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A Brief Introduction To Dialectical Behaviour Therapy
A Brief Introduction To Dialectical Behaviour Therapy
Behaviour Therapy
Dr. Nathalie Lovasz, C.Psych (Supervised Practice)
Head of Adult DBT Program – The Mindfulness Clinic
DBT-informed Therapy:
- Any treatment that does not include ALL FOUR of the above
components
- E.g. CBT therapy that incorporates some DBT skills
- Group only Skills Training
- Skills Group + Individual Therapy without Phone Coaching
- Skills Group, Individual Therapy, Phone Coaching but no consultation team
Assessment and Case Conceptualization
Symptoms of Borderline
Personality Disorder
• Emotion Dysregulation – Suicide/Self-harm
– Unstable Emotions/Mood • Identity/Self Dysregulation
– Intense Anger/Difficulty – Unstable Sense of
Controlling Anger Self/Identity
• Interpersonal – Feelings of Emptiness
Dysregulation • Cognitive Dysregulation
– Unstable/Intense – Stress Related Paranoid
Relationships Thoughts
– Frantic Efforts to Avoid – Dissociation
Abandonment
• Behavioural Dysregulation
– Impulsive/Self-Damaging
Behaviours
Practice 1
Identify Areas of Dysregulation in a Practice
Case
Choose one of the two case vignettes provided. Identify as many
areas of dysregulation as possible in the case vignette:
• Emotion
• Interpersonal
• Cognitive
• Behavioural
• Identity/Self
Biosocial Model of BPD
EMOTIONAL VULNERABILITY
EMOTIONAL VULNERABILITY
+
INVALIDATION
=
BORDERLINE PERSONALITY DISORDER
Practice 2
Apply the Biosocial Model to a Practice Case
Thought: Action:
Emotion: Urge: Take “Will be Walk to Action:
Despair pills to better if bathroom Take pills
forget I’m and get
dead” pills
Vulnerability
Factors
Prompting Event: Ways to prevent prompting event in future:
E
Actual Behaviors and Events: Skillful alternative behaviors:
Problem
Behavior
Consequences
Consequences in the environment? Plans to repair, correct, and over-correct harm:
and Harm
(Immediate and
delayed)
Consequences in myself?
Adapted from Marsha Linehan’s Chain Analysis Worksheet by Seth Axelrod, PhD 2/13/04
Practice 5
Practice chain analysis using a practice case
1. Get into pairs
2. Choose one of the two vignettes provided
3. One person will role play the client, one person will role play
the counsellor
4. Choose a specific behaviour from the case vignette to chain
analyze e.g., cutting, waiting for faculty member in the
parking lot
5. Role play a chain analysis of this behaviour. The counsellor
will have to ask as many questions as needed to “fill in the
links of the chain”
DBT Skills
• Distress Tolerance
• Emotion Regulation
• Interpersonal Effectiveness
• Mindfulness
Distress Tolerance
“How to get through a crisis without
making things worse”
Distress Tolerance: Crisis Survival
Skills
• CRISIS SURVIVAL SKILLS are needed:
– When client is in a situation that is
• Highly stressful
• Short-term
• Creating intense pressure to resolve the crisis now
– AND
• Acting on emotions and urges will make things worse
• Client cannot make things better right away
• Client must temporarily tolerate painful events and emotions
• CRISIS SURVIVAL SKILLS are not for:
– Everyday use
– Solving all of life’s problems
– Making life worth living
STOP Skills
Stop
Do not just react. Stop! Freeze! Do not move a muscle! Your emotions may try to
make you act without thinking. Stay in control!
Observe
Take notice of what is going on inside and outside of yourself. What is the
situation? What are your thoughts and feelings? What are others saying or doing?
Proceed mindfully
Act with awareness. In deciding what to do, consider your thoughts and feelings, the situation,
and the thoughts and feelings of other people. Think about your goals. What do you want to get
from this situation? Which actions will make it better or worse?
TIPP Skills
• TIP YOUR TEMPERATURE
• INTENSELY EXERCISE
• PACE YOUR BREATHING
• PROGRESSIVELY RELAX YOUR MUSCLES
TIPP Skills
• Tip the TEMPERATURE of your face: use ice water to calm
yourself down fast by changing the response of your
autonomic nervous system
– Put your face in a bowl of ICE WATER (30 seconds)
– OR splash ICE WATER on your face,
– OR hold a gel ICE pack (or zip-lock ICE WATER) on your
face.
• INTENSELY EXERCISE to calm down a body revved up by
emotion
– Engage in intense exercise, if only for a short while.
– Expend your body’s stored up physical energy by: Running,
Walking , Fast Jumping, Playing Basketball, Weight Lifting,
etc.
TIPP Skills
• PACE YOUR BREATHING BY SLOWING IT DOWN
– Slow your pace of inhaling and exhaling way down (on
average 5 to 7 breath cycles per minute).
– Breathe deeply from the abdomen.
– Breathe more slowly out than when breathing in (for
example, 4 seconds in and 8 seconds out).
• PROGRESSIVELY RELAX YOUR MUSCLES
– Starting with your hands, moving to your forearms, upper
arms, shoulders, neck, forehead, eyes, cheeks & lips,
tongue & jaw, chest, upper back, stomach, buttocks,
thighs, calves, ankles, feet.
– TENSE (5 seconds), then let go and RELAX each muscle (all
the way).
– NOTICE the tension. NOTICE the difference when relaxed.
Pros and Cons
• Use PROS and CONS anytime you have to decide between two
courses of action.
Pros Cons
Acting on Crisis
Urges
Resisting Crisis
Urges
Distraction
A way to remember these skills is the acronym “ACCEPTS”
Activities:
– Refocus your attention on the task you have to get done
– TV, events, exercise, internet, sports, hobbies
Contributing:
– Volunteering, help a friend, encourage someone
Comparisons:
– Compare how you are feeling now to a time when you felt different
Different Emotions:
– Books, stories, movies, music
Pushing Away:
– Leave the situation; block thoughts from your mind
Other Thoughts:
– Counting; puzzles
Other Sensations:
– Squeeze a rubber ball; hold ice; go out in the rain
Self-Soothing
A way to remember these skills is to think of soothing each of your FIVE
SENSES:
Vision:
• Stars at night; pictures in a book, nature, candles
Hearing:
• Soothing music; invigorating music; sounds of nature; sounds of the
city
Smell:
• Soap, incense, coffee, essential oils, boil cinnamon
Taste:
• Favourite foods; soothing drinks; chew gum
Touch:
• Hot baths; pet your dog or cat; creamy lotion; comfortable clothing
Group Discussion 1
Discuss how Distress Tolerance skills may be
helpful to our practice cases
At your table, choose one case vignette.
1. How could these distress tolerance skills help the client in the
vignettes accomplish their treatment goals?
2. How would you teach these skills to a client?
Emotion Regulation
“How to understand emotions, change
ineffective emotions, and be less vulnerable
to negative emotions”
Emotion Encyclopedia
Basic Emotion Related Emotion Words
• Fear
– Urge: Freeze, run, avoid
– Opposite action: Approach
• Anger
– Urge: Attack, hit, yell
– Opposite action: Gently avoid; do something nice
• Sadness
– Urge: Withdraw, cry, isolate
– Opposite action: Get active
• Guilt/Shame
– Urge: Hide/avoid
– Opposite action: Face the music; repair mistakes
Group Discussion 2
Discuss how Emotion Regulation skills may be
helpful to our practice cases
At your table, choose one case vignette.
1. How could these emotion regulation skills
help the client in the vignettes accomplish
their treatment goals?
2. How would you teach these skills to a client?
Interpersonal Effectiveness
“How to get your needs met while
maintaining your relationships and self-
respect”
Identifying Interpersonal Priorities
• Goal Effectiveness
– What do I want from the other person?
• Relationship Effectiveness
– How do I want the other person to feel about me?
• Self-Respect Effectiveness
– How do I want to feel about myself?
Goal Effectiveness – DEAR MAN
Effectively making a request
Publically Funded
• Toronto, ON
– Centre for Addiction and Mental Health
– Davenport Perth Neighbourhood Centre – Surfing
Tsunamis Program
• London, ON
– London Health Sciences Centre – Victoria Hospital
• Hamilton, ON
– St. Joseph’s Health Care DBT Program
Options for Treatment Referrals in Ontario
Private Treatment Options
– The Mindfulness Clinic: Toronto, ON
• Comprehensive Adult and Adolescent DBT Program
– Individual Therapy
– Adult Skills Training Groups
– Adolescent Multi-Family Skills Training Groups
– Phone Coaching
– Weekly Therapist Consultation Team
– More info: http
://www.themindfulnessclinic.ca/therapy-training/dialec
tical-behaviour-therapy-dbt
/
Options for Treatment Referrals in Ontario
Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically
parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.
Koerner, K. (2011). Doing Dialectical Behavior Therapy: A practical guide. New York: Guilford Press.
Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A.
(2001). Efficacy of Dialectical Behavior Therapy in Women Veterans with Borderline Personality Disorder. Behavior Therapy, 32,
371-390.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior
Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292.
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2006). Dialectical Behavior Therapy with suicidal adolescents. New York: Guilford
Press.
Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , Stijnen, T., & Van Den Brink, W. (2003). Dialectical
Behaviour Therapy for Women with Borderline Personality Disorder, 12-month, Randomised Clinical Trial in The Netherlands.
British Journal of Psychiatry, 182, 135-140.