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. 

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

 

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.

  

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. 

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.

Biosocial Theory in a Nutshell

The theoretical orientation of dialectical behavior therapy (DBT) is the biosocial theory.  Here, there is a biological component and environmental component to understanding behavior.

From genetics, we know that some people have more sensitivity, or predisposition, to triggers.  In borderline personality disorder, there is a biological side of the emotional reaction that starts with heightened reactivity that spikes faster than others and takes longer to go back to baseline.  It is physiological.  Individuals with borderline personality disorder may need 20% more time to return to baseline for most emotional reactions.

Having this heighten emotional response can be off-putting for people who are not as sensitive.  Some may draw comparisons to the reactions of others, which can be invalidating.  For example, "Your brother didn't even cry when his dog ran away, and here you are being a cry-baby about your dog being at the vet's office to have his teeth cleaned.  It's really not that big of a deal.  He'll be back to normal in soon, so just stop crying."

This sensitivity is not inherently bad or a signal that someone is "broken and just needs to be fixed."  The world is enriched by the passion and excitement of emotionally sensitive individuals.  Marsha Linehan is an intellectual example of this, as she too carries the diagnosis of borderline personality disorder.  It is true in art, music, writing, sports, science, and almost anything we do.  

In looking at problem solving, there can be an oversimplification of problem solving.  No one is born knowing how to regulate emotions.  We watch others and they show us how to regulate our emotions in a healthy way. 

Change is hard.  Change is gradual.  Change is a process.  Remember, one goal is progress, not perfection.  As the main dialectic in DBT, we have radical acceptance of the person and the need for change.  Change can definitely be worth the work.

The second part of the biosocial theory is the invalidating environment.  Invalidation is independent of the actual validity of the emotion or behavior (Manning & Hall, 2013).  Invalidation is not necessarily intentional or malicious, so this is not to blame others for the person's problems. 

In looking at invalidation, families can negate the person's private experiences. 

Parent: "How could you possibly be hungry?  You just ate!" 
Child: "But my tummy is growling and I am hungry."
Parent: "No, you just ate.  Ignore that.  You will be fine soon."

In this situation, the parent has invalidated the child's experience and has told the child what his body is really telling him.  Soon, the child will distrust his body's signals that he is, in fact, hungry.  

If the environment punishes emotions, the person may escalate the emotional response.  This results in dysregulation, meaning a disruptive emotional, cognitive, and/or physiological response.  Others may react to the dysregulated person and give them what they want.  Behaviorally, the problem with this is that the dysregulated behavior has been reinforced.  In reinforcing the behavior, this may become a pattern that increases over time. However, it is important to validate the person's emotional experience and not be judgmental or accusatory, in content, process, and tone. 

Others can label the internal experiences or exhibited behaviors as a pathological problem, such as calling the person lazy or selfish.  This, too, is invalidating.

The environment can teach unrealistic problem solving skills.  Examples of this include magical thinking and oversimplification.  "Magical thinking is thinking that one's thoughts by themselves can bring about effects in the world or that thinking something corresponds with doing it" (Colman, 2012).   

The discussion of the emotional vulnerability and invalidating environment is more of an explanation as to what has happened, what is happening, and what we can do about it.  The DBT skills are a part of how to regulate emotions, to tolerate distress, and to be more effective in interpersonal relationships.

What I have learned from DBT: Suicide

What I have learned about suicide from DBT is hard for me to portray with succinct phrases.  

The first lesson was that suicide must be off the negotiating table with the client.  With suicide as a legitimate option, it is very hard to move forward into building a life worth living.  

In looking at it scientifically, there is no evidence that suicide will make life any easier.  Common beliefs are that "all of my problems would be over if I were dead" and "my pain would stop if I killed myself."  Both lack evidence to support these claims.  Perhaps you could look at the dialectic, asking what would make life harder if you tried to kill yourself. 

The second lesson was that knowing the suicide and risk assessment protocols are essential, with both classmates and clients.  Knowing how to respond to these issues can save lives.  The questions can be awkward and seem like an attack, but I imagine that the benefit of helping the suicidal person get the care she needs outweighs the risk of awkwardness.

The third lesson is that mind-reading with sick people is not effective: "You only know until you ask" and are open to their point of view.  It can be harder with individuals with borderline personality disorder because masking emotions can be a part of how they regulate their emotions.  At times, the facial expressions reflect what the borderline individual wants you to see, like putting on a smile when you feel horrible and sad on the inside.  The internal state and the external expression may not always match, so it is important to probe and explore these emotions and emotional reactions.

I will look forward to adding to this list as I continue in my DBT training.  Until then, think about the lessons you've learned from working with suicidal individuals.  Let me know what you think!

 

Dialectical View of Dealing with Expectations

A sense of being a failure, one who falls short of expectations, can be seen in so many populations, not just individuals with borderline personality disorder.  There are several perspectives about expectations.  The expectations we hear can come from the words we speak to ourselves, the direct words we hear from others, and the wordless comments that we perceive from others.  

Trying to live up to expectations can take the fun out of life.  For the client, her expectations for herself could be too grandiose to accomplish.  The expectations we hear from others may create dissonance, in the pursuit of trying to meet the expectations of others and trying to be yourself.  The expectations she perceives from others may be the result of mind-reading.  

So what do we do with these expectations?  We have many options, like weighing the facts, the What Skills of Mindfulness (observe and describe), chain analysis, and finding the kernel of truth.  

Let's start with Observe and Describe.  Observe, Describe, and Participate are the three What Skills of Mindfulness.  Observing is just noticing without attaching words, judgments, or meaning.  Describing is adding words to the observations, while still maintaining a one-minded, effective, nonjudgmental stance.  We'll talk about Participate in a later post, but generally Participate means whole-heartedly diving into an activity; I have heard others say that Participate is a similar concept to Mihaly Csikszentmihalyi's Flow. 

Let's go to weighing the facts.  In this context, it's a little on the Reasonable Mind side of Wise Mind; focusing on the facts can draw us out of Emotion Mind.  Questions could include: Who was talking?  What was said?  We're looking for the actual words, not interpretations.  What is the context of the discussion?  When did the discussion start?  We're looking for this most recent, specific discussion; try not to dig in the pain of the past.

Chain analysis is a key process in DBT, as the roots of DBT are in behavioral analysis and cognitive behavioral therapy.  Essentially, chain analyses link the triggering event to the emotions, perceptions, actions, and consequences.  More will be coming about chain analyses.  

Last, finding the kernel of truth involves dialectical thinking.  There are many ways to view an event.  In looking at the stated expectations from another person, try to see her perspective.  What does she see?  What is she saying?  Take these questions into consideration, especially when trying to find the dialectic.  Find what your Wise Mind knows to be true.  Now integrate these concepts. 

DBT Core Mindfulness Skills: States of Mind

The DBT Training starts on Thursday.  I could not be more excited.  I will be meeting people who are as fascinated by the DBT skills and illness as I am.  

So the four structural posts of DBT are Core Mindfulness Skills, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.  In the next three days, we will have an overview of these modules and questions for consideration.
 It can be hard for individuals with borderline personality disorder to trust their perceptions, in part because the emotional reactions can be so strong and pervasive invalidation can be detrimental in trusting your perspective.  In working with individuals with borderline personality disorder, remember that there is not a single "right way" to look at a situation.  There are often dialectics that can be explored. To explore these different perspectives, turn to the source.

So let's look at the States of Mind.  No one can live exclusively in one mind, so expect to see a mixture of Minds.  

Marsha Linehan defines Reasonable Mind as "your rational, thinking, logical mind.  It is the part of you that plans and evaluates things logically.  It is the cool part" (Linehan's Little Red Book, p. 65)

She also describes being in Emotion Mind as: ". . . your emotions are in control- when they influence and control your thinking and behavior" (Linehan's Little Red Book, p. 65).

So DBT emphasizes the synthesis of opposites.  Wise Mind is the synthesis of logical thinking and passion.  It takes the most effective aspects of the Emotion Mind and Reasonable Mind and integrates them into the processing of situations, moods, emotional reactions, and time for contemplative thought.

Marsha Linehan describes Wise Mind as "that part of each person that can know and experience truth" (Linehan's Little Red Book, p. 66).  

I like to call Wise Mind truths the things we know in our bones.  Like a skeleton, these thoughts help us to have structure and mobility to act on what we know to be true.

I found this poem recently.  It is true for me and the battles that we face in the realization of dwelling in the poles of Reasonable Mind and Emotion Mind, but also in Fixed Mind.

Found myself here in this place again
caught up in this moment
seeing that slavery brings security,
but in what, for what, and by what means?
It is moving from the known-
the constants and forces of what works within me-
to the uncertainty of hope and the freedom it brings.

Day Three: Emotion Chain Analysis

Marsha Linehan has a strong background in behavior modification.  DBT has a firm foundation of creating change and documenting the process.

Individuals with borderline personality disorder often have strong emotional reactions to events, at times feeling the emotion more intensely than other individuals and for a longer time than others individuals.  

Mindfulness will be a key component of this process.  You will need the observe and describe skills to be present and ready to look at your strong emotion and the event that prompted it. 

The What skills of mindfulness are Observe, Describe and Participate.  

The How skills are one-mindfully, nonjudgmentally, and effectively.  These will be discussed in future entries.

This is Marsha Linehan's process for the chain analysis:

1. Observe and describe the event prompting the emotion.  Just the facts- no judgments, "I should have" statements, or rationale.

2. Observe and describe the interpretations of the event that prompt the emotion.  

3. Observe and describe the phenomenological experience, including the physical sensation, of the emotion.  Phenomenology is the study of the "lived experience."  What is it like to experience the emotions this event?

4. Observe and describe the behaviors expressing the emotion.

5. Observe and describe the aftereffects of the emotion on other types of functioning.

Day One: Biosocial Approach to Borderline Personality Disorder

DBT maintains the biosocial approach to understanding borderline personality disorder.  Biological and environmental factors directly affect behavior.  

"According to Linehan, BPD is primarily a disorder of emotion dysregulation and emerges from transactions between individuals with biological vulnerabilities and specific environmental influences. The dysfunction proposed by Linehan is one of broad dysregulation across all aspects of emotional responding. As a consequence, individuals with BPD have (a) heightened emotional sensitivity, (b) inability to regulate intense emotional responses, and (c) slow return to emotional baseline" (Crowell, Beauchaine, & Linehan, 2009, p. 495).


Emotional dysregulation. . .?

What does this mean?  One definition of emotional dysregulation is "a maladaptive pattern of regulating emotions that may involve a failure of regulation or interference in adaptive functioning" (Hilt, Hanson, & Pollak, 2011, p. 160).  What I like about this definition is that it describes these reactions as a pattern, not just a moment of strong, heightened emotions.  

What does this look like?  Let's look at self-harm.  For some individuals, there is a pattern of dealing with strong emotions by creating physical pain.  The logic may be that the pain moves from an abstract internal event to a concrete physical event; another view is that the emotional energy is channeled and controlled.  This cycle of a need for control and emotional release progresses with increasing distress.

For individuals with borderline personality disorder, their home environments are often invalidating, resulting in emotional dysregulation and the use of coping behaviors.  These coping behaviors could include impulsive decisions that are ultimately maladaptive and destructive but temporarily effective in emotional regulation. 

Meeting Marsha Linehan

"Dr. Linehan, hi, my name is Sarah.  I love your work.  Would you sign my copy of your book?"  I asked as I held out The Big Red Book,Cognitive-Behavioral Treatment of Borderline Personality Disorder.

I had the honor of listening to Dr. Linehan at a talk when she accepted the 2012 Joan and Stanford Alexander Award in Psychiatry.  She talked about the history of dialectical behavior therapy (DBT), where it has been, where it is now, and where it is going.  

I want to be a part of this movement, to be a part of the DBT community.  Over the next three months, I will be learning and practicing the skills presented in the Skills Training Manual for Treating Borderline Personality Disorder (Linehan, 1993). 

Schedule:

Monday: Mindfulness, Specific Topic (ex: Biosocial Approach), and Goal Setting

Tuesday: Mindfulness, Distress Tolerance, and Radical Acceptance

Wednesday: Mindfulness, Emotional Regulation, and Validation

Thursday: Mindfulness, Interpersonal Effectiveness, and Dialectics

Friday: Mindfulness, Weekly Review, and Goal Setting