WALKING THE MIDDLE PATH: ART THERAPY AND DBT PROMOTING RECOVERY 50th Anniversary American Art Therapy Association Conference Kansas City, MO November 3rd, 2019 Jane DeSouza, MPS, ATR-BC, LCAT, Program Director Personalized Recovery Oriented Services Saint Vincent’s Hospital Westchester, NY OBJECTIVES

1. Describe how a structured art therapy directive can reduce impulsivity/anxiety and increase behavioral change.

2. Describe a mindfulness directive that promotes integration of DBT skills.

3. Describe how to use DBT-informed art therapy directives in own practice. DIALECTICAL BEHAVIOR THERAPY Behavioral, problem-solving focus blended with acceptance-based strategies

Emphasis on dialectical processes FIVE COMPONENTS OF DBT 1. Skills Training 2. Individualized behavioral treatment plans 3. Generalization of skills 4. Programmatic emphasis on reinforcement of adaptive behaviors 5. Therapist team consultation group LEARNING PROCESS DIALECTICAL BEHAVIOR THERAPY •Education •Understanding •Belief that a life worth living is possible •PRACTICE PRACTICE PRACTICE •REPEAT REPEAT REPEAT ART THERAPY INTEGRATED INTO SKILLS TRAINING CURRICULUM CORE CONCEPTS •Mindfulness •Dialectics •Validation

DIALECTICAL THINKING

Opposing perceptions can both be true. VALIDATION Your responses makes sense based on what has happened to you. VALUES AND BELIEF SYSTEMS (MYTHS) CORE MINDFULNESS • The goal is to develop a lifestyle of participating with awareness

• “Paying attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment to moment.” –Jon Kabat Zinn IF YOU ONLY REMEMBER ONE THING “DON’T REACT” CORE MINDFULNESS SKILLS States of Mind

Reasonable Mind Emotion Mind “I think” “I feel”

Wise Mind “I know” DBT MODULES: MINDFULNESS “What” Skills “How” Skills •Observe •Non- •Describe Judgmentally •Participate •One-mindfully •Effectively DBT MODULES: INTERPERSONAL SKILLS Concepts to understand •Attending to Relationships •Balancing and Prioritizing •Building Mastery IF YOU ONLY REMEMBER TWO THINGS “DON’T REACT” “REMEMBER YOUR GOAL” DBT MODULES: INTERPERSONAL SKILLS •DEAR •MAN •GIVE •FAST EMOTION REGULATION EXERCISE EMOTION REGULATION Concepts to understand •Purpose of emotions •How emotions work •Emotional Vulnerability •Emotional Suffering vs. Pain IF YOU ONLY REMEMBER THREE THINGS “DON’T REACT” “REMEMBER YOUR GOAL” “KEEP BREATHING” MODEL OF EMOTIONS EMOTIONAL REGULATION SKILLS P L E A S E M A S T E R BEHAVIORAL CHAIN ANALYSIS Connecting a prompting event (trigger) to an impulsive ineffective behavioral response. DISTRESS TOLERANCE

Concepts to Understand •Crisis vs. Everyday Issues •Avoidance vs. Distraction •Consequential Thinking vs. Impulsivity IF YOU ONLY REMEMBER FOUR THINGS “DON’T REACT” “REMEMBER YOUR GOAL” “KEEP BREATHING” “DON’T MAKE IT WORSE” DISTRESS TOLERANCE SKILLS

•Distracting •Self-Soothing •Improving the Moment •Problem Solving (Pros and Cons) DISTRESS TOLERANCE: WHAT IT IS AND WHAT IT IS NOT •Awareness of Reality vs. Distorted Perceptions •Radical Acceptance vs. Impossible Expectations •Willingness vs. Willfulness PAIN WITHOUT ACCEPTANCE = SUFFERING STRATEGIES FOR CHANGING BEHAVIORS

“Don’t Shoot the Dog” ACCEPTANCE AND •It is what it is. CHANGE •I can’t change if I don’t accept my reactions aren’t working for me now. •If I change everything around me will be changed in some way. RESPONSE TO TREATMENT

•Outcomes based on agreed goals and expectations

•Client’s level of engagement QUIZ: WHAT ARE THE FOUR THINGS TO REMEMBER IF YOU DON’T REMEMBER ANYTHING ELSE? WHO CAN BENEFIT FROM DIALECTICAL BEHAVIOR THERAPY?

PROBLEM DIAGNOSIS POPULATIONS BEHAVIORS

Self-harming Borderline Children/Adolescents behaviors Personality Disorder Adults Suicide Attempts Other Personality Elderly Disorders Substance Abuse Forensic Eating Problems Depression Offending Behavior Anxiety OCD PTSD USING DBT OUTSIDE OF SKILLS TRAINING CURRICULUM •DBT-informed art therapy (any of the creative arts therapies modalities) •DBT Coaching •DBT-informed group therapy •Other ideas? DISCUSSION/QUESTIONS How to use what you learned today in your own practice! References from Proposal Abstract

• Davidson, L., O’Connell, M. J., Tondura, J., Lawless, M., & Evans, A. C. (2005). Recovery in serious mental illness: A new wine or just a new bottle. Professional Psychology:Research and Practice, 36(5), 480-487. • DeSouza,J., Drass, J., Kuchinov, K., & Manley, S., (2015, July) Expanding the Lens of Art Therapy: Building DBT skills. A Post Conference Course presented at the annual conference of the American Art Therapy Association, Minneapolis, MN. • Kernberg, O.F. (1975). Borderline Conditions and Pathological Narcissism. New York: Jason Aronson. • Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. • Young, S. L., & Ensing, D. S. (1999). Exploring recovery from the perspective of people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 22(3), 219–231. EXTENDED REFERENCE LIST

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, D.C.: American Psychiatric Publishing. (Original work published in 1952).

Chapman A. L. (2006). Dialectical behavior therapy: current indications and unique elements. Psychiatry 3, 9, 62–68. Accessed on 5/1/2019 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963469/

Huckvale, K. & Learmonth, M. (2009). A case example of art therapy in relation to Dialectic Behavior Therapy. International Journal of Art Therapy. 14(2), 52-63.

Lamont, S., Brunero, S., & Sutton, D. (2009). Art psychotherapy in a consumer diagnosed with borderline personality disorder: A case study. International Journal of Mental Health Nursing. 18( 3), 164-172.

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. and Heard, H.L. (1991). Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of general psychiatry. 48. 1060-1064. Accessed 5/12/19 at https://www.ncbi.nlm.nih.gov/pubmed/1845222

Linehan, M.M. (2015a) DBT Skills Training Manual (2nd ed.). New York, NY: Guilford Press. (Original work published in 1993). Linehan, M.M. (2015b) DBT Skills Training Manual (2nd ed.), Handouts and Worksheets. New York, NY: Guilford Press. (Original work published in 1993).

Linehan, M.M. (2015c) Balancing Acceptance and Change: Dialectical Behavior Therapy (DBT) and the Future of Skills Training. You Tube Family Action Network. Accessed 12/1/18. https://www.youtube.com/watch?v=JMUk0TBWASc

Parker, A., Boldero, J. and Bell, R. (2006). ‘Borderline personality disorder features: The role of self- discrepancies and self-complexity.’ Psychology and Psychotherapy: Theory, Research and Practice. 79, 3, 306-321. Accessed 12/11/14 at https://www.ncbi.nlm.nih.gov/pubmed/16945194

Paris, J. (1994). Borderline personality disorder: A multimodal approach. Washington, DC: American Psychiatric Press.

Paris, J. (2008). Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice. New York, NY: The Guilford Press.

Pipher, m. (2019). Reviving Orphelia: Saving the selves of adolescent girls. New York, NY: Riverhead Books. (Original work published in 1994). Pryor, K. (1999). Don’t shoot the dog!: the new art of teaching and training. New York, NY: Bantam Books. (original work published in 1985).

Substance Abuse and Mental Health Services Administration (2012) 10 Guiding Principles of Recovery. Accessed on 3/31/2013 on https://store.samhsa.gov/system/files/pep12-recdef.pdf CONTACT INFORMATION: JANE DESOUZA [email protected]