Dialectical Behaviour Therapy (DBT)

A Brief Introduction to Dialectical

Behaviour Therapy

Dr. Nathalie Lovasz, C.Psych (Supervised Practice)

Head of Adult DBT Program – The Mindfulness Clinic

Dr. Andrew Spice, C.Psych (Supervised Practice)

Head of Adolescent DBT Program – The Mindfulness Clinic

Agenda

Overview of DBT

–

Definition, development, research, adaptations

Section 1: Assessment and Case Conceptualization

•

Areas of Dysregulation: Signs that DBT may be helpful

•

Theoretical model

•

Stages of treatment; organizing treatment targets hierarchically

Section 2: Treatment

•

Core treatment strategies: Validation and chain analysis

•

DBT Skills

–

Distress Tolerance

–

Emotion Regulation

–

Interpersonal Effectiveness

–

Mindfulness

Section 3: Additional Issues in DBT

–

DBT and Other Professionals

–

Recommended Readings

–

Further Training

What is DBT?

•

Comprehensive cognitive-behavioural

treatment

–

Developed by Dr. Marsha Linehan at University of

Washington

–

Originally developed to treat chronically suicidal

clients diagnosed with Borderline Personality

Disorder

–

Found to be effective for suicidal clients with

multiple other co-occurring behavioural problems

Development of DBT

•

CBT did not work for clients with chronic

suicidality and BPD

–

Change focus was invalidating

–

Clients unintentionally reinforced therapists for

behaviours that were not helpful and

punished/extinguished helpful behaviours

–

Unrelenting crisis interfered with treatment/skills

acquisition

•

Solutions: Validation, Dialectics, Treatment

Hierarchy, Multi-modal treatment

Research Findings

•

DBT has been found to reduce

–

Suicidality

–

Parasuicidal behavior

–

Treatment drop-out

–

Hospitalizations

–

Substance Use

–

Depression, Hopelessness, Anger

(Linehan et al., 1991;1999; Koons et al., 2001, Verheul et al., 2003)

Adaptations of DBT

•

Substance Use

•

Adolescents/Children

•

Binge Eating

•

Bipolar Disorder

•

Couples

•

Inpatient

Components of a DBT Program

1.

Individual (DBT) Therapy

2.

Weekly Skills Training Group

3.

Phone Coaching

4.

Therapist Consultation Team

DBT-informed Therapy:

-

Any treatment that does not include ALL FOUR of the above

components

-

E.g. CBT therapy that incorporates some DBT skills

-

Group only Skills Training

-

Skills Group + Individual Therapy without Phone Coaching

-

Skills Group, Individual Therapy, Phone Coaching but no consultation

team

Assessment and Case

Conceptualization

Symptoms of Borderline

Personality Disorder

•

Emotion Dysregulation

–

Unstable Emotions/Mood

–

Intense Anger/Difficulty

Controlling Anger

•

Interpersonal Dysregulation

–

Unstable/Intense

Relationships

–

Frantic Efforts to Avoid

Abandonment

•

Behavioural Dysregulation

–

Impulsive/Self-Damaging

Behaviours

–

Suicide/Self-harm

•

Identity/Self Dysregulation

–

Unstable Sense of

Self/Identity

–

Feelings of Emptiness

•

Cognitive Dysregulation

–

Stress Related Paranoid

Thoughts

–

Dissociation

Practice 1

Identify Areas of Dysregulation in a Practice

Case

Choose one of the two case vignettes provided. Identify as many

areas of dysregulation as possible in the case vignette:

•

Emotion

•

Interpersonal

•

Cognitive

•

Behavioural

•

Identity/Self

Biosocial Model of BPD

EMOTIONAL VULNERABILITY

•

Emotional Sensitivity: More easily triggered emotions

–

Responding with intense emotions to things that may

not cause any emotion for someone else

–

“Thinner emotional skin”

•

Emotional Reactivity: More intense emotions

–

Higher emotional baseline

•

Slow Return to Baseline: Emotions that stick around

longer

Biosocial Model of BPD

INVALIDATION

•

Emotional Fit: It can be difficult for people with less

intense emotions to understand or teach those with

more intense emotions how to manage their emotions

•

Denial/Suppression of Emotions: With more intense

emotions, people either doubt and ignore their emotions

until they explode or become more intense in emotional

expressions

•

Reciprocal Effects: Emotions that are more intense than

average are more likely to be dismissed by others

•

Absence/Abuse/Neglect: These can also teach people to

ignore, doubt, or push away emotions

Biosocial Model of BPD

EMOTIONAL VULNERABILITY

+

INVALIDATION

=

BORDERLINE PERSONALITY DISORDER

Practice 2

Apply the Biosocial Model to a Practice Case

Choose one of the vignettes provided. Identify any information

you have that applies to the Biosocial Model:

•

Emotional Vulnerability

•

Experiences of Invalidation

Stages of Treatment

•

Stage I: Stabilization

–

Focus:

•

Treatment Hierarchy:

–

Reduce Life-Threatening Behaviours

–

Reduce Therapy-Interfering Behaviours

–

Reduce Quality-of-Life-Interfering Behaviours

–

Increase Skills that Replace Ineffective Coping

–

Goal:

•

Move from behavioural dyscontrol to control to achieve

a normal life expectancy

Target Hierarchy in Stage I

1.

Life-Threatening Behaviours

–

Suicide

–

NSSI

2.

Therapy-Interfering Behaviours

–

E.g. Missing sessions, not completing homework,

behaviours that interfere with therapist’s motivation to

treat client

3.

Quality-of-Life-Interfering Behaviours

–

E.g. Substance use, eating disordered behaviours, inability

to keep employment, educational Issues

4.

Skills Acquisition

–

To replace dysfunctional behaviours

Stages of Treatment

•

Stage II: Suffering in Silence

–

Focus:

–

Address inhibited emotional experiencing

–

Reduce PTSD symptoms

–

Goal:

•

Move from quiet desperation to full emotional

experiencing

Stages of Treatment

•

Stage III: Build a Life Worth Living

–

Focus:

•

Problems in Living

–

Goal:

•

Life of ordinary Happiness and Unhappiness

•

Stage IV: Address Issues of Meaning (Optional)

–

Focus:

•

Spiritual Fulfilment

•

Connectedness to Greater Whole

–

Goal:

•

Move from incompleteness to ongoing capacity for

Experiences of Joy and Freedom

Practice 3

Identify stages of treatment and applicability of

the treatment hierarchy to a practice case

1.

Choose one of the provided case vignettes. List any therapy

goals you and the client might choose to work on

2.

Identify at what stage of treatment you would work on each

of these goals

3.

For Stage I Goals, create a treatment hierarchy:

•

Life-Threatening Behaviours

•

Therapy-Interfering Behaviours

•

Quality-of-Life Interfering Behaviours

•

Skills Acquisition

Treatment

Core DBT Strategies

•

Validation 

and 

problem-solving 

form the core

of DBT

–

All other strategies built around them

•

Problem-solving strategies are 

change-based

–

Analyzing behaviour, committing to change, taking

steps to change

•

Validation strategies are 

acceptance-based

–

Engaging client in understanding actions,

emotions, and thoughts

Core DBT Strategies: Validation

•

VALIDATION MEANS:

–

Communicating to the client that their

responses make sense and are

understandable within current life context

–

Finding the kernel of truth in the client’s

perspective or situation

–

Acknowledging causes of emotions,

thoughts, and behaviours

Core DBT Strategies: Validation

•

IMPORTANT THINGS TO VALIDATE:

–

Emotions: Feelings, wanting, suffering, difficulties

–

Thoughts: Beliefs, opinions, or thoughts

–

Actions

–

Abilities

•

REMEMBER:

–

Every invalid response makes sense in some way

–

Validation is not necessarily agreeing

–

Validation doesn’t mean you like it

–

Only validate the valid

A “How To” Guide to Validation

•

PAY ATTENTION: Listen actively with body and

mind.

•

REFLECT BACK: Say back what you heard

descriptively and non-judgmentally.

•

READ MINDS: Be sensitive to what is not being

said by the client. 

Be open to correction.

•

UNDERSTAND: Look for how the client’s

emotions, thoughts, and actions make sense

given their history, state of mind, or current

situation, 

even if you don’t approve 

of the

behaviour, emotion, or action itself.

A “How To” Guide to Validation

•

ACKNOWLEDGE THE VALID: Show you are

taking the client seriously by what you say and

do

•

SHOW EQUALITY: Be yourself! Treat the client

as an equal, not as fragile or incompetent

Practice 4

Practice validation

1.

Get into pairs

2.

One person will be the “storyteller,” one person will be the

“validator”

3.

The storyteller tells a story of something that recently

happened to them and that elicited some emotion

4.

The validator listens and responds 

only

 with validation

5.

Switch roles

Core DBT Strategies: Chain Analysis

•

Core 

problem-solving 

strategy

•

Purpose: examine events and situational

factors leading up to and following a

problematic response

Steps of a Chain Analysis

1.

Choose a specific instance of behavior to

analyze

2.

Describe the behavior specifically

–

Topography (“What exactly did you do?”; “What

exactly do you mean by that?”)

–

Frequency (“How many times did you do that?”)

–

Intensity (“How intense was the feeling on a 1-100

scale?”)

Steps of a Chain Analysis

3.

Determine 

antecedents

–

Link client’s behavior to environmental events

•

Internal 

and 

external 

events

–

Ask when the problem began

•

“What set that off?”

•

“What was going on the moment the problem started?”

–

Fill in links in terms of 

small 

units of behavior

•

Doing, feeling, thinking, imagining

–

Once one link is described, determine the next

•

“What next?”

•

“How did you get from feeling like you wanted to talk to me

to calling me on the phone?”

Steps of a Chain Analysis

4.

Determine 

consequences

–

Those influencing problem behaviour by

maintaining, strengthening, or increasing it

–

E.g., preferable events, stopping of aversive

events, opportunities to engage in preferable

behaviours

–

Assess 

external 

and 

internal 

events

5.

Determine function of the behaviour

Sample Chain Analysis

Behaviour: Overdose (with suicidal intent)

Vulnerability:

Intoxicated

Event:

Fight with

boyfriend

Thought:

“He will

leave

me”

Emotion:

Panic

Thought:

“I can’t

live

without

him”

Emotion:

Despair

Urge: 

Take

pills to

forget

Thought:

“Will be

better if

I’m

dead”

Action:

Walk to

bathroom

and get

pills

Action:

Take pills

Event:

Picked up

by EMS

Event:

Boyfriend

visits in

hospital

Emotion:

Love

and

affection

 Problem

 Behavior

D

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      Name: _______________  Date: ______  Target Behavior: _________________________

 Vulnerability

    Factors

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Things in myself and my environment that made me

vulnerable:

  Ways to reduce vulnerability in the future:

Consequences in the environment?                                    Plans to repair, correct, and over-correct harm:

Consequences in myself?

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Prompting Event:

                                                           Ways to prevent prompting event in future:

Adapted from Marsha Linehan

’

s Chain Analysis Worksheet by Seth Axelrod, PhD 2/13/04





Actual Behaviors and Events:

                                 Skillful alternative behaviors:

Consequences

    and Harm

(Immediate and

delayed)

Practice 5

Practice chain analysis using a practice case

1.

Get into pairs

2.

Choose one of the two vignettes provided

3.

One person will role play the client, one person will role play

the counsellor

4.

Choose a specific behaviour from the case vignette to chain

analyze e.g., cutting, waiting for faculty member in the

parking lot

5.

Role play a chain analysis of this behaviour. The counsellor

will have to ask as many questions as needed to “fill in the

links of the chain”

DBT Skills

•

Distress Tolerance

•

Emotion Regulation

•

Interpersonal Effectiveness

•

Mindfulness

Distress Tolerance

“How to get through a crisis without

making things worse”

Distress Tolerance: Crisis Survival

Skills

•

CRISIS SURVIVAL SKILLS are needed:

–

When client is in a situation that is

•

Highly stressful

•

Short-term

•

Creating intense pressure to resolve the crisis now

–

AND

•

Acting on emotions and urges will make things worse

•

Client cannot make things better right away

•

Client must temporarily tolerate painful events and emotions

•

CRISIS SURVIVAL SKILLS are 

not 

for:

–

Everyday use

–

Solving all of life’s problems

–

Making life worth living

STOP Skills

S

top

Do not just react. Stop! Freeze! Do not move a muscle! Your emotions may try to

make you act without thinking. Stay in control!

T

ake a step back

Take a step back from the situation. Get unstuck from what is going on. Let go.

Take a deep breath. Do not let your feelings put you over the edge and make you

act impulsively.

O

bserve

Take notice of what is going on inside and outside of yourself. What is the

situation? What are your thoughts and feelings? What are others saying or doing?

P

roceed mindfully

Act with awareness. In deciding what to do, consider your thoughts and feelings, the

situation, and the thoughts and feelings of other people. Think about your goals. What do

you want to get from this situation? Which actions will make it better or worse?

TIPP Skills

•

T

IP YOUR TEMPERATURE

•

I

NTENSELY EXERCISE

•

P

ACE YOUR BREATHING

•

P

ROGRESSIVELY RELAX YOUR MUSCLES

TIPP Skills

•

T

ip the TEMPERATURE of your face: use ice water to calm

yourself down 

fast 

by changing the response of your

autonomic nervous system

–

Put your face in a bowl of ICE WATER (30 seconds)

–

OR splash ICE WATER on your face,

–

OR hold a gel ICE pack (or zip-lock ICE WATER) on your

face.

•

I

NTENSELY EXERCISE to calm down a body revved up by

emotion 

–

Engage in intense exercise, if only for a short while.

–

Expend your body’s stored up physical energy by: Running,

Walking , Fast Jumping, Playing Basketball, Weight Lifting,

etc.

TIPP Skills

•

P

ACE YOUR BREATHING BY SLOWING IT DOWN 

–

Slow your pace of inhaling and exhaling 

way down 

(on

average 5 to 7 breath cycles per minute).

–

Breathe deeply from the abdomen.

–

Breathe more slowly 

out 

than when breathing 

in 

(for

example, 4 seconds in and 8 seconds out).

•

P

ROGRESSIVELY RELAX YOUR MUSCLES 

–

Starting with your hands, moving to your forearms, upper

arms, shoulders, neck, forehead, eyes, cheeks & lips,

tongue & jaw, chest, upper back, stomach, buttocks,

thighs, calves, ankles, feet.

–

TENSE (5 seconds), then let go and RELAX each muscle (all

the way).

–

NOTICE the tension. NOTICE the difference when relaxed.

Pros and Cons

•

Use PROS and CONS anytime you have to decide between two

courses of action.

Distraction

A way to remember these skills is the acronym “ACCEPTS”

A

ctivities:

–

Refocus your attention on the task you have to get done

–

TV, events, exercise, internet, sports, hobbies

C

ontributing:

–

Volunteering, help a friend, encourage someone

C

omparisons:

–

Compare how you are feeling now to a time when you felt different

Different 

E

motions:

–

Books, stories, movies, music

P

ushing Away:

–

Leave the situation; block thoughts from your mind

Other

T

houghts:

–

Counting; puzzles

Other

S

ensations:

–

Squeeze a rubber ball; hold ice; go out in the rain

Self-Soothing

A way to remember these skills is to think of soothing each of your

FIVE SENSES:

Vision:

•

Stars at night; pictures in a book, nature, candles

Hearing:

•

Soothing music; invigorating music; sounds of nature; sounds

of the city

Smell:

•

Soap, incense, coffee, essential oils, boil cinnamon

Taste:

•

Favourite foods; soothing drinks; chew gum

Touch:

•

Hot baths; pet your dog or cat; creamy lotion; comfortable

clothing

Group Discussion 1

Discuss how Distress Tolerance skills may be

helpful to our practice cases

At your table, choose one case vignette.

1.

How could these distress tolerance skills help the client in the

vignettes accomplish their treatment goals?

2.

How would you teach these skills to a client?

Emotion Regulation

“How to understand emotions, change

ineffective emotions, and be less

vulnerable to negative emotions”

Emotion Encyclopedia

Model of Emotion: Observe and

Describe Emotions

•

Prompting Event

–

What set off the emotion?

•

Emotion

–

i.e., anger, fear, joy

•

Interpretations

–

Thoughts, judgments, beliefs

•

Experiencing

–

Body changes

•

Action Urges

–

e.g., withdraw, attack, eat

•

Expressing

–

Behaviours – what you said or did

•

Aftereffects

–

Consequences – your state of mind; others’

reactions; reinforcements

Opposite Action

•

Fear

–

Urge: Freeze, run, avoid

–

Opposite action: 

Approach

•

Anger

–

Urge: Attack, hit, yell

–

Opposite action: 

Gently avoid; do something nice

•

Sadness

–

Urge: Withdraw, cry, isolate

–

Opposite action: 

Get active

•

Guilt/Shame

–

Urge: Hide/avoid

–

Opposite action: 

Face the music; repair mistakes

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Group Discussion 2

Discuss how Emotion Regulation skills may be

helpful to our practice cases

At your table, choose one case vignette.

1.

How could these emotion regulation skills

help the client in the vignettes accomplish

their treatment goals?

2.

How would you teach these skills to a client?

Interpersonal Effectiveness

“How to get your needs met while

maintaining your relationships and self-

respect”

Identifying Interpersonal Priorities

•

Goal Effectiveness

–

What do I want from the other person?

•

Relationship Effectiveness

–

How do I want the other person to feel about me?

•

Self-Respect Effectiveness

–

How do I want to feel about myself?

Goal Effectiveness – DEAR MAN

•

What to say: DEAR

–

D

escribe: 

Describe the situation. Stick to the

facts.

–

E

xpress: 

Express feelings using “I” statements.

–

A

ssert: 

Ask for what you want.

–

R

einforce: 

Explain positive effects of getting what

you want.

Effectively making a request

Goal Effectiveness – DEAR MAN

•

How to say it: MAN

–

M

indful: 

Keep your focus on what you want.

–

A

ppear confident: 

Make eye contact; confident

tone of voice

–

N

egotiate: 

Be willing to give to get. Ask for the

other person’s input.

Effectively making a request

Practice 6

Practice using DEAR MAN to make a request

1.

Get into pairs

2.

One person will make a request using DEAR MAN

for something a person might ask of another person

3.

Switch roles

Mindfulness

“How to pay attention to the present

moment without judgment, rejection, or

attachment”

Mindfulness

“WHAT” SKILLS

•

Observe

•

Describe

•

Participate

“HOW” SKILLS

•

Non-judgmental

•

Effective

•

One-mindful

Non-judgmental

•

Notice, but don’t evaluate as “good” or “bad”

•

Acknowledge harmful and helpful, but don’t judge

–

E.g., replace “You’re a jerk” with “I feel mad when you do that”

•

Catch judgments so that you have more control over

your emotions

•

Steps

1.

Notice judgments

2.

Don’t judge your judgments

3.

Replace judgments with descriptions (things you can see,

hear, feel, taste, touch)

Practice 9

Practice non-judgmental

1.

Get into pairs

2.

Think of a difficult client you have worked with or

choose a client from the case vignettes

3.

Describe your client to the other person without

judgment

4.

For the listener: pay attention and note any

judgments that occur

5.

Switch roles

Additional Issues in DBT

•

Interacting with Other Professionals

•

Further Training

•

Recommended Readings

DBT and Other Professionals

•

Ancillary mental health treatments are acceptable in DBT

–

However, there can be only one primary individual therapist at

a time

•

“Consultation to the patient” approach:

–

Teach the client to act as their own agent in obtaining

appropriate care

–

Do not intervene, solve problems, or act for the patient with

other professionals

•

Rationale:

–

Teaching effective self-care

–

Decreasing “splitting”

–

Promoting respect for the client

When Another Professional Calls:

•

Obtain as much information about the

situation as they will give

•

Provide caller with necessary information the

client cannot give, and verify information

client has given

•

Tell them to follow their normal procedures

•

Ask to talk to the client

•

Coach client on how to best cope with

situation and interact with the professionals

Further Training and Certification

•

Training Opportunities

–

Behavioral Tech

•

Founded by Marsha Linehan

•

Gold Standard for Training

•

Online workshops/training, Web Shorts, Multi-day

Workshops, Consultation, Intensive Trainings for Individuals

and Teams

•

http://behavioraltech.org/training/

–

Oshawa Psychotherapy Training Institute

•

Facilitated by Clinicians from CAMH

•

Four-part Training – 2 days each, often offered to suit 9-5

work schedules (evening and weekend)

•

Parts can be taken individually

•

http://www.oshawapsychotherapytraining.com/courses/certi

ficate-programs/dbt-1

Further Training and Certification

•

Training Opportunities

–

CAMH

•

Dialectical Behaviour Therapy Certificate Program

•

Four-part training – A-D, 8 evenings each

•

http://www.camh.ca/en/education/about/AZCourses

–

The Mindfulness Clinic

•

Supervision, Consultation, Individualized Workshops

•

DBT Training Courses may be offered in the future

•

Parts can be taken individually

•

http://www.themindfulnessclinic.ca/therapy-

training/dialectical-behaviour-therapy-dbt/

Further Training and Certification

•

DBT Certification

–

Offered through Linehan Institute

–

Requires:

•

Graduate Degree from Accredited Institution

•

Licensed as independent mental health provider

•

40-hours of Didactic DBT Training

•

Completion of Treatment with at Least Three DBT cases using full-mode

DBT

•

12-months and current participation on DBT consultation team

•

Read skills manual, complete all homework in skills manual, facilitate

teaching of all skills in manual in individual or group format

•

Exam

•

Letter of Recommendation

•

Work Product Demonstration

•

Demonstrated Mindfulness Experience

–

Other Certification Programs Exist but do not offer the same

standards/credibility

Options for Treatment Referrals in

Ontario

Publically Funded

•

Toronto, ON

–

Centre for Addiction and Mental Health

–

Davenport Perth Neighbourhood Centre – Surfing

Tsunamis Program

•

London, ON

–

London Health Sciences Centre – Victoria Hospital

•

Hamilton, ON

–

St. Joseph’s Health Care DBT Program

Options for Treatment Referrals in

Ontario

Private Treatment Options

–

The Mindfulness Clinic: Toronto, ON

•

Comprehensive Adult and Adolescent DBT Program

–

Individual Therapy

–

Adult Skills Training Groups

–

Adolescent Multi-Family Skills Training Groups

–

Phone Coaching

–

Weekly Therapist Consultation Team

–

More info:

http://www.themindfulnessclinic.ca/therapy-

training/dialectical-behaviour-therapy-dbt/

Options for Treatment Referrals in

Ontario

Private Treatment Options

•

Broadview Psychology: Toronto, ON

•

http://www.broadviewpsychology.com/

•

Behavioural Health: Guelph, ON

•

Comprehensive DBT Program

•

http://www.behaviouralhealth.net

•

Dr. Carmen Weiss & Associates: Burlington, ON

•

Group and Individual DBT-based Treatment

•

http://drcarmenweiss.ca/group-options/dialectical-

behaviour-therapy-dbt-options/

Further Reading

Further Reading

References

Dimeff, L. A., & Koerner, K. (Eds.) (2007). 

Dialectical Behavior Therapy in clinical practice: Applications across disorders and

settings. 

New York: Guilford Press.

Linehan, M. M. (1993). 

Cognitive Behavioral Treatment of Borderline Personality Disorder

. New York: Guilford Press.

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