, condescending disrespectful 7. Match vulnerability 7. Exploit vulnerabilities 26 Behavioral Chain Analysis: Dysregulated Behavior Vulnerabilities to getting dysregulated “Links” – thoughts, emotional reactions, problematic actions 27 (c) Alan E. Fruzzetti 2020 9

DBT Part 4, NPA Las Vegas July 2020 Behavioral Chain Analysis Vulnerabilities to getting dysregulated Possibly Relevant Parent or Partner Behaviors 28 Double Chain Individual’s history, Hurt feelings, especially with child or further partner dysregulated Thoughts & emotion & Verbal/public emotions behavior behaviors Judgments & secondary emotions Situation/ Event Thoughts & emotions Negative Outcome – Individual’s history, Attacking or especially with parent or Withdrawing partner 29 Staying Inside the DBT Model Individual Adherence/Certification Program Adherence/Certification 30 (c) Alan E. Fruzzetti 2020 10

DBT Part 4, NPA Las Vegas July 2020 Consultation: Consider 1. Is the therapist adhering? Target misses… 2. Is the therapist’s target for consultation clear? Is the problem definition clear? 3. How is the therapist’s motivation? 4. What is getting in the way (of adherence, of motivation, etc.)? a. Lack of skills b. Emotion c. Judgments/cognition d. Contingencies 31 http://www.borderlinepersonalitydisorder.c om/Conferences/Yale2011/Yale11- demonstrations.shtml (see adherence write-up) ADHERENCE SCALE (Linehan) Structural Strategies Problem Assessment Problem Solving Contingency Management Exposure & Response Prevention Cognitive Modification Validation Reciprocal Communication Irreverent Communication Dialectical Case Management Crisis and other protocols (c) Alan E. Fruzzetti 2020 11