Top Five Questions to Ask Therapists Before Starting DBT

1.  When does your consultation group meet?

Treatment adherent dialectical behavior therapy groups have specific criteria that a clinic or program must follow.  DBT clinics must have a consultation group for their therapists.  These meetings are designed to support the treatment team.


2.  How are you using coaching?


The integration of technology in counseling has added a new dimension for supporting skill generalization and connection with the treatment team.  Even though confidentiality can be compromised, clients and therapists who use text messages, phone coaching, and emails can guide the client to practice mindfulness skills to regulate, check the facts, reframe the situation, and see the dialectic. 


3.  How are you using assessment to track change over time?


Diary Cards are essential for tracking the change over time for emotions, target behaviors, and DBT skills.  For more information about customized diary cards for clients with specific diagnoses and target behaviors, please contact Sarah C. Turner (me) at scturner@uh.edu. 


I have developed the DBT Diary Card--Texas Edition that includes the emotions, areas for target behaviors, and updated skills from the DBT(R) Skills Training Manual, Second Edition (Marsha Linehan, 2014).


Be sure to ask about developing the life-worth-living-goal, diary cards, chain analyses for working through the problem and target behaviors, and the transition the conversation into solution analyses.


4.  What types of training in dialectical behavior therapy and professional development did you and the staff receive to become DBT therapists?


Different training programs have different approaches for training mental health professions, clinicians, researchers, and staff.  Some are more intensive than others.


5.  Do all clients who come for treatment for a broad range of symptoms and diagnoses receive DBT?


Treatment choice is complicated.  Individuals who are seeking DBT usually carry comorbidities, such as depression and borderline personality disorder.  When looking at evidence-based practice, dialectical behavior therapy is not as effective for certain disorders as other evidence-based treatments. 

Symptoms of Borderline Personality Disorder: DBT versus DSM-5

Marsha Linehan's early work with individuals with chronic suicidal thoughts and behaviors became the solid foundation for applications of dialectical behavior therapy for individuals with borderline personality disorder.


Dr. Linehan's biosocial model with symptoms of Borderline Personality Disorder


Dr. Linehan viewed the symptoms of borderline personality disorder as a biosocial model of pervasive dysregulation.  Her biosocial approach was atypical, as most treatments for personality disorders were grounded in psychoanalytic and psychodynamic theoretical orientations.  Biosocial combines the biological/physiological and social perspectives to describe the extreme dysregulation and an invalidating environment.  To clarify, dysregulation (prefix "dys-" not + regulation); for example, emotional dysregulation refers to intense feelings and reactions based on the feelings that can fluctuate quickly and can come without a behavioral cue or warning.

1. Emotional Dysregulation (emotional ups and downs)
2. Behavioral Dysregulation (impulsivity)
3. Interpersonal Dysregulation (managing relationships)
4. Cognitive Dysregulation (focusing attention)
5. Self Dysregulation (knowing who you are, owning your identity, what you stand for)

The Diagnostic and Statistical Manual of Mental Disorders 5^th Edition (DSM-5)


DSM-5 is a manual that sets symptoms and threshold levels for the diagnosis of a psychiatric disorder or illness (American Psychiatric Association, 2013).  For the diagnosis of borderline personality disorder, five of the nine following symptoms must be present. 


DSM-5 categorical model of symptoms of Borderline Personality Disorder

1. Frantic effort to avoid real or imagined abandonment
2. Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance with markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging: spending (money), risky sex, substance abuse, reckless driving (speeding), binge eating
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilation behavior
6. Affective instability due to a marked reactivity of mood (“mood swings,” intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely for more than a few days
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

The sticky part of the DSM-5 categories for borderline personality disorder is the presentation.  Two individuals with marked, out-of-control behavior may only share a single criterion, but receive the same diagnosis.  Some clinicians and researchers pushed for a dimensional approach to personality disorders, not a categorical approach. 

My DBT Diary Card--Texas Edition © Sarah C. Turner, October 20, 2015

Thank you for your interest in the debut of

My DBT Diary Card--Texas Edition

Users must register and complete this form before I send the free PDF document to the email address provided in the form.






To preview screenshots and instructions of My DBT Diary Card--Texas Edition, visit my website at http://dbtin3months.blogspot.com.






My DBT Diary Card--Texas Edition is the new personalized instrument for diary cards that track specific behaviors, emotions, and DBT skill use. For a limited time, My DBT Diary Card--Texas Edition is a free resource for anyone interested in DBT, with the agreement for periodic user feedback and updates.






Please visit http://goo.gl/forms/nUgTpM9uiq to complete the form and receive the PDF version of My DBT Diary Card--Texas Edition, sent the email you provide in the user registration form.

Marsha Linehan's Long Awaited 2nd Edition DBT Skills Training Manual Comes to Amazon on October 20, 2014!

Marsha Linehan's groundbreaking Skills Training Manual is now in

the Second Edition and will be available on October 20, 2014!

Guilford Press and Amazon.com have pre-order options for Marsha Linehan's Second Edition of the Skills Training Manual.  




Click here to visit Marsha Linehan's page on Guilford Press.  You'll find more details about her other publications.  In a quick view of Guilford's website, you'll find many options to meet your interests and learning about evidence-based practice. 


"Most new and recent Guilford titles are available as e-books. Readers can now download e-books directly from Guilford or purchase them through Amazon (for the Kindle), Barnes & Noble (for the Nook), Kobo, Google Play, Apple's iBookstore, and eBooks.com, as well as other e-book vendors. Many public and university libraries also have access to Guilford e-books. Please visit our e-books page regularly to browse available subject areas and new titles.

"[Guilford's] website has been designed to make it simple to find exactly what you're looking for. You can view complete information on all in-print titles (and share it with your social networking contacts), including tables of contents, reviews, full-chapter excerpts for selected titles, and samples of reproducible handouts and forms. The site also includes electronic mailing lists for early notice on releases in specific fields, desk and exam copy information for instructors, information on publishing with Guilford, and job listings.

"Google book search on the Guilford website makes searching our titles easier than ever. This function allows you to view entire pages that contain your keyword or phrase. You can search a wide array of Guilford books or search an individual book (from the book's product page). Of course, you can also still search for Guilford products by title, author, or keywords to find the resources that meet your needs."

Click here to visit Marsha Linehan's page on Amazon.com. 

New to This Edition of the DBT Skills Training Manual (Amazon.com)

*Handouts and worksheets (available online and in the companion volume) have been completely revised and more skills and examples added, yielding over 225 in all.

*Each module has been expanded with additional skills.

*Multiple alternative worksheets to tailor treatment to each client.

*More extensive teaching notes, with numerous clinical examples.

*Curricula for running skills training groups of different durations and with specific populations (such as adolescents and clients with substance use problems).

Preliminary Reviews

"DBT is a proven evidence-based treatment that combines the best of our science with the knowledge and compassion of Marsha Linehan--an exceptional researcher and clinician whose innovative work has advanced the field and shifted many individuals from lives of suffering to lives of hope. These outstanding second editions offer guidance on how to implement DBT skills training, while providing the tools needed to deliver this state-of-the-art treatment. They will stand as the authoritative guides for teaching DBT skills, partnering with clients to build lives worth living, and helping us to address our national and international priorities of saving millions of lives lost to suicide worldwide. These 'must-have' books belong on the shelves of every clinician and will be valuable course texts." 

—Joan Rosenbaum Asarnow, PhD, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles

“DBT skills are useful not only for individuals who suffer from persistent emotion regulation difficulties, but also for individuals in extreme circumstances and people who have ordinary problems. This updated manual provides the ‘flexibility within fidelity’ in teaching these skills that practitioners and treatment adopters need. New, improved, expanded, and much clearer skills—they’re all here! Skills trainers and their clients will benefit from Linehan and her colleagues’ decades of systematic research and time spent developing, testing, and refining these skills, empowering practitioners to confidently offer multiple ways of understanding and practicing new behavior. Experienced skills trainers will notice the evolved richness and depth, while the explanations and teaching points will provide new trainers and students with an excellent foundation for skills training with both adults and adolescents. Providing a solid evidence-based foundation for core clinical training curricula, this manual and the accompanying volume of handouts and worksheets will be essential across the mental health disciplines.”

—André Ivanoff, PhD, Columbia University School of Social Work

 

Meeting Karyn Hall and a Mindfulness Activity: Observe and Describe Your Thoughts

Karyn Hall is one of the most talented psychologists I have ever met.  Her practice, the DBT Center- Houston, provides clients with options for comprehensive treatment teams with psychiatrists and DBT therapists.  Her books about validation and mindfulness activities are available on Amazon; click here to see "The Power of Validation" by Karyn Hall and Melissa Cook and click here for "Mindfulness Exercises" edited by Karyn Hall.

Karyn will call a spade a spade in an irreverent, non-judgmental way.  In the training exercises, she was dramatic in the role plays and captured the emotions presented in the dialogue.  With her, there are always teachable moments for reflection and new concepts to incorporate into schema about the therapeutic processes in DBT.  Her expertise in validation was evident, and, by the end of the activity, she had reached all of the levels of validation. 

 

She weaved mindfulness skills into the conversation, while teaching the DBT skills and explaining them in a clear, behaviorally-specific way. 


During the first training session at the Menninger Clinic, Karyn led one of my favorite mindfulness activities: Observe and Describe Your Thoughts.  DBT has a specific language that you adopt as you learn the skills and treatment protocols.  The What and How skills of Core Mindfulness are a good place to start. 

 

Mindfulness is about paying specific attention in a particular way on purpose. 

 

In Observe, you are directed just to notice your thoughts without attaching words, judgments, or preferences, as though you're watching waves come and go at the beach.  A wave is a wave. 

 

In Describe, you attach words to your thoughts. 


This is a place for the How Skills of Core Mindfulness. 


Shari Manning's explanation started in the heart of English grammar. 

• The What Skills (Observe, Describe, and Participate) are the verbs. 
• The How Skills (Non-judgmentally, One-Mindfully, and Effectively) are the adverbs.   

Adverbs are connected to verbs, in that adverbs provide context or thorough descriptions to show time, manner, place or degree.  
 

 The wonderful aspect about the Core Mindfulness skills is that you learn something new about yourself, your client, and your world outside your office. 

Dialectical Behavior Therapy Presents "DBT As Gambler" with Lyrics

"DBT As Gambler"

"DBT As Gambler" (to the tune of "The Gambler") was written by Charlie Swenson (2012) and performed by Charlie Swenson, Marsha Linehan, Helen Best, Shireen Rizvi, Melanie Harned, Adam Payne, Alec Miller, and Clive Robins at the annual ISITDBT conference in November 2013.  

Charlie Swenson and Shireen Rizvi performed the karaoke version of "The Gambler" after a long day of intensive training.  Swenson later wrote "DBT As Gambler" during a training in Maine. 

"DBT As Gambler" by Charlie Swenson (2012)

On a warm summer's evenin'
On my way back from treatment
I met up with a gambler
His game was DBT

We took turns a talkin'
'bout how things were goin'
Whether I was changin'
Through my therapy

He said, "Son I've made my life
Out of hearing people's stories
Seein' where they're stuck
And helpin' them to see,
So if you don't mind my sayin'
I can see you're goin' nowhere
If you give me some commitment
I'll try to set you free."

I knew he had me goin' 
When I gave him my commitment
That I would change my life
Instead of waitin' 'til I die
And the air grew very still
He sounded so irreverent,
Said, "if you want to fix your problems
Ya' got to look 'em in the eye."


Refrain
You've got to know when to solve 'em
Know when to soothe 'em
Know when to suck it up
And know when to run


You've never made no progress
Avoidin' all the struggles
You gotta sit down at the table
And join in on the fun


Now every gambler knows
The secret to effectiveness
Is knowin' when to validate
And knowin' when to fight
'Cause every day's a good one
And every day's a bad one
And the best you can hope for
Is to go to sleep each night.


So when he finished speakin'
And vanished into nowhere
I knew that he had dealt me
Some cards that I could play.
Now every time I hit a wall
And I think I'm goin' nowhere
I focus my attention
On the words I heard him say.

Refrain
You've got to know when to solve 'em
Know when to soothe 'em
Know when to suck it up
And know when to run


You've never made no progress
Avoidin' all the struggles
You gotta sit down at the table
And join in on the fun

Refrain (repeat)
You've got to know when to solve 'em
Know when to soothe 'em
Know when to suck it up
And know when to run


You've never made no progress
Avoidin' all the struggles
You gotta sit down at the table
And join in on the fun

DBT Chain Analysis and Solution Analysis with Shireen Rizvi and Lorie Ritschel

"Mastering the Art of Behavioral Chain Analyses in Dialectical Behavior Therapy" was presented by Dr. Shireen Rizvi and Dr. Lorie Ritschel at the Association of Behavioral and Cognitive Therapies (ABCT) on November 23, 2013.  

The primary topics were designed for therapists to review and learn the steps of creating chain analyses and solution analyses.  This was not limited to therapists who use dialectical behavior therapy.  Some of the terms used below have roots in other disciplines and theoretical orientations.  These terms will be presented using standard DBT terminology.

Chain analysis is the DBT term for behavior analysis.  One of the goals in creating chains is "to understand fully all events that led to the antecedents and consequences," said Shireen Rizvi.  

One of the differences between the solution analysis is DBT and other therapies is the emphasis on DBT solutions and skills, rather than focusing only on the consequences of the problem behavior. 

The chains presented used the visual model of DBT chains: starting with the vulnerability factors, determining the prompting event, following the links in the chain, creating alternative responses, targeting problem behaviors, and considering the consequences.  

The content in the chain analysis might not be presented in this order.  Dr. Marsha Linehan's manual for Cognitive-Behavioral Treatment for the Treatment of Borderline Personality Disorder begins with defining the problem behavior.  This might not be the first round of information presented by the client.  

The treatment hierarchy will determine which problem behavior will be analyzed first. In order, the treatment hierarchy is life-threatening behaviors, therapy-interfering behaviors, and quality of life behaviors.  These will be discussed in greater detail in a future post.

There can be multiple problem behaviors.  In sifting through a set of life-threatening behaviors, assess if the behavior is an action, urge, or ideation.   

The action is the trump card and will be discussed first, followed by urge, and ideation in the hierarchy.  

"Vulnerability factors provide context" for precipitating events and what led up to the straw that broke the camel's back (Koerner, 2012, p. 37-38).  Vulnerability factors can be thoughts, behaviors, actions, and emotions.  I would imagine that there are often multiple vulnerability factors that created the setting that led to the problem behavior.

In looking at the links in the chain, there needs to be a high level of detail.  Shari Manning described this as writing a movie script that is so specific that it could be directed and viewed by others.  Look for emotions, thoughts, sensations, and events. Be concise, specific, and precise. 

Physiological sensations: "What were you feeling in your body when you saw the email from your ex-boyfriend?"

Thoughts: "What were you thinking about when you looked at your iPhone after your ex-boyfriend emailed you?"

Emotions: "What was your emotion when you read the email from your ex-boyfriend?"

The last part of the DBT chain analysis is clarifying the consequences.  DBT describes consequences as "immediate or delayed reactions of the client and others that followed the problem behavior" (Koerner, 2012, p. 42).  These can be distal and proximal.  

The process of clarifying the consequences can be very dysregulating and may trigger strong emotions, such as shame and anger.  Therapists may be sure to orient the client to explain that dysregulation may arise from a thorough discussion of the problem behavior. 

 Shireen Rizvi discussed this as a possibility that the therapist may not want to hold the cue, which can result in changing the topic and reinforcing emotional avoidance.  She said this process is hard for the therapist and client.  Sometimes the therapist might not want to hold the cue, noticing the client's pain and tears.  She pointed back to the function of chain analyses as a way to understand behaviors so that they can work together to prevent them from coming back.