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.

DBT Assumptions about Therapy

DBT has a series of assumptions about clients and therapy.  Remember the first two assumptions are that the clients are doing the best they can and they want to improve, in part because they are motivated to change and their lives are unbearable as they are being lived.  For more information about the citations and references from Shari Manning, Kelly Koerner, and Marsha Linehan, please see the last paragraph of this post.

Before we look at the DBT assumptions about therapy, let's review the terms.  

To clarify, assumptions are not facts, so these assumptions might not fit with every client 100% of the time.  They do, though, set the context for the for treatment planning (Linehan, 1993, p. 106).

The most caring thing therapists can do is to help clients change in ways that bring them closer to their ultimate goals, also termed life-worth-living goals. 

Clarity, precision, and compassion are of the utmost importance in the conduct of DBT.  Shari Manning describes dialectical behavior therapy as compassionate behaviorism.  One goal is to hold up hope, "I know this can be better."   This is a reminder for both the client and therapist because therapy is intense and, at times, a painful process, as change and acceptance of "what is" are not easy to do.

The therapeutic relationship is a real relationship between equals.  In DBT, therapists are not on pedestals, so they do not have "more power" in the relationship dynamic. 

Principles of behavior are universal, affecting therapists no less than clients.  At times, there are characteristics and/or behaviors that the client does not like about the therapist and vice versa.  The client can bring these concerns to light during the session, just as the therapist can mention characteristics and/or behaviors that are affecting the therapy.

DBT therapists can fail and DBT can fail even when therapists do not.  "The analogy here is much like chemotherapy: when the patient dies, we don't blame the patient.  Rather, the assumption is that 'treatment fails' because the practitioner failed to follow the protocol or it could be that the treatment itself is inadequate and must be improved" (Koerner, 2012, p. 23).

Therapists treating highly dysregulated clients need support.  Highly dysregulated clients can be difficult to treat.  "Some of the problem stem from the patient's intense cries for immediate escape from suffering.  Often therapists are capable of soothing the pain, but giving such relief frequently interferes with providing help for the longterm.  Therapists get caught between these demands for immediate relief and for long-term cure" (Linehan, 1993, p. 108).  Therapists can do this by joining a consultation team that meets regularly and getting supervision when needed.

Citations and references: Shari Manning and Kelly Koerner have published a series of DBT assumptions about therapy in DBT.  Marsha Linehan also has a series of assumptions about therapy mentioned in the section about Assumptions About Borderline Patients and Therapy in "Cognitive-Behavioral Treatment of Borderline Personality Disorder;" see pages 106 to 108.  

 

To see Kelly Koerner's list, you will find this information on pages 20 to 24 of "Doing Dialectical Behavior Thearpy: A Practical Guide" (Koerner, 2012).  Both books can be purchased at Amazon.com or Guilford.com.

Quotes from Shari Manning and the Treatment Implementation Collaborative are published in the Core Clinical Training in Dialectical Behavior Therapy Participant Materials (Manning & TIC, 2013). 

Shari Manning and the Treatment Implementation Collaborative Present An Overview of Dialectical Behavior Therapy

There are great resources available online for those who would like to learn more about dialectical behavior therapy (DBT) and its applications in the clinical world.

For more information about Shari Manning and her work with dialectical behavior therapy, please visit the Overview of Dialectical Behavior Therapy by Shari Manning.

  

DBT Assumptions about Patients

In Marsha Linehan's Cognitive-Behavioral Treatment of Borderline Personality Disorder (The Big Red Book of DBT), there are eight assumptions about patients and therapy; the DBT assumptions about therapy will be discussed in an upcoming post.  This section can be found on pages 106 to 108 of the Big Red Book of DBT.  

Shari Manning and Kelly Koerner have published that there are seven assumptions about clients and many DBT assumptions about therapy, so right now we'll focus on the DBT assumptions about the patient or client.  Before we look at the assumptions, let's look at the terms.

To clarify, assumptions are not facts, so these assumptions might not fit with every client 100% of the time.  They do, though, set the context for the for treatment planning (Linehan, 1993, p. 106).  

Also, the terms in the Big Red Book (1993) and the Skills Training Manual (the Little Red Book; 1993) differ in how the text refers to the individual in treatment.  The Big Red Book uses the term patient, while the Little Red Book uses the term client.  To address this, Marsha Linehan's response in the Skills Training Manual is that "a case can be made for using either term" (1993, p. 7).  In this blog, the terms will be left as they were written by the author.  While this can be confusing to have inconsistencies, I would like for the author's direct terms to be left intact. 

First, patients are doing the best they can.  This is why the terms resistant and self-sabotaging are not used to describe the patient.  Metaphorically, individuals with borderline personality disorder can be described as having very thin emotional skin or having third degree burns, so the slightest touch, be it criticism or general comment, can be very painful.  This heightened sensitivity can lead to pain and suffering, so they look for something to deal with these emotions, thoughts, and physiological responses.  

"In my experience, borderline patients are usually working desperately hard at changing themselves.  Often, however, there is little visible success, nor are the patient's efforts at behavioral control particularly obvious much of the time.  Because their behavior is frequently exasperating, inexplicable, and unmanageable, it is tempting to decide that they are not trying. . . The tendency of many therapists to tell these patients to try harder, or imply that they indeed are not trying hard enough, can be one of the patient's most invalidating experiences in psychotherapy" (p. 106).  

Second, patients want to improve. "Assuming that patients want to improve, of course, does preclude analysis of all factors interfering with motivation to improve. . . The assumption by therapists that failures to improve sufficiently or quickly are based on failure of intent, however, is at best faulty logic and at worst one more factor that interferes with motivation (Linehan, 1993, p. 106).  

Kelly Koerner adds that the first two assumptions, that patients are doing the best they can and they want to improve, "lead us back to examine factors that interfere with needed behaviors" (Koerner, 2012, p.23). 

Third, patients need to do better, try harder, and/or be more motivated to change.  "The task of the therapist, therefore, is to analyze factors that inhibit or interfere with a patient's efforts and motivation to improve, and then to use problem solving strategies to help the patient increase her efforts and purify (so to speak) her motivation" (Linehan, 1993, p. 107).

How do we do this?  We can help them stay motivated through reinforcement and validation; coaching the patient to self-validate and find skillful ways to reinforce himself/herself is a way for the patient to build mastery and work toward the life worth living goals.

Fourth, patients may not have caused all of their own problems, but they have to solve them anyway.  "A borderline patient has to change her own behavioral response and alter her environment for her life to change. . . Improvement will not result from the patient's simply coming to a therapist and gaining insight, taking a medication, receiving constant nurturing, finding the perfect relationship, or resigning herself to the grace of God.  Most importantly, the therapist cannot save the patient. . . Surely if we could save patients, we would save them" (p. 107).  

Fifth, patients' lives are unbearable as they are currently being lived.  "Given this fact, the only solution is to change their lives" (Linehan, 1993, p. 107).  What do we do with the knowledge that his or her life is unbearable?  We look at the dialectic, acknowledge that it is unbearable, and work together about how to make it bearable (Manning & TIC, 2013).

Sixth, patients must learn new behaviors in all relevant contexts.  "Times of stress are the times to learn new ways of coping" (p. 107).  

Seventh, patients cannot fail in therapy.  "When patients drop out of therapy, fail to progress, or actually get worse while in DBT, the therapy, the therapist, or both have failed" (p. 108).  Prior to Stage 1 treatment, the client makes a commitment to therapy for a specific number of months.  

Dropping out is the only way for a client to leave DBT.  If the client misses four individual sessions or skills group sessions in a row, the Four Miss Rule comes into effect.  So as therapists, we need to motivate and encourage the clients to come back to group.  Participating in group and individual therapy is often mentally and emotionally taxing.  Look for creative ways to keep the clients and therapists motivated.  

Marsha Linehan's eighth DBT assumption about patients and therapy is that therapists treating borderline patients need support.  We will look into this in an upcoming post.

Shari Manning's Loving Someone With Borderline Personality Disorder: A Model of Emotion Regulation

Shari Manning is a leading expert in dialectical behavior therapy and author of "Loving Someone with Borderline Personality Disorder: How to Keep Out-of-Control Emotions from Destroying Your Relationship."

This lecture is available through the Treatment Implementation Collaborative and the NEA BPD.  Click here for the link to Shari Manning's Loving Someone With Borderline Personality Disorder: A Model of Emotion Regulation.  Here's the link: http://www.youtube.com/watch?v=Pstv6FZZlQw.

It's really insightful in deepening one's understanding of borderline personality disorder, looking at it from a compassionate, evidence-based perspective.  Shari explains dialectical behavior therapy as compassionate behaviorism, with behaviors as emotions, cognitions, and actions.  She provides the basic guidelines to responding to other people and building a life worth living. 

This is video is 2 hours and 19 minutes in length. Take a minute to find a pen and paper to take notes. 

Words to Avoid in Dialectical Behavior Therapy

Dialectical behavior therapy has roots in cognitive behavior therapy and has added validation and acceptance strategies into the theoretical framework. 
Shari Manning described DBT as compassionate behaviorism (Manning & TIC, 2013)

This series of words to avoid in DBT comes from the Core Clinical Training in DBT by the Treatment Implementation Collaborative (TIC) at the training in Houston by Shari Manning (2013). These words have also been mentioned in my counseling courses as a graduate student by students and instructors.

Terms used in DBT are behaviorally-specific and clearly defined.  "What you describe is what it is" (Manning & TIC, 2013).  When the words we say lack precision, we don't know exactly what the behavior occurred.  To know what happened, we need specific descriptions of the behavior to give us more information and ways to look for patterns.
 
These are terms that are not used in DBT, as they could be viewed as judgmental, pejorative, not descriptive, and/or not behavior-specific.  

Attention-seeking behavior.  This is not a specific behavior and it implies knowing the intention behind the behavior. 

Resistant.  This is not a specific behavior either.  One of the DBT assumptions about clients is that they are doing the best they can in the moment. 

Split.  This is a term from object relations theory by Robert Fairbairn that is also used in psychoanalysis.  Shari Manning described DBT as compassionate behaviorism (Manning & TIC, 2013).  Most often, behaviorists do not use this term, so it is not part of the DBT vocabulary.

Entitled.  This is a judgment and its use does not clearly define or describe a behavior.

Game-playing.  This implies intention that may or may not be there.  Again, game-playing is a subjective term without additional data about the observed behavior(s).

Gesturing.  Gesturing often refers to suicidal behaviors and implies intention.  We cannot determine intention based only on this word in a client's chart.

Acting out.  This is a common phrase in therapy and my study of educational psychology.  I could posit a few guesses about what the behavior could have been.  It is more helpful to have specific details about specific behaviors.  It seems to be a catch-all for behavior that may not meet the norms or rules in a specific setting.

Help-rejecting.  This one is particularly pejorative and implies the client's intentions, which are speculative at best.  We need more data before writing this in a chart or in case notes.

Self-sabotaging.  This implies intention.  Marsha Linehan discussed the issues of behavior change in the Big Red Book of DBT on page 106.

"In my experience, borderline patients are usually working desperately hard at changing themselves.  Often, however, there is little visible success, nor are the patient's efforts at behavioral control particularly obvious much of the time.  Because their behavior is frequently exasperating, inexplicable, and unmanageable, it is tempting to decide that they are not trying. . . The tendency of many therapists to tell these patients to try harder, or imply that they indeed are not trying hard enough, can be one of the patient's most invalidating experiences in psychotherapy" (p. 106).

Monitoring Change over time in DBT: DBT Diary Cards

In DBT, behavior patterns are monitored by self-report in diary cards.  These diary cards look like a table with a list of behaviors on the left and seven boxes that have ratings of 0 to 5 of the intensity of the urge for each day of the week; asterisks are placed adjacent to the rating if the adolescent acted on the urge. 

For example, an adolescent, whose target is cutting, experiences the urge to cut as a 4, which would be noted as 4* if she did decide to cut; see the left corner, so look at Monday and the urge column. 

Diary cards are filled out by the adolescent each day, often around bedtime.  The backside of the diary card tracks skill use with a similar chart system, as the adolescent places a check mark beside the skills she used each day.  This side is also important for the skills trainers to see that the adolescent is practicing the skills presented in the DBT skills group. 

There is a section of the diary card that asks for the number of times the adolescent filled out the card, as it can be difficult to remember or desire to find and fill out the diary card consistently.  See the upper right corner.

Sammy Banawan developed the DBT Diary Card app that is available in the App Store for $4.99.  The app keeps track of entries that can be downloaded and printed by the adolescent for use in individual therapy.  

A Dialectical View of Change

Knowing is not enough;

we must apply. 

Willing is not enough;

we must do.

(Goethe)  

With knowledge comes an understanding that there is a need for action, that we are not passive in this world. We are active agents in the course of our lives.  As humans we interact with others, therefore impacting them as well.  We influence their lives in ways that we cannot understand or appreciate in the moment.  One breathed word travels through waves to crash on the ears of another, bringing with it a message.

We cannot turn back to our previous selves because of the changing power of a message. Knowing more has set the stage for change.  With this new information comes a new perspective, an opportunity to see the dialectic. 

Let's explore dialectics.  Dialectics are the “synthesis of opposites” (Linehan, 1993a), or the merging of two opposing perspectives into a third new perspective that has elements of both perspectives.  The concept is similar to blending paints.  One splash of blue paint combines with a splash of yellow paint creates green paint.  We can see the value in all colors, just as we can see value in different perspectives.   

In dialectical thinking, the answer may be found in shades of gray, as opposed to the black-and-white world of absolutes and all-or-nothing views.  Maintaining a dialectical stance is essential because it allows us to see truth from many perspectives, not just our view, the adolescent’s view, or her family’s view.  

Incorporating multiple perspectives gives an increased knowledge base and may help in finding Wise Mind.  Wise Mind seeks the balance in emotions and thoughts to yield balanced behavior. 

Factors to Consider in Finding a DBT Treatment Center

A parent may ask, “In doing research online, I’ve seen and heard about cognitive behavioral therapy. What is the difference?”  Dialectical behavior therapy began as a cognitive behavioral therapy that soon added dialectics and validation.  CBT principles are used to target suicidal and other problem behaviors.  However, the unique foci of DBT are on dialectics, validation, and the dialectic of acceptance-oriented and change-oriented skills and strategies (Manning & TIC, 2013). 

In looking at selecting a treatment center for the individual, be sure to ask the center if their clinicians are members of a DBT consultation team who have attended the Core Clinical Training© in DBT, use diary cards in sessions to monitor behavioral changes over time, and follow the processes in Linehan’s treatment manuals (1993a; 1993b).  

There are inpatient and outpatient options in Houston, Texas.  The Menninger Clinic uses a combination of clinical approaches, including mentalization-based treatment (MBT) and DBT.  The Dialectical Behavior Therapy Center offers outpatient treatment with an intensive outpatient program (IOP) with skills groups and individual therapy with a DBT therapist, skills groups that meet each week, individual therapy, and medication management with board certified psychiatrists.  There are treatment sites in other locations across the U.S. and Canada.  There are often waiting lists to join a DBT program. 

In DBT, individual therapists focus on targeting specific behaviors that the client has agreed to work on changing, as arranged in the following hierarchy: life-threatening behaviors, therapy-interfering behaviors, and quality of life behaviors.  “You only get what you target. . . and what changes is what you work on” (Manning & TIC, 2013).  In adolescents with borderline personality disorder, common behavioral targets include: cutting, intentional overdosing, suicidal ideation, driving over the speed limit, purging, and restricting.  Consider the individual's concerns and behaviors when looking for the treatment plan that is a good fit for her.

The relationship between the individual and her therapist is essential in pushing for change while simultaneously accepting the adolescent in the moment and helping her radically accept herself; acceptance is not approval or agreement with the behavior or thought.  “Those who practice DBT are compassionate and dedicated to understanding the experience of BPD but at the same time believe, unwaveringly, that the most compassionate thing we can do is help people with BPD to change” (Manning, 2011). 

Dialectical Behavior Therapy versus Mentalization-Based Treatment for Borderline Personality Disorder

Two evidence-based treatment options for adolescents with borderline personality disorder are dialectical behavior therapy (DBT) and mentalization-based treatment (MBT).  

Dialectical behavior therapy emerged from a cognitive behavioral framework and added dialectics and validation to catalyze behavior change and acceptance.  The overall goal of DBT is a life worth living (Linehan, 1993; Manning & TIC, 2013). 

Mentalization emerged from investigating theory of mind and is defined as the “process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes” (Bateman & Fonagy, 2010, p. 11).  “Mentalization-based treatment is a model of psychodynamic therapy rooted in attachment theory that aims to enhance the individual’s capacity to represent thoughts, feelings, wishes, beliefs and desires in themselves and in others in the context of attachment relationships” (University College London Psychoanalysis Centre, 2013). 

The primary difference between the two approaches is that DBT is rooted in behaviorism, so there are specific targets and goal behaviors, and is more concrete than mentalization’s focus on thoughts and their frameworks, called schemata; essentially, the targets and goals are based on different perspectives and objectives.  Both have evidentiary support from randomized controlled trials, though DBT has a more substantial base of evidence with nine randomized controlled trials.

To learn more about mentalization-based treatment, visit the University College London's Psychoanalysis Centre at http://www.ucl.ac.uk/psychoanalysis/research/mbt.htm.