Dialectical Behavior Therapy

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Dialectical Behavior Therapy

• Creating a Life Worth Living
• May 17, 2007
• Christy Hutton, PhD

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What is BPD?

• Nine DSM Criteriathe only diagnosis that
  includes self-harm as a criteria.
• Historically considered as an excess of
  aggression disorder.
• Evolved into a disorder about which treaters
  became hopeless, burned out.
• Now viewed as an affective continuum disorder
  similar to bipolar with strong anxiety components.

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Borderline Personality Disorderis common and
deadly

• 11 of psychiatric outpatients 19 of
  inpatients meet DSM-IV criteria for BPD
• 33 of personality-disordered outpatients meet
  criteria
• 74 of BPD population is female

• 70-75 have a history of at least one
  self-injurious act
• Suicide rates for BPD are 9
• Those with history of parasuicidal behavior have
  double the risk of completed suicide

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Why should we use DBT?

• Dramatically reduces suicide attempts and
  parasuicide behaviors over Treatment as Usual
  (TAU) or Treatment by Experts (TBE).
• Decreases anger and anxiety related impulsive
  behaviors.
• Reduces hopelessness.
• Improves coping skills.

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The DBT approach to treatment

• Based on behavioral theory, cognitive theory, and
  mindfulness practice.
• A stages of treatment model with hierarchies of
  treatment at each stage.

• Problem solving
• Behavioral Analysis
• Insight Strategies/Cognitive Restructuring
• Didactics
• Contingency Management
• Behavioral Rehearsal
• Exposure therapy

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Dialectics

• The process of change whereby an idea or
  event (THESIS) generates and is transformed into
  its opposite (ANTITHESIS) and is preserved and
  fulfilled by it, leading to a reconciliation of
  opposites (SYNTHESIS).

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Dialecticsin English

• Helping clients find true balance in emotion,
  thoughts, and behavior/choices.
• Teaching clients how to live in balance.
• Modeling living in balance
• BothAnd
• Pushing for change.

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Dialectical Strategies
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Emotion Dysregulation

• Emotions out of control
• No steering wheel
• Cant control behavior
• Mood driven behavior

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The client is doing the best she can

• Did you choose to have these moods?

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Biosocial Model
Biological Mood Sensitivity/Dysregulation Innate
sensitivity to stimuli or predisposition to mood
disorder (To a greater or lesser degree)
Learning Environment Ill-equipped to meet the
needs of the individual (physical, emotional,
intellectual) Expressiveness and displays or
needs are not tolerated, dismissed, trivialized
or criticized. Rational responses are highly
valued/ only highly reactive/disruptive requests
and responses are recognized.
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BiologicalEmotional Vulnerability

• High Emotional Sensitivity
• Immediate reaction
• Low threshold for emotional arousal
• High Emotional Reactivity
• Extreme reaction
• Hard to think clearly
• Slow Return to Baseline
• Long-lasting reactions
• Sensitized before next event

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Resources

• Money
• Education
• Patience
• Support
• Access to services
• No mental illness
• Coping Strategies

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Behavioral PatternsDialectical Dilemmas
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A Disorder of Dysregulation

• Emotional Dysregulation rapidly shifting
  feelings and moods. Problems with anger.
• Interpersonal Dysregulation chaotic
  relationships, fear of being left alone or
  abandoned.
• Self Dysregulation fluctuating or absent sense
  of self. Sense of emptiness.
• Cognitive Dysregulation dissociation, paranoid
  thinking, over personalization.
• Behavioral Dysregulation self harm behaviors,
  impulsive behaviors

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THE PROBLEM
AVOIDANCE OR ESCAPE
PROBLEM BEHAVIOR
EMOTION DYSREGULATION
CUE
TEMPORARY RELIEF
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DBT INTERVENES
Teaches how to problem-solve/ control problem cues
AVOIDANCE OR ESCAPE
X
PROBLEM BEHAVIOR Teaches how to stop this
behavior
EMOTION DYSREGULATION Teaches how to tolerate
distress
Teaches how to avoid or distract without
problem behavior
CUE
X
Teaches how to change this association through
behavioral exposure or stimulus control
TEMPORARY RELIEF
Stopping problem behavior stops reinforcement
Teaches how to regulate emotions
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Functions of Comprehensive DBT

• 1. Enhance capabilities
• (self-regulation)
• 2. Improve motivation
• (Cue exposure/response prevention/skillful
  response reinforcement)
• 3. Assure generalization to the natural
  environment
• 4. Structure the environment
• 5. Enhance therapists capabilities and
  motivation to treat effectively

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Levels of Disorder Stages of Treatment

• Level 1 Severe Behavioral Dyscontrol
• Stage 1 Behavioral Control
• Level 2 Quiet Desperation
• Stage 2 Non-Traumatic Emotional
• Experiencing
• Level 3 Problems in Living
• Stage 3 Ordinary Happiness
  Unhappiness
• Level 4 Incompleteness
• Stage 4 Capacity for Joy

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STAGE 1 Targets

• Decrease
• Life-threatening behaviors
• Therapy-interfering behaviors
• Quality-of-life interfering behaviors
• Joblessness homelessness relationship chaos
  Axis I disorders environmental structuring
• Increase Behavioral Skills
• Mindfulness
• Interpersonal Effectiveness
• Emotion Regulation
• Distress Tolerance
• Self-Management

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Goals of Skills Training

• Behaviors to Increase
• Mindfulness Skills
• Interpersonal Skills
• Emotion Regulation Skills
• Distress Tolerance Skills

• Behaviors to Decrease
• Identity Confusion
• Emptiness
• Cognitive Dysregulation
• Interpersonal Chaos
• Fears of Abandonment
• Labile Affect
• Excessive Anger
• Impulsive Behaviors
• Suicide Threats

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Tasks in Core Mindfulness

• Increase sense of self and decrease emptiness
  through learning to observe and describe on-going
  experience
• Increase control over thoughts/emotions by
  learning to suspend judgment and watch thoughts
  pass and emotions ebb and flow.
• Increase spontaneity and personal decision
  making by learning to participate skillfully in
  the moment integrating emotion and reasoning
  ability

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States of Mind
Wise Mind
From Mindfulness Handout I Taking Hold of Your
Mind
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Tasks in Interpersonal Effectiveness

• 1. Learn to say no and make requests
  effectively while maintaining self-respect and
  important relationships
• 2. Learn how to balance over-commitment and
  involvement with undercommitment and isolation.
• 3. Learn how to balance assertiveness and
  joining with others to increase interpersonal
  relationships and self-acceptance.

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Tasks in Emotion Regulation

• Decrease (or increase) physiological arousal
  associated with emotion
• Re-orient attention
• Inhibit mood dependent behavior
• Experience emotions without escalating or
  blunting
• Organize behavior in the service of external,
  non-mood-dependent goals

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Tasks in Distress Tolerance

• 1.Replace maladaptive coping that works in the
  moment with non-destructive in the moment coping
  devices.2. Learn to Accept on-going events and
  discomfort in order to reduce severe misery.

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Stage II Decrease Quiet Desparation/ Increase
Emotional Experiencing

• Orient to exposure treatment
• Exposure to internal and external cues
• Community/Home/In-vivo work
• Completion of Outpatient Skills Group
• Develop trust in client wise-mind

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Stage III Decrease Problems in Living/ Increase
Ordinary Happiness and Unhappiness

• Model, discuss, reinforce normal behaviors,
  life management skills
• Implement long-term goals
• Build stamina
• Decrease individual sessions
• Reduce advice-giving
• Participate in Advanced Group

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Stage IV Decrease Incompleteness/ Increase
Capacity for Joy

• Increase community involvement
• Focus on career, relationships and spirituality
• Terminate treatment

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Christy Hutton, PhD, LLC

• DBT training (1 hour to 5 full days)
• Consulting services for beginning and enhancing
  DBT programs and skills training
• 2710 Forum Boulevard
• Columbia, MO 65203
• Phone [phone] Fax [phone]
• Cell 573-823-0858