"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.
Behavior analysis is a key part of dialectical behavior therapy. In finding the patterns of behavior, we can better understand what happens, when it happens, and how we can shape the response in a more adaptive way by figuring out alternative solutions.
Natalie Hill has a great blog post about behavior chain analysis in DBT.
Here is a link to Practice Wisdom: http://practicewisdom.blogspot.com/2012/10/behavior-chain-analysis.html
One of the cool images is a visual chain analysis.
I will approach the behavior chain analysis from a checklist perspective, as found in Marsha Linehan's Cognitive-Behavioral Treatment of Borderline Personality Disorder (The Big Red Book; 1993; p. 256).
Step One: The therapist helps the client DEFINE THE PROBLEM BEHAVIOR.
- The therapist helps the client formulate the problem in terms of behavior.
- The therapist helps the client describe the problem behavior specifically, in these terms: FREQUENCY of behavior, DURATION of behavior, INTENSITY of behavior, and TOPOGRAPHY of behavior.
- The therapist weaves validation throughout.
Note: These topics can be very dysregulating for the client, potentially bringing out shame, angry, sadness, guilt, despair, hopelessness, and even suicidality. Be sure to avoid shaming the client or instituting a punishment. Why? Punishment is not effective in the long-term; as DBT therapists, our goal is to use reinforcement to shape behavior. She likely feels enough guilt or shame already, so there is no need to add more. In looking at guilt and shame, there is a key distinction: shame is feeling bad about who you are, while guilt is feeling bad about something you did.
Step Two: The therapist conducts a CHAIN ANALYSIS
- The therapist and client choose one instance of a problem to analyze.
- The therapist attends to small units of behavior (the links of the chain), with attention to defining the chain's beginning (antecedents), middle (the problem instance itself), and the end (consequences) in terms of the following: EMOTIONS, BODILY SENSATIONS, THOUGHTS and IMAGES, OVERT BEHAVIORS, and ENVIRONMENTAL FACTORS.
- The therapist conducts brief chain analyses as necessary of events in the session.
- The therapist maintains client's (and own) cooperation.
- The therapist helps the client develop methods to monitor her behavior between sessions.
Step Three: The therapist GENERATES HYPOTHESES with the client about variables influencing or controlling the behaviors in question.
- The therapist uses the results of previous analyses to guide the current one.
- The therapist is guided by DBT theory.
Now that we have an outlined list of what to do, let's explore what not to do.
Avoid avoiding behavior chain analyses. I know they're tedious and can be triggering for the therapist and the client. But think of the rich data that comes in knowing what happened and the potential for finding patterns that can isolate the environmental factors that influenced the target behavior.
As a therapist, avoid insisting that your hypothesis is the right hypothesis. A) Forcing your conclusion on the client can invalidate her perspective, as this perpetuates the cycle of invalidation. B) This is not dialectical. The dialectical perspective would find a way to take the "truth" of each perspective and integrate them.
As a therapist, avoid putting on the blinders in the case conceptualization and treatment. As in horse racing, when the therapist has a limited view of what she views as the problem behavior, she runs straight down the path and misses information on either side. Searching for the observations/data that match your hypotheses is biased and not scientific.
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.
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.
