The Shaping Game: integrating DBT, ACT & FAP

1. The Shaping Game: integrating DBT, ACT & FAP SANDRA GEORGESCU, PSY.D. & Paul Holmes Psy.D.

2. 1st - an apology • Then, some compliments

3. All boxes everywhere • Classifying client presentation based on categories in the DSM is ….. • Classifying different treatment packages based on developer/lab is…. • Yet most of us see folks whose presentation doesn’t neatly fit into the criteria AND use interventions that are more or less consistent with each package

4. This talk • Is about the integration of behavioral interventions across DBT, FAP & ACT to: • Meet client needs where they are at • Provide ongoing care & shaping behavior over time • Stimulate thinking outside the package box (but within the theoretical community)

5. Some assumptions…. • If you are here, you have known “difficult, multi-problem” clients and have struggled • Are at least somewhat familiar with all three treatment packages • Have struggled (or are just curious about how) to integrate techniques • Are friendly to the ACBS mission and functional/contextual approach

6. some behaviors/solutions are “louder” or more disturbing than others…..

7. Quick… • Notice and jot down a few reactions…. • What comes to mind?

8. This is Jeanne & she’s in distress

9. Do you know this person?

10. How Todd spends his nights…

11. From an FC perspective… • Different strokes for different folks… • Drinking, binging, cutting, crying, panic • Sexing, dissociating, changing the subject, • Violence, inactivity/passivity, over-activity, • Work-a-holism, intellectualization, burning, • Fighting, impression management, blaming, • Ruminating, worrying….. • Are functionally equivalent, yet our contexts require different levels of intervention

12. Strosahl (2004) says • Behavior differs in degree not in kind! • Distinctive features: • Behaviors are pervasive • Responses gain habit strength • Behaviors are resistant • Self-defeating • & the crisising takes on a life of its own….

13. Distress • In medicine = an aversive state in which an animal is unable to adapt completely to stressors and their resulting stress and shows maladaptive behaviors Institute for Laboratory Animal Research (1992). Recognition and alleviation of pain and distress in laboratory animals • Psychologically: situationally evoked intense emotions, which usually scare us and prompt us into action to terminate it Holmes & Georgescu (in preparation). Acceptance Based DBT. • We all experience this some of the time (e.g. panic)

14. & then there are folks • Who handle distress quite well • Who handle distress ok • And who seem to develop patterns of chronic distress…. • Or seem to experience distress constantly, become preoccupied with being distressed and fail to ever address the source • So that they are constantly reacting to their reactions

15. Chronic Distress • What is it? • In medicine • Use of the term is associated with heart failure & put forth by Dr. Denollet in the Netherlands • Has been linked with “type D personality” (not a mental illness) • Defined by 2 emotional states: • negative affectivity (worry, irritability, gloom) • social inhibition (reticence and a lack of self-assurance)

16. Behaviorists’ take • On Chronic Distress • Ongoing preoccupation with distress which we have evaluated as “intolerable” and prompts us to work harder, faster, in more drastic ways to control, reduce or eliminate the “intolerable” • Evaluative reaction to reactions • Emotion-phobia - much like panic disorder but overly vigilant to one’s emotions

17. A frequent occurrence Hpersensitivity to emotions! Trigger In about 2 minutes! Intense emotion Judgment about emotion Urges to self injure Fear & panic re: urges Action

18. Case example • 40 year old white female with a history of sexual abuse, rejection, isolation, & crisising behavior • Has had multiple hospitalizations residential care for cutting and suicidal gestures • She comes to you for outpatient treatment to work on trauma from sexual abuse

19. Theories applied • Emotional Dysregulation √ • Heightened sensitivity to emotions • Increased intensity • Slow return to baseline • Fusion & Experiential Avoidance √ • Interpersonally reinforced self-injury/crisis behavior√

20. How our treatments see it…. • DBT: emotional dysregulation pain + acceptance = pain pain + non-acceptance = suffering Target skill deficit • ACT: experiential avoidance dirty vs clean pain Target functional class • FAP: interpersonally reinforced over time/people Target CRBs

21. Treatment Request “I want to work on my trauma and sexual abuse history so I can stop feeling this way”

22. Using Control Flexibly • Depending on the consequences of target behaviors, aim for control in the service of eventual flexibility • Start with where the client is…. • It’s a shaping game: “loud” behaviors may require to be brought under control so that they can be shaped flexibility • Commitment, skill coaching and accountability • Sometimes offering fewer options is the effective thing to do

23. What Tx Packages Offer • DBT - based on skills deficit model & targets emotional dysregulation • Requires & assumes commitment to skills use throughout • Provides hierarchy • Self-injurious, other injurious • Therapy interfering behavior • Quality of life interfering behavior • Skills generalization

24. Packages Offer cont’d • ACT - based on RFT • targets experiential avoidance as functional class • Assumes choice throughout • FAP - based on behavioral principles • Provides framework for targeting in session moment to moment behaviors • Prioritization is functionally based

25. Common ingredients • All involve acceptance & defusion (implicitly or explicitly) • All are functional/ contextually based (functional analysis as home base) • All prioritize treatment targets • All use the therapeutic relationship • All provide a context for life-style change • All target behavioral/psychological flexibility in the long run

26. Building up the straw man

27. And exposing her to choice • The louder & more pervasive the presenting behavior (e.g. the stronger the reaction it elicits across environments), the more likely the need for shaping of new/alternate behaviors (skills) that are more “functional” • Commitment, coaching & accountability

28. Mapping Behavioral Processes • Stage I • Stage II Start here! DBT Mindfulness/FAP DBT Commitment & here! DBT Commitment/ Skills Training

29. Arbitrary lines in the sand • Self/other destructive • Relationship damage • Q of Life damage F A P Values _____________________________________________________ time Commitment Choice pliance augmenting tracking Stage I DBT ACT (Stage II DBT) threshold

30. Acceptance Based DBT Stage I • Replaced cognitive restructuring • Mindfulness/defusion • Willingness • Functional assessment • Introduced Values • During commitment conversation • In Emotion Regulation • Renamed skill areas • Living in the present • Living with Distress • Living with Emotions • Living with Others

31. ACT as stage II DBT • Slow progression from committing to choose (skills) to choosing to commit • Armed with skills (& ++ present moment awareness), shift from working on the one’s problematic solution to working on “the problem” • Greater interpersonal risks • Trust, Love & Companionship (CBR2) • Increased psychological (& behavioral) flexibility

32. Practically Speaking • Flexible therapeutic dance • Commitment (or not) by choice for some, perhaps not all behaviors • Articulating values across life domains • Facing past demons in the present with the safety of a new behavioral repertoire • Choice in mindfulness; experiential exercises; living a vital life

33. Successive approximations • Required structured mindfulness exercises • Attention control Attention • Practice like one would a fire drill - over & over • With time…. A choice, based on utility… • more experiential exercises (eyes on)

34. Successive approximations • Invalidation, self-invalidation, reactivity to one’s own experience With time & work… • Validation, self-validation, mindfulness of experience, action • Other validation & relationship flexibility

35. Successive approximations • Self under public control - I am who you say I am… • self-as content - I’m wrong…. With practice… self-as-process via mindfulness, behavior chains • Self under private control I though X I felt X I did X I could have used X skill • ACT as Stage II DBT… self-as context

36. I still use… • A hierarchy… • Self-injurious, other injurious • Therapy interfering behavior • Limits of the therapist (my CRB1) • Quality of life interfering behavior • Committed Action

37. Now for some practice! • Pick a client… who struggles LOUDLY! • Identify target behaviors for Stage I (DBT) • Prioritize using DBT’s hierarchy • Outline a “commitment talk” • Outline CRB1 & CRB2 that you will target • Prepare transition: Imagine it’s a year later and that the loudest behaviors have  • What choices would you offer them? • What commitments would you still hold them to? • Outline CRB1 & CRB2 (are they different?)

38. Role play! • 1st • Role-play the commitment conversation when they enter treatment: what will you tell them? • Then, • Role play the initial ACT (as Stage II) session: what choices will you giveoffer them? • When/how will you integrate the DBT skills previously learned? • & Don’t forget the FAP • How are the CRB1 & CRB2 different across time?

39. My Client • Committed to “building a life worth living” before working on trauma • Targeted self-injury, in session hostility & skill use (esp. overuse of telephone consultation) • Increased behavioral activation (job, living situation & friendships) • Choosing to commit at every step • Targeted experiential avoidance more broadly: ACT for trauma