Dialectical Behaviour Therapy in Perth North Metro Area

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Dialectical Behaviour Therapyin Perth North
Metro Area

• Margaret Cole
• 11th July 2006

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• Goal
• To Build A Life Worth Living

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• Steps
• 1. Clear Structure
• 2. Do Behaviour Therapy
• 3. Add Validation
• 4. Add Dialectics
• 5. Add Mindfulness

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1. Clear Structure
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Assumptions About Clients Therapy

• 1. Clients are doing the best they can
• 2. Clients want to improve
• 3. Clients need to do better, try harder and be
  more motivated to change
• 4. Clients may not have caused all of their own
  problems but they have to solve them anyway
• 5. The lives of suicidal borderline individuals
  are unbearable as they are currently being lived
• 6. Clients must learn new behaviours in all
  relevant contexts
• 7. Clients cannot fail in therapy
• 8. Therapists treating borderline clients need
  support

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Assumptions about Therapy Therapists

• 1. The most caring thing a therapist can do is
  help clients change in ways that bring them
  closer to their ultimate goals (unwavering
  centredness)
• 2. Clarity, precision and compassion are of the
  utmost importance in the conduct of DBT
• 3. The therapeutic relationship is a real
  relationship between equals (there are
  differences in expertise but no arbitrary power
  differential)
• 4. Principles of behaviour are universal,
  affecting therapists no less than clients
• 5. DBT therapists can fail
• 6. DBT therapy can fail even when therapists do
  not
• 7. Therapists treating borderline clients need
  support

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AgreementsTherapist Agreements

• EVERY REASONABLE EFFORT AGREEMENT
• ETHICS AGREEMENT
• PERSONAL CONTACT AGREEMENT
• CONSULTATION AGREEMENT

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Therapist Consultation Agreements

• DIALECTICAL AGREEMENT
• CONSULTATION TO THE CLIENT AGREEMENT
• CONSISTENCY AGREEMENT
• OBSERVING LIMITS
• PHENOMENOLOGICAL EMPATHY AGREEMENT
• FALLIBILITY AGREEMENT

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Client Agreements

• ONE YEAR THERAPY AGREEMENT
• ATTENDANCE AGREEMENT
• SUICIDAL BEHAVIOURS AGREEMENT
• THERAPY-INTERFERING BEHAVIOURS AGREEMENT
• SKILLS TRAINING AGREEMENT
• RESEARCH AND PAYMENT AGREEMENT

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2. Do Behaviour Therapy
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• The consequences of a behaviour affect the
  probability of the behaviours occurring again.
• Every therapist response experienced by the
  client can be neutral, punishing or reinforcing,
  thus every contingent response is an informal
  contingency procedure.

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Behavioural Assessment

• There is no substitute for good behavioural
  analysis to determine what is prompting and
  maintaining maladaptive behaviour
• Chain Analysis

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Assess Necessary Intervention

• 1. Are the behaviours in the persons behavioural
  repertoire?
• No Behavioural Skills Training
• 2. Are ineffective behaviours being reinforced?
• Yes Contingency Management
• 3. Are effective behaviours inhibited by
  unwarranted fears or guilt? Is the person
  emotion phobic?
• Yes Exposure
• 4. Are effective behaviours inhibited by faulty
  beliefs and assumptions?
• Yes Cognitive Modification

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3. Add Validation
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Levels of Validation

• 1. Staying awake unbiased listening and
  observing
• 2. Accurate reflection summarising
• 3. Articulate the unverbalised emotions,
  thoughts or behaviour patterns take a slight
  leap and read beyond what theyve said, may be
  safer to use a multiple-choice approach
• 4. Validation in terms of past learning or
  biological dysfunction
• 5. Validation in terms of present context or
  normative functioning
• 6. Radical genuineness being yourself with the
  client as you are with others, same tone of
  voice, same language, not stepping into a role

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4. Add Dialectics
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Dialectics 1 - A World View

• 1. The Principle of Interrelatedness and
  WholenessSystems perspective on reality
  (identity is relational)
• 2. The Principle of PolarityReality is not
  static but is comprised on internal opposing
  forces out of which synthesis is
  achieved.Contradictory truths do not
  necessarily cancel each other out or dominate
  each other, but stand side by side, inviting
  participation and experimentation Goldberg
  (1980)
• 3. The Principle of Continuous ChangeChange, or
  process, rather than structure or content, is the
  essential nature of life.Role of conflict and
  opposition in the change process.

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Dialectics 2Dialogue Relationship

• About balancing with the client see-saw example
• Change by persuasion
• Personal account of events, exposing
  contradictory positions
• The spirit of a dialectical point of view is
  never to accept a final truth or indisputable
  fact.
• Thinking what is being left out of our
  understanding?
• (To avoid splitting, which almost always results
  from a clinician assuming that they, and
  sometimes they alone, have the truth about a
  client or clinical problem)

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Dialectical Dilemmas Posed by Borderline Clients

• Active Passivity VS Apparent Competence

Some times appear competent Able to cope in some
situations Coping followed by crisis Difficulty
generalising
Passive, helpless problem solving Tries to get
others to help Emotion focused coping
Dilemma Needs help but feels shame for asking Is
it lack of motivation or lack of
skills? Therapist too demanding vs too rescuing
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Dialectical Therapist Characteristics

• Finding a balance between apparently opposing
  stances
• Oriented to Change VS Oriented to
  Acceptance

Necessity of change Clients wish to
change Principles of Behaviour Change
Acceptance exactly in this moment As things are
right now Inherent wisdom and goodness of
current moment
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Mistakes are inevitable what the therapist does
afterwards is a better index of good
therapyLinehan
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Dialectical Therapist Techniques

• Finding a balance between apparently opposing
  stances
• Validation VS Problem Solving

Active observing Reflection Search for validity
Active approach Behavioural focus
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Dialectical Behaviour Patterns Balanced
Lifestyle

• Walking the middle path through the following
  areas
• Skill enhancement VS Self-acceptance
• Problem solving VS Problem acceptance
• Affect regulation VS Affect tolerance
• Self-efficacy VS Help seeking
• Independence VS Dependence
• Transparency VS Privacy

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5. Add Mindfulness
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General Goal of Skills Training

• To learn and refine skills in changing
• behavioural, emotional and thinking
• patterns associated with problems
• in living, that is, those
• causing misery and
• distress.

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General Points

• Shot gun approach some of the skills will work
  for some of the people some of the time
• The parts of the skills are rarely new, but the
  combination often is
• Clients need to be convinced that what theyre
  learning is going to be useful, relevant to them
  (marketing the skills)
• Clients will often have attended other groups,
  need to discuss how this might be different (e.g.
  not process oriented)
• Emphasize goal of long-term relief vs. immediate
  relief
• Emphasize need for practice, practice, practice

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The Skills

• Core mindfulness
• Interpersonal effectiveness
• Emotion regulation
• Distress tolerance

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Mindfulness

• bringing an unshakeable friendliness and deep
  degree of curiosity and interest to what is
  happening in and around you and doing this again
  and again and acclimatising to this way of being
• Tarchin Hearn

Mindfulness in totality has to do with the
quality of awareness that a person brings to
activities Marsha Linehan
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Interpersonal EffectivenessAsking Saying No
Objectives Effectiveness How to get what you
want Relationship Effectiveness How to maintain
the relationship Self-Respect Effectiveness How
to keep your self-respect
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Emotion Regulation
Goals 1. Understand emotional experience 2.
Reduce emotional vulnerability 3. Decrease
emotional suffering
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Distress Tolerance
Surviving a situation you cant change Crisis
Survival Reality Acceptance
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North Metro DBT Program

• Referral Process
• Entry to group every 6 months
• 12 month commitment
• 8-10 per group desirable
• Weekly skills group, 2½ hours
• Weekly individual therapy
• Fortnightly consultation meeting
• Follow-up group
• Annual 2 day training for NMMHS staff
• Outcomes research