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.

"What keeps us stuck?" Emotion Mind and Homework

In DBT, clients and skills trainers have homework assignments from week to week.  "Repetition is the mother of understanding."  The intentional practice prompts the client to develop and hone her skills.  The interpersonal effectiveness skills really require practice with others because they involve interactions with others, so it can be difficult to practice by yourself; DEAR MAN, GIVE, and FAST are the main interpersonal effectiveness skills.

In skills groups, there is a designated time for a review of the homework.  This is usually after the mindfulness activity and before the skill lesson. 
Sometimes the homework isn't completed when the clients arrive for group, so there might be clients writing quickly as the other clients talk about their homework.  If skills trainer asks about the unfinished homework, she may ask the client to complete the work and bring it next week and/or to write a chain analysis about what kept her from completing her homework.  

The chain analysis may elucidate the emotional factors and cognitive factors that influenced the outcome.  Sometimes emotional responses hinder the likelihood of completing tasks. It's a difficult process to figure out "what happened when."  

Chain analyses are not punishments and should not be punitive.  They are tools for helping the client identify the behavior(s), what led up to it (emotional vulnerabilities), the prompting event, and what happened as a result of the behavior(s).  It can be dysregulating and difficult to write the chain analysis alone, so it may be helpful to work through a chain analysis with the individual therapist.  She or he can help the client self-soothe and regulate her emotions when filling out the chain.

Looking at factors that keep us from working effectively, procrastination is an application of Emotion Mind.  Fear and anxiety can create a hostile environment for effective task completion.  Randy Pausch described procrastination as one of the hindrances to completing tasks in his lecture, "Time Management;" click here to watch the YouTube video of "Time Management." 

"If you are procrastinating, you've got to find some way to get back into your comfort zone.  Identify why you are not enthusiastic. Whenever I procrastinate on something, there's always a deep psychological reason. Usually it's, I'm afraid of being embarrassed because I don't think I'll do it well, or I'm afraid I'm going to fail at it."

Let's look at homework experiences to see the effects of the anxiety and fear that can come with being in Emotion Mind. 

I don’t want to be avoidant today.

I want to look at the theories book,

pick up it up and say,

I am not going to live in fear.

I will read this

one section at a time.

I can do this.

I may need help

along the way.

You will not define me.

I will not label myself as a

bad, ignorant, or avoidant

student.

I can do this.

In looking at the poem, there is a consistent cheerleading statement: I can do this.  It also has components of goal setting: reading the book one section at a time.  There are also elements of Wise Mind and non-judgmental stance in not wanting to add labels that could increase avoidance, diminish motivation to finish the work, increase the likelihood of living in fear, and keep us from reaching our potential.

Mindfulness 101: The What and How Skills

As Eastern practices infuse into Western medicine, mindfulness is becoming popular and is widely utilized in dialectical behavior therapy (DBT).  Mindfulness is an ideal skill set that supports active listening and enhances the clarity of thoughts, potentially yielding more authentic and precise questions and feedback. 

               

At its core, Linehan’s mindfulness is the fusion of Zen meditation and “Western contemplative thought” (Linehan, 1993, p. 144).  It integrates attention and heightened awareness techniques with emotion regulation and distress tolerance by involving the “what” and “how” skills of mindfulness.    

The activities of mindfulness, the “what” skills, are to observe, describe and participate.  Observation is the back seat perception of one’s immediate environment without labels or judgments.  Description is the verbal acknowledgment of what is observed internally and externally and equally cognitively and behaviorally.  Participation is akin to Csíkszentmihályi’s positive psychology concept of flow and is “entering completely into the activities of the current moment, without separating oneself from ongoing events and interactions” (Linehan, 1993, p. 146). 

The ways to practice them are the “how” skills: taking a nonjudgmental stance, focusing your thoughts on the here and now, and “using skillful means,” also termed “being effective,” to respond to one’s internal and external environments.  These concepts are the foundation for urge surfing (Linehan, 1993). 

               

Mindfulness 101: Urge Surfing

The goal for using mindfulness is to bring oneself back to focus on the here and now, which then aids in the fading of the urge (Linehan, 1993).  Urge surfing is an aspect of mindfulness that guides people through the cognitive reactions, emotional waves and drives that come with everyday life.  Urge surfing allows people to ride the waves of intense emotions and urges, or drives, to act. 

The basic procedure is:

1) To notice, or observe, the thought, urge, or emotion;

2) To describe it;

3) To self-validate, which looks for the reasonable aspects of one’s response to confirm that something is valid and makes sense under the circumstances and in the appropriate context (Fruzzetti, 2006); and

4) To let it pass. 

Do not be surprised if the urge does not cease immediately; generally urges last for approximately twenty-one minutes with varying levels of intensity (Honig, 2009).  Urge surfing works well when it is accompanied with other skills, such as distracting by writing in a journal.  Another option for distraction is playing a game of solitaire with actual playing cards.  This engages your body and your mind to focus on the present moment and not on the distressing situation.

Remember, things come and go in waves, so hang ten and ride the waves of life as they come.