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DBT with Debbie Barrett & Robin Sansing 10/3/2019 UNC-CH

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DBT with Debbie Barrett & Robin Sansing 10/3/2019 UNC-CH DBT with Debbie Barrett & Robin Sansing 10/3/2019 UNC SCHOOL OF SOCIAL WORK CLINICAL INSTITUTE SERIES Day 1 Agenda Dialectical Behavioral 9:00 Welcome & Housekeeping Therapy (DBT) 9:10 I. DBT: Introduction 10:15 Break DAY 1 10:30 II. Nuts and bolts: How DBT works Deborah Barrett, PhD, LCSW 12:00 LUNCH & 1:00 III. DBT in action 2:30 Break Robin Sansing, MSW, LCSW 2:45 IV. Strategies during therapy October 3 & 4, 2019 4:30 END University of North Carolina at Chapel Hill Dialectical Behavioral Therapy Developed by Marsha Linehan Began as intervention for I. Introduction chronically suicidal women To history, theory, and practice Combines behavioral principals with Buddhist practice of “mindfulness” (1993) History Formative history Late 1970s, Marsha Linehan attempted to apply DBT created in response to problems Linehan noted: cognitive behavioral therapy (CBT) to adult women with chronic suicidal attempts and para- Reinforcement – little incentive to broach difficult topics suicidal behaviors. EXAMPLE: therapists back off when clients express anger or mention self-harm; clients respond with warmth to topic change Dilemma: How can therapist teach adaptive behaviors when client is in continuous crisis? Invalidating nature of “change” therapies UNC-CH School of Social Work Clinical Institute 1 DBT with Debbie Barrett & Robin Sansing 10/3/2019 Balance Core Strategies DBT Approach 1. CBT 2. plus: Acceptance strategies (validation & Change Acceptance mindfulness) Problem Solving 3. plus: Dialectical worldview and strategies Validation - both/and (not all or nothing) - opposites can both be true and be synthesized; change is inevitable and constant; everything is connected Dialectics Originally created for people with BPD BPD (according to DSM-5) Frantic efforts to avoid abandonment; pattern of unstable Borderline Personality relations (vacillating between idealization and devaluation) Disorder Identity disturbance, unstable self-image or sense of self (BPD) Impulsivity in self-damaging ways (sex, spending, eating, substance use, reckless driving) Recurrent suicidal behavior, gesture, threats or self-injuring What comes to mind? behavior Affect instability; chronic feelings of emptiness; inappropriate anger or difficulty controlling anger Transient, stress-related paranoid ideation, delusions or dissociation Biosocial theory BPD (according to Biosocial Theory) 1. Genetic vulnerability: (a) predisposition of high emotional sensitivity, (b) high reactivity, (c) slow return to baseline o BPD is a pervasive disorder of emotional regulation system reactivity slower return o Develops as a result of a genetic to baseline vulnerability in transaction with an Emotionreaction invalidating environment sensitivity UNC-CH School of Social Work Clinical Institute 2 DBT with Debbie Barrett & Robin Sansing 10/3/2019 Biosocial theory Biosocial theory 1. Genetic vulnerability + 2. Pervasively invalidating environment Invalidating environment Phobia of valid, natural responses to experience Symptoms of dysregulation Self-invalidation / rejection of self Emotional overwhelm Biological predisposition Maladaptive behaviors (all/nothing) Emotional dysregulation Borderline personality All BPD criteria are: disorder (BPD) Kiera Van Gelder Natural consequences of emotion author of dysregulation The Buddha and the Borderline OR https://vimeo.com/13606126 Behaviors that regulate emotions Notice strength-based framework Trauma and diagnosis Borderline Personality Disorder diagnosis, reorganized by DBT problem/skill area Behavioral Dysregulation Cognitive Dysregulation - Self-harm or suicidal behaviors - Slowed, confused, or paranoid - Impulsivity thinking Borderline Emotional Dysregulation Chronic ? personality - Rapidly shifting feelings PTSD and moods disorder - Problems with anger Interpersonal Dysregulation Self Dysregulation - Chaotic relationships - Fluctuating or absent sense of - Fear of being left alone or self abandoned - Feelings of emptiness UNC-CH School of Social Work Clinical Institute 3 DBT with Debbie Barrett & Robin Sansing 10/3/2019 DBT: Evidence basis for Substance use disorders DBT has become a Eating disorders Study population? trans-diagnostic approach Bi-polar depression Suicidal adolescents Depressed elderly DBT- Family skills training Forensic population DBT-Prolonged Exposure (PE) Protocol Developed by Melanie Harned, PhD Targets emotion dysregulation in Concomitant and/or integrated DBT + prolonged exposure general rather than disorders specifically Outcome: - Reduction in dissociation, trauma-related guilt, shame, anxiety, depression, and increase in global social adjustment measures. (Harned et al., 2012; Meyers et al., 2017) Overall goal: Goals of DBT Helping clients create a II. Nuts & Bolts “Life Worth Living” How DBT Works UNC-CH School of Social Work Clinical Institute 4 DBT with Debbie Barrett & Robin Sansing 10/3/2019 DBT Framework DBT Stages & Targets Acceptance •Includes four stages of treatment and a & comprehensive framework Change Skills •Sessions are guided by structured yet flexible target hierarchy, which varies based on → Middle Path stage of treatment 26 Stages of Treatment Personal DBT Primary Treatment Targets Stage IV. choices Completeness about Behaviors to Decrease Stage III. Work on therapy PTSD & problems of “ordinary” type or 1. Decrease suicide and NSSI (non- trauma work happiness and amount unhappiness suicidal self injury) - thoughts, urges, Stage II. From emotionally shut down actions to experiencing fully DBT Skills (behaviors are under control, suffering Group, continues) 2. Therapy interfering behaviors Individual therapy Stage I: From Out-of-Control to In-Control 3. Quality of life interfering behaviors and Decrease behaviors that threaten life, therapy, and coaching life quality. Teach DBT skills. Hierarchy followed in each session 28 1. DBT: Individual therapy • Begins with review of diary card 1. Individual therapy • Daily rating of target behaviors, urges, How is DBT 2. Coaching calls emotions Practiced? • Review card *In session if necessary* 3. Skills group • Set session agenda based on target hierarchy *Solicit client input* 4. Consult team • Behavioral shaping through “chain analysis” of “targets,” structuring of session, & therapeutic strategies UNC-CH School of Social Work Clinical Institute 5 DBT with Debbie Barrett & Robin Sansing 10/3/2019 Example Diary Card Example Diary Card (cont.) Dialectal Behavior Therapy Diary Initials ID# Filled out in session? Y How often did you fill out this side? Date Started Dialectical Behavioral Therapy Card N _____ Daily _____ 2-3x ______ Once Instructions: Circle the days you worked Filled out in session? How often did you fill out this side? __Daily Day & TARGETS EMOTIONS BEHAVIORS DIARY CARD on each skill Y / N __2-3x __Once Date Use SI S-H Anger Shame Fear Sad Illicit ETOH Prescrip S-H Lying Joy Skills R 1. Wise mind Mon Tues Wed Thurs Fri Sat Sun 2. Observe (Urge Surfing) Mon Tues Wed Thurs Fri Sat Sun 0-5 0-5 0-5 0-5 0-5 0-5 0-5 # Specify # Specify # Specify Y/N # 0-5 0-7 3. Describe: put words on, non-judgmentally Mon Tues Wed Thurs Fri Sat Sun Mon 4. Participate: enter into the experience Mon Tues Wed Thurs Fri Sat Sun 5. Non-judgmental stance ListMon Tuesof SkillsWed Thurs Fri Sat Sun Tues 6. One-mindfully: in-the-moment Mon Tues Wed Thurs Fri Sat Sun Wed Skill use and 7. Effectiveness: focus on what works Mon Tues Wed Thurs Fri Sat Sun 8. Objective effectiveness: DEAR MAN Mon Tues Wed Thurs Fri Sat Sun Thur Targets Emotions Behaviors reinforcement 9. Relationship effectiveness: GIVE Mon Tues Wed Thurs Fri Sat Sun Fri 10. Self-respect effectiveness: FAST Mon Tues Wed Thurs Fri Sat Sun 11. Reduce vulnerability: PLEASE Mon Tues Wed Thurs Fri Sat Sun Sat 12. Accum. positives, Build mastery, Cope ahead Mon Tues Wed Thurs Fri Sat Sun Sun 13. Opposite Action Mon Tues Wed Thurs Fri Sat Sun 14. Mindfulness of Emotion Mon Tues Wed Thurs Fri Sat Sun *USED SKILLS 3 = Tried but couldn’t use them Mon Tues Wed Thurs Fri Sat Sun 0 = Not thought about or used 4 = Tried, could do them but they didn’t help 15. Loving the Emotion 1 = Thought about, not used, didn’t want to 5 = Tried, could use them, helped 16. TIP Skills Mon Tues WedDaysThurs ofFri weekSat toSun 2 = Thought about, not used, wanted to 6 = Didn’t try, used them, didn’t help 17. Problem Solving Mon Tues Wed Thurs Fri Sat Sun 7 = Didn’t try, used them, helped Mon Tues Wed Thurs Fri Sat Sun Before After Belief in control of . Before After 18. Distract: “Wise Mind ACCEPTS” 19. Self-Soothe using Five Senses Mon Tues Wed Thurs circleFri Sat Sun Urge to use (0-5): Emotions: 20. IMPROVE the Moment Mon Tues Wed Thurs Fri Sat Sun Urge to quit therapy (0-5): Behaviors: BRTC Diary Card Mon Tues Wed Thurs Fri Sat Sun Copyright 1999 Marsha M. Linehan, Ph.D. 21. Observe the Breath 22. Pros and Cons Mon Tues Wed Thurs Fri Sat Sun Urge to harm (0-5): Thoughts: 23. Radical Acceptance and Willingness Mon Tues Wed Thurs Fri Sat Sun 2. DBT: Phone consultation 3. DBT: Skills training group • Therapist is “coach” on the use of skills • More like “class” than “group therapy” • Can only call before acting out (24 hr rule) • Meets weekly for 2 hours • Focus on skills: “what have you tried • Format already?” • Mindfulness practice • Client must be willing to accept help • “Business” • Call should be brief: 5 or 10 minutes • Review homework • Teach and practice new skill * Some therapists will use text rather than calls • Closing awareness Remember, you set the guidelines. DBT: Skill Modules 2 full cycles = ~ 1 year, but varies 1. Core Mindfulness 2. Interpersonal IE ER DT DBT: Skills group 4 Modules effectiveness 3. Emotion Regulation 4. Distress Tolerance Core-Mindfulness 35 UNC-CH School of Social Work Clinical Institute 6 DBT with Debbie Barrett & Robin Sansing 10/3/2019 4. DBT: Therapist Consultation Team • Focus on therapist behavior not client’s • Addresses therapy interfering behaviors of therapist • Provides support to therapist to decrease burn-out and enhance motivation • Often begins with mindfulness exercise DBT – Assumptions about clients DBT – Assumptions about therapy 1. Clients are doing the best they can. 1. The most caring thing a therapist can do is help 2.
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