DBT -- Lane Pederson

For a therapy to be considered DBT, the following conditions must be met:

1. It flows from the biosocial theory (C7).  
2. It is structured and has clear client and therapist expectations and protocols (C10). 
3. It contains the five DBT functions: motivating clients, teaching skills, generalizing skills to natural environments, motivating and improving the skills of therapists, and structuring the treatment environment (C9). 
4. DBT must contain both therapy and skills training (C19). 
5. DBT therapists must have ongoing consultation (C27). 
6. Case conceptualization and interventions are centered in behaviorism.
7. Therapists follow DBT philosophies and assumptions (C8). 
8. DBT promotes mindfulness (C18). 
9. DBT follows a dialectical philosophy (C6).

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Dialectics

(1) Validation vs. Change. "When clients feel validated, movement toward change can be made, and as clients struggle to change, movement back to validation and acceptance are indicated." (2) Acceptance of Experience vs. Distraction. (3) Doing One's Best vs. Needing to Do Better. (4) Nurturance vs. Accountability. Dialectical Abstinence: You must take an undialectical stance when particular behaviors are "so harmful that engaging in them cannot be justified."

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Biosocial Theory

Biosocial theory holds that BPD and many other problems are caused by a combination of emotional dysregulation and insufficient validation. Like BPD, depression, anxiety, and anger "can be characterized as disorders with emotional dysregulation at their core, with the associated issue that others do not understand their problems (i.e., they feel invalidated by others." (Emotional dysregulation is at least in part biological.)

Emotional dysregulation "consists of being emotionally sensitive and emotionally reactive and having a slower return to baseline when emotions are activated."

Validation: "Communicating the nonjudgmental acknowledgement and acceptance of one's own or another person's feelings, thoughts, and experience." Invalidation intensifies emotions, while validation decreases the intensity of emotions. In DBT, validation is the primary intervention. "Because validation down-regulates and holds emotions within safe containment, clients can then experience what is felt without escape and avoidance, and they learn that emotions can be tolerated."

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Assumptions

Client Assumptions. (1) Clients are responsible for changing (in other words, you cannot force someone else to change), (2) Clients are doing their best (and need to do better), (3) Clients cannot fail DBT, but DBT can fail them (if DBT doesn't work for a client, you should recommend another therapy for them), (4) Clients want to improve yet need skills to do so, (5) Skills need to be generalized to all relevant areas of life.

Therapist Assumptions. (1) Therapists practice empathy, respect, genuineness, and validation (these are all necessary for a good alliance) (2) Therapists assume a nonjudgmental approach to clients, (3) Therapists must be strengths-based, (4) Therapists require consultation to stay motivated and effective, (5) Therapists, like clients, need to practice skills, (6) Therapists should favor consulting to the client over intervening for the client.

Treatment Assumption. (1) Treatment must emphasize and reinforce behaviors that "work in life" while not allowing clients to practice behaviors in treatment that do not work in life. "As a rule, any behavior that would not be tolerated at school, at work, socially, or in healthy relationships should not go unaddressed in therapy."

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Five Functions of Comprehensive DBT

Motivate Clients. To motivate, you must understand the client's goals; identify relevant strengths, resources, and barriers; ensure collaboration on the methods enlisted to reach goals. Teach Skills. Skills training is enough for clients with low intensity problems, but others need the other components of DBT. Generalize the Skills. Generalization does not happen on its own. Motivate Therapists to Maximize Effective Therapist Responses. This is primarily done in consultation. Structure the Environment.

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Treatment Structure

Structure creates "predictability and safety" and it "assists in maintaining therapeutic focus and determining what to treat when."

The Standard Model. Weekly individual therapy (increases client motivation), weekly group skills training (increases client capabilities), 24/7 phone coaching (helps clients generalize skills), weekly consultation group for therapists (increases therapist motivation and skills).

Individual Therapy Treatment Structure. Greet client; note the client's affective state; begin with mindfulness; check in with other aspects of client's treatment; check in with homework; review diary card to craft agenda; do the established work of the session; assign homework; end with mindfulness.

Explicit expectations are essential. A "a nebulous, unstructured situation" causes "anxiety, fear, frustration, or other emotions that can be difficult to tolerate. Clients who already have emotional dysregulation and chaotic, unskillful behaviors need clarity in their environments in order to learn skills. Not being clear about what is expected is unfair and puts clients in needless distress, an iatrogenic treatment response."

When clients resist expectations. "These reactions can tempt us to abandon ship and allow for greater flexibility and a lack of accountability. However, if you abandon your structure or change your rules for a client, or if you fail to address a broken rule or agreement, you are participating in therapy-interfering behavior (TIB) with the client. Clients do not always need to agree with the philosophy of certain expectations and rules, but they need to respect them and follow them. Sticking to agreements is difficult for both clients and therapists, but it models what tends to be effective in real life."

"Remember that it is compassionate to have expectations and rules and to stick to them, even if the consequence is discharging a client from the program or from individual therapy. Predictability and consistency are paramount to success, for to do otherwise may recreate the type of environment that contributed to clients' problems in the first place."

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DBT Treatment Stages

(Stage 1) Stability and Behavioral Control -- focuses on behaviors that threaten the client's life, cause self-harm, and interfere with therapy. (Stage 2) Treating PTSD, Significant Stress Reactions, and Experiencing Emotions More Fully -- goal is for client to learn to accept emotions (neither get stuck in suffering nor avoid experience). (Stage 3) Solving Routine Problems of Living. (Stage 4) Finding Freedom, Joy, and Spirituality.

DBT Therapeutic Factors Hierarchy (what therapists should prioritize)

(1) Develop and Maintain the Therapy Alliance -- done through validation, reciprocal communication, and therapist-driven attitudes and qualities like nonjudgment, authenticity, and respect. (2) Develop Mutual Goals and Collaboration on Methods. (3) Identify and Engage Client Strengths and Resources to Maximize Helpful Extratherapeutic Factors. (4) Establish and Maintain the Treatment Structure.

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Diary Card

This is how self-monitoring works in DBT. Identifies what to focus on in session. Lets you see what has improved, what has worsened. All information relevant to therapy can be monitored on diary card.

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Validation

Validation is not a means to an end but an intervention in its own right. Validation shows clients that they will be accepted in the therapy sessions. Validation provides a safe place for experiencing painful emotions, thus showing clients that painful emotions can be experienced; it is thus like a form of exposure therapy. In time, validation from a therapist leads to self-validation. 

Six levels of validation. (1) Being mindfully attentive and alert. (2) Verbally acknowledging what the client said. Client: I'm just here b/c I have to be. Won't do no good. Therapy's always been a waste of time. Therapist: I understand you were told to come here and that therapy hasn't helped you. (3) Acknowledge both what the clients says and what the client communicates nonverbally. (4) Articulate how the client's experience makes sense given history/biology. (5) Show how the client's experience makes sense in the present moment. (6) Be in genuine human contact with client. 

Validation is not normalization. "Validation is about connecting with the unique experience of an individual whereas normalization is about communicating that other people have the same experience."

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Changing Behaviors

DBT's behavioral interventions center on functional analysis (i.e., determining the function of a client's behavior). The behavior examined is the target behavior, and the functional understanding of a target behavior comes from examining what precedes and follows it. 

Terms. Reinforcer: consequence that makes it more likely that the behavior will happen again. Punishment: consequence that decreases behavior. Positive Reinforcement: desirable consequence given, making behavior more likely to occur again (e.g., student does homework, teacher praises). Negative Reinforcement: undesirable consequence taken away, making behavior more likely to occur in future (e.g., student does homework, teacher stops nagging). Positive Punishment: undesirable consequence given, making behavior less likely to occur again (e.g., child picks nose, teacher reprimands him). Negative Punishment: desirable consequence taken away, making behavior less likely to occur again (e.g., student hits a peer, loses recess). Extinction: when a reinforcer that normally follows a behavior is withheld, thereby decreasing the frequency of a behavior. Contingency: the If-Then relationship between a behavior and its consequence (e.g., If you speed, you will get a ticket) (for If-Then contingencies to work, consequences must be delivered in a reliable and predictable manner). 

Behavioral Methods. Noncontingent reinforcement -- some clients learn that complaining is the only way to elicit concern from others, so therapist provides care no matter how the client is doing. Model effective behavior -- e.g., therapist says, "Wow, I'm feeling a lot of stress in my body -- I'm going to take a few deep breaths to calm and center myself." Reinforce nonproblem behaviors -- e.g., don't just reinforce client for not engaging in target behavior, but reinforce him/her for engaging in replacement behavior. Train Skills to reinforce -- DBT does not hold that insight or motivation alone are enough to decrease target behaviors; if a client is asked to give up a behavior, the therapist must teach a replacement behavior. The Premack [pre-mack] Principle -- making high-probability behaviors contingent on performing low-probability behaviors to increase the desirability of desirable but scarce behaviors; e.g., "If you eat your vegetables (low-probability behavior), you can go out to play (high-probability behavior). Combat vulnerabilities -- e.g., if stress is a vulnerability (client is more likely to engage in target behavior when stressed), then teach stress management. Harness higher motivations to leverage change -- e.g., a client might be motivated to stay clean because she wants to be a good parent. 

Behavioral Chain Analysis. Identifying behaviors, antecedents, and consequences. (1) Identify behavior to analyze. (2) Identify prompting event (trigger). (3) Identify vulnerabilities that made behavior more likely to occur (e.g., disrupted sleep, missed medication). (4) Identify emotions that followed the prompting event. (5) Identify self-talk that followed the prompting event. (6) Identify action urges that followed the prompting event. (7) Identify consequences of the behavior. You can start anywhere on the chain and work forward or backward, and then identify other skills or choices you could make. 

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Misc.

Commitment Strategies. Increase compliant with therapy. (1) Foot in the Door -- have client agree with something that almost anyone would agree with. (2) Door in the Face -- ask for enormous commitment, expecting that client will refuse and you can then negotiate. (3) Doing a Cost-Benefit Analysis. (4) Tying to Prior Commitments. (5) Freedom and Choice in the Absence of Alternatives. (6) Devil's Advocate. 

Educating, Socializing, and Orienting. The DBT process must be straightforward and transparent to clients. Orienting: Describing how the therapy will be of benefit to the client's goals. 

Communication Styles. (1) Reciprocal Communication -- "being interpersonally accessible, warm, and connected to the client in the moment, ready to listen and respond with validating verbal and nonverbal communication." Appropriate types of self-disclosure: (a) examples of skill use, (b) tell client that you have or would have done same thing in similar situation, (c) let client know how you feel in the moment (e.g., this can comfort client who is used to feeling rejected, encourage client who is afraid of sharing). (2) Irreverent Communication -- purpose is to use the comment's offbeat nature to shift emotions, thoughts, or behaviors. 

Dialectical Strategies. Entering the Paradox -- discuss contradictions of which the client isn't aware, thus prompting the client to resolve this conflict (e.g., where client's words and actions don't match). Refusing Right and Wrong -- recognizes that opposing viewpoints can be both true and false. Use of Metaphor or Stories -- e.g., "You can't control the wind, but you can adjust your sails." Devil's Advocate. Extending -- join the flow with the client's energy rather than meeting it with opposition; this leaves the client off-balance and in need of self-correction. Wise-Minded Activation -- ask the client to consider the problem from a wise-minded perspective. Making Lemonade out of Lemons. Allowing Natural Change. Prescribing the Feared Behavior. Exception Rule. Role Reversal.