Leslie Karwoski Anderson, Ph.D.
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
What is DBT? Behavioral treatment approach Uses dialectical thinking Embraces validation and change Focuses on problem solving and skill building Highly organized and structured
Model of Emotion Regulation and Impulsive Behaviors Attempts to reduce or avoid the painful emotion Cue or trigger EMOTION DYSREGULATION Temporary Relief
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
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
DBT is designed for the severe and chronic multi-diagnostic, difficult-to-treat patient with both Axis I and Axis II disorders
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
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)
The Core Strategies in DBT Problem Solving Validation Dialectics
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., 1989. 2 debate establishing truths on both sides rather than disproving one argument. Encarta World, English Dictionary, North American Edition
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
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
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
DBT Skills Training Group Format Length: 1.5 Hours Mindfulness 5 minutes Homework Review 35 minutes Didactic/New Teaching 50 minutes
Mindfulness
Mindfulness States of Mind Wise Mind, Reasonable Mind, Emotion Mind What skills Observe, Describe, Participate How skills Non-judgmentally, One-mindfully, Effectively
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
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
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
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
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. 174-221). 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