The Shaping Game: integrating DBT, ACT

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The Shaping Game integrating DBT, ACT FAP

• SANDRA GEORGESCU, PSY.D.
• Paul Holmes Psy.D.

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• 1st - an apology
• Then, some compliments

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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
  doesnt neatly fit into the criteria AND use
  interventions that are more or less consistent
  with each package

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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)

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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

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some behaviors/solutions are louder or
more disturbing than others..
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Quick

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

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This is Jeanne shes in distress
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Do you know this person?
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How Todd spends his nights
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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

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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.

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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)

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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

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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)

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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 ones emotions

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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
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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

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Theories applied

• Emotional Dysregulation v
• Heightened sensitivity to emotions
• Increased intensity
• Slow return to baseline
• Fusion Experiential Avoidance v
• Interpersonally reinforced self-injury/crisis
  behavior v

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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

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Treatment Request

• I want to work on my trauma and sexual abuse
  history so I can stop feeling this way

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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.
• Its 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

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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

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Packages Offer contd

• 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

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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

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Building up the straw man
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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

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Mapping Behavioral Processes

• Stage I
• Stage II

Start here!
DBT Mindfulness/FAP
DBT Commitment
here!
DBT Commitment/ Skills Training
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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
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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

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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 ones
  problematic solution to working on the problem
• Greater interpersonal risks
• Trust, Love Companionship (CBR2)
• Increased psychological ( behavioral)
  flexibility

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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

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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)

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Successive approximations

• Invalidation, self-invalidation, reactivity to
  ones own experience
• With time work
• Validation, self-validation, mindfulness of
  experience, action
• Other validation relationship flexibility

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Successive approximations

• Self under public control - I am who you say I
  am
• self-as content - Im 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

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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

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Now for some practice!

• Pick a client who struggles LOUDLY!
• Identify target behaviors for Stage I (DBT)
• Prioritize using DBTs hierarchy
• Outline a commitment talk
• Outline CRB1 CRB2 that you will target
• Prepare transition Imagine its 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?)

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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?
• Dont forget the FAP
• How are the CRB1 CRB2 different across time?

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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