Dialectical Behavior Therapy for Borderline Personality Disorder

1. Dialectical Behavior Therapy forBorderline Personality Disorder Milton Z. Brown, Ph.D. Alliant International University DBT Center of San Diego www.dbtsandiego.com

2. A first DBT session isa lot like a first DBT classClients and students should know what to expect and make an explicit and firm informed commitment

3. Class Participation • Modeling is essential • TIB, like arriving late • Awake – ask about nonverbal behaviors in class • Awake – comment on dysfunctional behaviors • DONB - problematic comments (e.g., judgment) • Practice is essential • in-class role-play • practice awake and DONB on other in class • weekly practice of DBT skills • daily sitting mindfulness practice

4. Commitment • Identify goals of client (or students) • Clear and thorough discussion of what therapy (or class) could involve and why • Collaborative discussion of what can be done to help client (or students) meet their goals • Elicit explicit and firm commitment to specific behaviors • Devil’s advocate strategy • highlight disadvantages of committing • highlight choice: “Are you sure? You don’t have to”

5. Commitment from Patient 1. By the end of the first session • commit to no suicide before the next session • removing lethal means 2. By the end of the fourth session • long-term commitment to not attempting suicide • long-term commitment to no self-harm • to work on therapy interfering behavior (target #2) • to do diary card and therapy homework • to engage in regular structured productive activities • to work on not avoiding everything

6. Commitment to Patient 1. Commit to four sessions • to decide if you can help the client • for client to decide if she will commit to therapy 2. By the end of the fourth session • make a time-limited commitment (e.g., 1 year) • specify progress required for you to agree to additional therapy after time period ends

7. DBT Interventions are based onTheory of BPD andTheories of Change

8. Development of BPDLinehan’s Biosocial Theory Biological and environmental factors account for BPD • BPD individuals are born with emotional vulnerability • BPD individuals grow up in invalidating environments • Reciprocal influences between biological vulnerabilities and an invalidating environment lead to a dysfunction in the emotion regulation system. • Mutual coercion (don’t repeat this!)

9. Development of BPDLinehan’s Biosocial Theory BPD individuals grow up in invalidating environments their emotions and struggles get trivialized, disregarded, ignored, or punished (even when normal) non-extreme efforts to get help get ignored only extreme communications/behaviors taken seriously sexual abuse Why? parents are cruel (invalidated or abused as children) low empathy and skill: don’t understand child’s struggle

10. Development of BPDLinehan’s Biosocial Theory • BPD individuals learn to invalidate themselves • intolerant of their own emotions and struggles (punish, suppress, and judge their emotions, even when normal) • They easily “feel invalidated” by others • They still influence others via extreme behaviors • self-injury/suicidality to get help • aggression, self-injury, and suicidality to get others to back off

11. Most Good TreatmentsDon’t Work for BPD Patients BPD has been associated with worse outcomes in treatments of Axis I disorders such as… • Major depression • Anxiety disorders • Eating disorders • Substance abuse probably because BPD patients have low tolerance for change-focused treatments.

12. Why DBT was Developed? 1. BPD patients resist efforts to change them 2. BPD patients insist you help them change 3. Parasuicidal behaviors destroy therapy 4. Many behaviors interfering with therapy 5. Too hard for a single therapist to respond to crises and provide both skills training 6. Burnout and negative reactions to patients are common and often lead to iatrogenic behaviors.

13. Acceptance and Change BPD clients often feel invalidated when: others focus on change (they feel blamed), but also insist that their pain ends NOW others try to get them to tolerate and accept BPD clients need to build a better life and accept life as it is feel better and tolerate emotions better Only striving for change is doomed to fail blocking emotions perpetuates suffering disappointed when change is too slow The Central Dialectic 13

14. Numerous serious problems suicidal behavior and nonsuicidal self-injury multiple disorders crisis-generating behaviors (self-sabotage) Too many therapy-interfering behaviors non-compliance strong emotional reactions to therapists therapist overwhelm, helplessness, and burnout therapists judge/blame clients Theory of BPD 14

15. Core Problem: Emotion Dysregulation pervasive problem with emotions high sensitivity/reactivity (i.e., easily triggered) high emotional intensity slow recovery (return to baseline) inability to change emotions inability to tolerate emotions (emotion phobia) vicious circle (upward spiral) desperate attempts to escape emotions vacillate between inhibition and intrusion inhibited grieving history of invalidation for emotions self-invalidation and shame inability to control behaviors (when emotional) Theory of BPD 15

16. THE PROBLEM AVOIDANCE OR ESCAPE e.g., interpersonal conflict (abandon, invalidation) PROBLEM BEHAVIOR Alcohol & Drugs Self-injury Aggression EMOTION DYSREGULATION CUE TEMPORARY RELIEF e.g., others back off Reinforcement strengthens this whole process

17. Why Self-harm Must Stop It is incompatible with a life-worth living 1. It is an escape behavior that removes the opportunity to learn new ways of dealing with difficult events (compare to drugs) 2. Continued sensitivity to triggers (suffering) 3. Strengthens self-hatred and shame. 4. Causes relationship and medical problems 5. I care about someone and let it continue

18. Theory of BPD Core Problem: Avoidance • Denial of problems (avoiding feedback) • Non-assertiveness and social avoidance • Drug and alcohol abuse • Self-injury, suicide attempts , and suicide • Self-punishment, self-criticism (block emotions) • Dissociation and emotional numbing • Anger to block other (more painful) emotions • Anger to divert away from sensitive interactions • Hospitalization to escape stressful circumstances

19. The Central Treatment Dialectic Acceptance and Change Soothing versus pushing the client Validation versus demanding

20. The Central Treatment Dialectic Balancing Acceptance and Change Balance therapist strategies validation and Rogerian skills CBT: problem-solving, skills, exposure, cognitive restructuring, contingency management Balance coping skills skills to change emotions and events acceptance skills are necessary since not enough change occurs and not fast enough 20

21. DBT Targets Serious problem behaviors targeted immediately and directly suicidal behavior and nonsuicidal self-injury excessive hospitalization therapy-interfering behaviors Start with stabilization (coping skills) reduce life chaos (problem solving) build structure (e.g., work) distraction and emotion regulation 21

22. Principles of DBT Functions: • Enhance capabilities • Improve emotion regulation • Activate non-mood-dependent behavior • Enhance motivation • Assure generalization • Structure the environment • Enhance capability and motivation of therapists

23. Principle-driven treatment minimal use of protocols flexible use of multiple strategies based on behavioral analysis (theory of client) based on theory of BPD function supersedes form Multiple modes and strategies skills training separate from individual telephone skills coaching consultation team (therapist support) DBT is a Principle-Driven Treatment 23

24. DBT Strategies • Individual therapy • weekly sessions (usually 60 minutes) • telephone skills coaching • telephone crisis management • Skill training (usually group of 5-10) • clients do not talk about self-injury or suicidal intent or behavior • very structured didactic format • not a process group

25. DBTINTERVENES Teach how to prevent triggers AVOIDANCE OR ESCAPE X PROBLEM BEHAVIOR Teach how to stop this behavior EMOTION DYSREGULATION Regulate or tolerate distress Teach alternative ways to avoid or distract CUE X X Reduce power of triggers and emotion vulnerabillity TEMPORARY RELIEF X Stop problem behavior or reinforcement Without escape, emotion dysregulation should improve

26. DBTINTERVENES Problem solving or stimulus control AVOIDANCE OR ESCAPE X PROBLEM BEHAVIOR Stop behavior: self-management EMOTION DYSREGULATION Regulate or tolerate distress Crisis Survival Skills CUE X Non-reinforced exposure, PLEASE, increase pos events TEMPORARY RELIEF X Stop reinforcement (extinction) Without escape, emotion dysregulation should improve

27. Focus on Emotion Regulation Reduce emotional reactivity/sensitivity exercise, and balanced eating and sleep exposure therapy Reduce intensity of emotion episodes heavy focus on distraction early on, which is a less destructive form of avoidance Increase emotional tolerance mindfulness block avoidance Act effectively despite emotional arousal DBT Strategies 27

28. Self-injury Intervention Options • Prevent, avoid, or solve interpersonal conflict • Reduce emotional reactivity to conflict • Regulate and tolerate emotions • Alternative short-term escape (e.g., distraction) • Behavioral control (e.g., highlight disadvantages, reduce opportunities/means) • Stop relief • naltrexone • do not back off

29. Dialectical Behavior TherapyTreatment Strategies • Problem-solving • Skills-focus* (new skills manual) • Exposure and opposite action • Reinforcement principles • Cognitive modification • Support/Validation/Acceptance • Dialectical Strategies

30. Levels of Validation • Listen and pay attention • Show you understand • paraphrase what the client said • articulate the non-obvious (mind-reading) • Describe how their behaviors/emotions… • make sense given their past experiences • make sense given their thoughts/beliefs/biology • are normal or make sense now • Communicate that the client is capable/valid • actively “cheerlead” • don’t treat them like they’re “fragile” or a mental patient

31. Validation What (“yes, that’s true” “of course”) • Emotional pain “makes sense” • Task difficulty “It IS hard” • Ultimate goals of the client • Sense of out-of-control (not choice) How • Verbal (explicit) validation • Implicit validation • acting as if the client makes sense • responsiveness (taking the client seriously)

32. Functions of Validation • Increases client willingness to change • Strengthens therapeutic relationship • Reinforces staying in therapy • Reinforces clinical progress • Provides feedback to shape behavior • Increases self-validation by modeling validation • Increases positive expectancies (believing in client)

33. Self-Validation Get the patient to say: “It makes perfect sense that I … because…” • it is normal or make sense now • of my past experiences • of the brain I was born with • of my thoughts/beliefs Get the patient to act as if she makes sense: • non-ashamed, non-angry nonverbal behavior • confident tone of voice

34. Marsha / Stacey Chain Analysis From session 2 video write on white board

35. Agenda • Mindfulness practice • today • regular practice • DBT Listserve • Chain analysis • Self-validation rational-emotional role-play • Observing limits

36. Problem Solving • Functional analysis (chain analysis) • Solution analysis • accept, tolerate, mindfulness • change, regulate • self vs. environment • Anticipate and solve obstacles • Skills acquisition (model) • Rehearse – “dragging out new behavior” • Commitment

37. Problem SolvingTargeting Figuring out what to focus on: • Self-injury • Therapy-interfering behavior • Emotion regulation and skillful behavior • shame and self-invalidation (judgment) • anger and hostility (judgment) • dissociation and avoidance • In-session behavior

38. Understand the Problem Do detailed behavioral analyses to discover: • environmental trigger • key problem emotions (and thoughts) • what happened right before the start of the urge? • what problem did the behavior solve? and conceptualize the problem (i.e., identify factors that interfere with solving the problem)

39. Understand the Problem Identify factors that Interfere with solving the problem • Lack of ability for effective behavior • Effective behavior is not strong enough • Thoughts, emotions, or other stronger behaviors interfere with effective behavior

40. DBT Assertiveness SkillDEAR MAN GIVE FAST Assertiveness is an effective alternative for • anger and aggression • helplessness (depression)

41. Therapy Interfering Behaviors (TIB) arrives late leaves early passive or helpless not do diary card excessively talks (hard for therapist to talk) complains but does not work in session excessively angry excessively judgmental/critical of therapist

42. CBT for Anger Work on anger collaboratively motivational interviewing style (no labels) frame the choice as “right versus effective” validate what is valid Problem solving act on anger when it helps reduce a threat Skills training Cognitive restructuring (be careful!) Exposure

43. Skills Training for Anger Gently avoid (time out) postpone for a specified amount of time distraction pros and cons Relaxation Assertive communication (DEAR MAN GIVE) Empathy and explicit validation (no “should”) Get help for a “reality check” Ask a friend: “Am I over-reacting?” What am I failing to understand about other person? Is it worth the battle/loss (even if I am right)?

44. Cognitive Restructuring for Anger Empathic interpretations of others notice “shoulds” external attributions (current causes) benefit of the doubt times client’s intent has been misunderstood historical causes Ask rather than assume Humor Acceptance and forgiveness

45. Exposure for Anger Thoroughly assess triggers In vivo exposure role-play verbal barbs homework Imaginal exposure client can write a script in advance Opposite action validation opposite thinking?

46. Responding to Anger in Session Discourage simple venting/catharsis Link behavior to clients goals Refuse to talk about anger-inducing situations when not productive Validate/apologize/repair to the extent that therapist made a mistake. Do not avoid the issues that prompt the anger if they are reasonable to deal with do not back down or appease

47. In-Session TIB ProtocolProblematic Behavior Excess • EXTINCTION: block behaviors • “that’s ineffective” (broken record technique) • return to the trigger or first emotion • Validate or use humor/irreverence • Comment on the therapy interactions (process) • Illusion of choice in absence of alternatives • Elicit collaboration (turn the tables) • EXTINCTION: Do not respond (at all!)

48. TIB ProtocolProblematic Behavior Excess Other Consequences Correction-Overcorrection (repair) Negative judgment from therapist Vacation from therapy Therapy termination

49. “Boundaries” in DBT= Observing Limits Hold natural rather than arbitrary limits Keep your sanity Model and reinforce effective interpersonal behavior Reinforce independent coping

50. Common Contingencies in DBT Observing limits “drag out new behavior” “talk it to death” (miss out on other topics) fill out diary card in session; make it useful schedule phone calls (not contingent on problems) withdraw warmth (or slightly aversive tone) minimize impact of hospitalization 24 hour rule