Leslie Karwoski Anderson, Ph.D.

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1 Leslie Karwoski Anderson, Ph.D.

2 Origins of DBT Marsha Linehan did a study on CBT and chronic SI, suicide attempts, and self-harm Found focus on unrelenting change in CBT to be invalidating Resulted in high treatment dropout Behavior of therapists reinforced dangerousness of patients Volume of problems overwhelm therapy

CBT to be invalidating Resulted in high treatment dropout Behavior of

3 What is DBT? Behavioral treatment approach Uses dialectical thinking Embraces validation and change Focuses on problem solving and skill building Highly organized and structured

4 Model of Emotion Regulation and Impulsive Behaviors Attempts to reduce or avoid the painful emotion Cue or trigger EMOTION DYSREGULATION Temporary Relief

5 Goals of DBT Enhance and maintain motivation to change Enhance capabilities Ensure new capabilities can be generalized Enhance therapists motivation Structure the environment so treatment can take place

6 Adolescent DBT Modes of Therapy Multifamily Skills training group Individual psychotherapy Telephone consultation Therapist consultation meeting Family Therapy or parent training as needed Diary Cards Behavioral Chain Analyses Focus on behavioral principles, validation, and empathy in the milieu

meeting Family Therapy or parent training as needed Diary Cards

7 DBT is designed for the severe and chronic multi-diagnostic, difficult-to-treat patient with both Axis I and Axis II disorders

8 Research on DBT for Adolescents Rathus & Miller (2002): 12-week trial of DBT for adolescents with BPD features (DBT=29, TAU=82). Psychiatric hosp during tx (DBT=0%, TAU=13%) Treatment retention rates (DBT=62%, TAU=40%) Katz et al. (2004): 2-week inpt DBT program (DBT=32, TAU=30) DBT group had significantly fewer incidents on the ward Both groups demonstrated significant reduction in selfharm and suicidal behavior in the year following treatment

Psychiatric hosp during tx (DBT=0%, TAU=13%) Treatment retention rates (DBT=62%, TAU=40%) Katz et al.

9 Research on DBT for Eating Disorders Study of DBT for binge eating disorder 89% of women were abstinent from binging after 20 weeks compared with 12% of wl controls (Telch, Agras & Linehan, 2001) Study of DBT for bulimia: n=31, DBT= 29% were abstinent from binging/ wl control= 0% abstinent (Safer, Telch, & Agras, 2001) Case series on DBT for adolescents with Eds: n=12; by tx end, 7 no longer met criteria for an ED. Significant reductions in ED behaviors (Salbach-Andrae et al., 2008)

were abstinent from binging/ wl control= 0% abstinent (Safer, Telch, & Agras, 2001) Case series on DBT for adolescents

10 The Core Strategies in DBT Problem Solving Validation Dialectics

11 Definition of Dialectics: 1 the process of thought by which such contradictions are seen to merge themselves in a higher truth that comprehends them. Oxford English Dictionary, Second Ed., debate establishing truths on both sides rather than disproving one argument. Encarta World, English Dictionary, North American Edition

Oxford English Dictionary, Second Ed., 1989.

12 Stages of Treatment Pre-Treatment: Commitment and Agreement Stage 1: Severe Behavioral Dyscontrol Behavioral Control Stage 2: Quiet Desperation Emotional Experiencing Stage 3: Problems in Living Ordinary Happiness & Unhappiness Stage 4: Incompleteness Capacity for Joy and Freedom

Desperation Emotional Experiencing Stage 3: Problems in Living

13 Stage 1 Primary Targets Dialectical Synthesis Severe Behavioral Dyscontrol Behavioral Control Decrease 1. Life-threatening behaviors 2. Therapy-interfering behaviors 3. Quality-of-life interfering behaviors Increase behavioral skills Mindfulness Interpersonal Effectiveness Emotion Regulation Distress Tolerance

15 Teach Skillful Behavior to Replace Problem Behavior Behaviors to Behaviors to Increase Decrease Mindfulness Skills Interpersonal Skills Emotion Regulation Skills Distress Tolerance Skills Identity Confusion Emptiness Cognitive Dysregulation Interpersonal Chaos Fears of Abandonment Labile Affect Excessive Anger Impulsive Behaviors Suicide Threats Parasuicide

Tolerance Skills Identity Confusion Emptiness Cognitive Dysregulation Interpersonal Chaos

16 DBT Skills Training Group Format Length: 1.5 Hours Mindfulness 5 minutes Homework Review 35 minutes Didactic/New Teaching 50 minutes

17 Mindfulness

18 Mindfulness States of Mind Wise Mind, Reasonable Mind, Emotion Mind What skills Observe, Describe, Participate How skills Non-judgmentally, One-mindfully, Effectively

19 Distress Tolerance Tolerating Distress rather than using a problematic emotional coping mechanism Crisis Survival Strategies tolerating short term pain Pros and cons, Self-soothe, Distract, Improve the Moment Guidelines for Accepting Reality tolerating long term pain Radical Acceptance, Turning the Mind, Halfsmile, Willingness

cons, Self-soothe, Distract, Improve the Moment Guidelines for Accepting Reality

20 Emotion Regulation Goals of Emotion Regulation Module Understand & identify emotions Change by acting opposite to painful emotions Opposite Action Reduce emotional vulnerability ABC PLEASE: Accumulate Positives, Build Mastery, Cope Ahead, Treat PhysicaL Illness, Balanced Eating, Avoid Mood-Altering Substances, Sleep, Exercise

emotional vulnerability ABC PLEASE: Accumulate Positives, Build Mastery, Cope

21 Interpersonal Effectiveness Objectives Effectiveness Getting your objectives or goals in a situation DEAR MAN: Describe, Express, Assert, Reinforce, Mindful, Act Confident, Negotiate Relationship Effectiveness Getting/keeping a good relationship GIVE: Gentle, Interested, Validate, Easy Manner Self-Respect Effectiveness Keeping/improving self-respect while achieving your objectives FAST: Fair, (no) Apologies, Stick to Values, Truthful

22 DBT: Can it be fun? Speed Movement Flow Radical genuineness Use Mindfulness Exercises: Blow bubbles, paper ball flicking, Mindfulness of objects Tailor discussion to the problems of the group Personalize comments Stickers Distress Tolerance boxes Use role plays in group

23 Recommended Readings Astrachan-Fletcher, E. & Maslar, M (2009). The DBT Workbook for bulimia. New Harbinger. Dimeff, L., & Koerner (Eds.), Dialectical Behavior Therapy in Clinical Practice (pp ). New York: The Guilford Press. Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press. Linehan, M.M. (1993). Skills training manual for treating borderline personality disorder. Guilford Press. Miller, A. L., Rathus, J. H., Linehan, M. M. (2007). Dialectical Behavior Therapy with Suicidal Adolescents. Guilford Press. Safer, D.L., Telch, C.F., & Chen, E.Y. (2009). Dialectical Behavior Therapy for Binge Eating and Bulimia. Guilford Press. For further information, contact Leslie at landerson@ucsd.edu

USING DIALECTICAL BEHAVIOR THERAPY WITH SUBSTANCE ABUSE DISORDERS

USING DIALECTICAL BEHAVIOR THERAPY WITH SUBSTANCE ABUSE DISORDERS PRESENTERS: GEOFF WECKEL, PSYD MARK FOSTER, MA, LPC 550 BAILEY AVE, SUITE 302, FORT WORTH, TEXAS WWW.RESTORATIONCEC.COM Dialectical Behavior