Putting dbt into your practice for notes revision 2 02 06 2013

Fiona Kennedy
www.greenwoodmentors.com
drkennedy@greenwoodmentors.com
copyright Fiona C Kennedy 2012

Programme for the day
Overview of DBT
Commitment
Structuring the therapy
Validation
Skills Training Group
Behaviour analysis
Dialectical strategies
Mindfulness
Questions & Evaluations

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

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

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).

Theoretical & Principle
Bases of DBT
Dialectical
Philosophy

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?

Component Parts of DBT
Skills Training Group
Individual Therapy
Support for generalisation of
skills – telephone coaching
Consultation Meeting

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

Orienting
client to
treatment
Building
commitment
(strategies)
Testing
motivation
and ability
Commitment (pre-therapy) stage

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

Review
Target
behaviours
Skills
acquired
Client’s
perception
Discharge
Planned
ending
Relapse
plan
Goodbye
letter?
Post
discharge
Stage 2
needed?
If relapse?
Gap
between
therapies?
Ending DBT therapy

acceptance change

Acceptance
Validation
Mindfulness
Collaboration
Client can comment on therapist
behaviour too!
Behaviour Analysis done together

Change
INCREASE
skills
DECREASE
problematic &
unskilful
behaviour

Change
Behaviour analysis
Problem solving
Exposure
Planning
Skills development

Dialectics=Accept
and Change
For when
you’re stuck!

Commitment
work
For clients with
Problems
of motivation

Commitment work
Orienting client to treatment
Building commitment
(strategies)
Testing motivation and ability

Commitment strategies
Pros and Cons
Foot in the Door, Door in the
Face
Door in the Face Foot in the Door
Shaping
Devil’s advocate
Linking to past commitment
Cheerleadingcopyright Fiona C Kennedy 2012

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................’

Life-threatening
Therapy-interfering
Quality-of-life interfering
STRUCTURING THE
TREATMENT-
target behaviours to reduce

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

Patient
behaviours
E.g.
Therapist
behaviours
E.g.
Therapy-interfering
behaviours

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

Behaviours to Increase
Mindfulness
Emotion
Regulation
Plus any other
specific skills
needed by client
Distress
tolerance
Interpersonal
Skills
Self-
management

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 we’re done?

Structuring a Session
Agenda for session
Homework review
Diary/thought record/observations review
Target behaviours to reduce
Chain analyse
Problem solve
Trouble shoot
End

Find the nugget of wisdom
somewhere in what the client
says/does!
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
Validation (Acceptance)

Client’s responses make sense
and are understandable in the
context in which they occur-
within the client’s current life
situation
Search for, recognise, reflect the
validity in her response to events
Validation

1. Stay awake , look and listen, Don’t
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. It’s Normal and understandable (Past)
5. It’s normal and understandable (Present)
6. Radical genuineness
Levels of Validation

Define the behaviour to reduce:
describe it exactly
‘Chain Analyse’ target
behaviours
Generate ideas about what is
keeping behaviour going
CHANGE
BEHAVIOURAL ANALYSIS

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!!

Example chain analysis

Reinforcement Strengthens
behaviour
Positive (reward)
Negative (escape)

Supermarket

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

Troubleshoot
Ask what might go wrong
with this plan

Coaching
Offer to be on the end of the
phone to help put the plan
into practice

Skills Modules
Interpersonal Effectiveness
Emotion Regulation
Distress Tolerance
Mindfulness

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)

Mindfulness
WHAT
Observe
Describe
Participate
HOW
Non-judgmental
stance
Focus on one
thing in-the-
moment
Being effective:
do what works

Interpersonal Effectiveness
Asking and saying no
Coping with conflict
Obtaining desired changes while
keeping the relationship and
one’s own self-respect

Emotion Regulation
Identify and label affect
Obstacles to change
Reducing vulnerability to
emotional mind
Mindfulness to emotion
Opposite to emotion action

Distress Tolerance
Distracting
Self-soothing
Improving the moment
Radical acceptance (turning
the mind, willingness)

Acceptance & change:
DIALECTICAL strategies

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

E.g. Using metaphor
Stories are easier to remember
Metaphors can communicate difficult
stuff-e.g. the effect of client’s
behaviour on others
Useful metaphors: Red-hot coals,
therapy-as –swimming
Keep a metaphor book
Dialectical strategies

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!

Dialectical Strategies
E.g. Entering the paradox: both-and not
either-or
Yes it’s true you feel better when you drink
Yes it’s 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

Ending DBT
Have we got better?
Contract
Target behaviours
Skills
Life goals and values
Start saying good bye at the beginning

A quick note:
DBT Special Interest Group
BABCP (British Association of Behavioural and
Cognitive Psychotherapists)
Please join us if you’re a BABCP member

Putting dbt into your practice for notes revision 2 02 06 2013

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (16)

Similar to Putting dbt into your practice for notes revision 2 02 06 2013

Similar to Putting dbt into your practice for notes revision 2 02 06 2013 (20)

More from GreenWood Mentors Ltd

More from GreenWood Mentors Ltd (20)

Putting dbt into your practice for notes revision 2 02 06 2013