Read Microsoft PowerPoint - BPD 4 - DBT-Based Skills.pptx text version

Third module in the Borderline Personality Disorder Series provided by the Northern Network of Specialized Care

Practical skills and their rationale


Mindfulness Exercise ­ Becoming Aware


Brief review DBT skills overview Adaption to DBT ­ The Bridge DBT Program Acceptance Strategies: Mindfulness & A t St t i Mi df l & Validation Interpersonal Effectiveness Skills Opposite Action Distress tolerance skills Closing


To refresh your memories...

1. 2. 3.

Our attitudes/reactions can contribute to the problem Better understanding plus more experience = attitude change BPD = Biological predisposition to emotional dysregulation + Invalidating environment

The core problem

Interpersonal Dysregulation

Self Dysfunction

Emotional Dysregulation

Cognitive Dysregulation

Behavioral Dysregulation

To refresh your memories...


Dialectical Behavior Therapy is a treatment approach involving:

Group skills training Individual psychotherapy Telephone consultation and coaching Therapist consultation team meetings Supportive group therapy (skills application group)


DBT involves validation and radical acceptance of the individual, balanced with problem solving and change strategies.


Problems and Solutions

Cognitive and self dysfunction (dissociation, hallucination, depersonalization, uncertainty)

Mindfulness, validation

Interpersonal problems (passivity ­ saying no or making requests)

Mindfulness, validation, problemsolving, interpersonal effectiveness skills (e.g. assertiveness) ff ti kill ( ti )

Emotional dysregulation (reactive emotions, chronic depression and anxiety)

Mindfulness, validation, emotion regulation skills (e.g. opposite action)

Behavioral Dysregulation (Impulsivity, selfharm)

Mindfulness, validation, distress tolerance skills

Adapted DBT for Intellectual Disability

The Bridge DBT Program (Lew, Matta, TrippTebo & Watts, 2006) People with disabilities have more frequent mental health needs Individuals with BPD are at greater risk for intrusive and restrictive treatments Caregivers and families get burned out or develop negative attitudes that perpetuate the problem.

Adapted DBT for Intellectual Disability

Argued that inclusiveness dictates provision of service but underscored time and resource consuming nature of the treatment and need for considerable system support for DBT. Individuals with ID often experience invalidating environments because of their disability and a skillsbased approach can help them and those supporting them.


Adapted DBT for Intellectual Disability

Essentially same as Linehan's approach with adaptations for individuals with ID Materials modified for intellectual level ­ pictures used and more roleplaying and active coaching Inclusion of staff and family in group skills training and individual therapy

Adapted DBT for Intellectual Disability

More flexibility in treatment provision ­ shorter more frequent individual sessions; coaching calls Modifications to skills to a be more appealing (distress tolerance skills) Inclusion of more individuals providing services to restructure environments to support DBT skills acquisition and generalization.

Individual DBT Plan

Suggested in Bridge DBT Program Incorporates goals from person centered plan and any behavioural interventions currently used d Distributed to all caregivers and staff Permits consistency with approach and guidance for caregivers and staff


DBT Hierarchy of Goals

What is the goal?

DBT is a comprehensive treatment approach that is most effective when it incorporates all aspects of DBT Skills derived from DBT can either confuse or help unless understood in context ­ the individual's context and the context of BPD theory Encouraging use of skills for change, by itself, can cause behavioral regression

Change as a goal

Scenario: individual appears angry and is yelling that "it is not fair" after being told that she is not permitted to do something she wants to do permitted to do something she wants to do ­ what is your goal? How would you normally achieve that goal? How is individual likely to react to your intervention?


Acceptance as a goal

Radical acceptance for its own sake Acceptance with validation as effective in the moment Willingness versus willfulness Acceptance can lead to change but not as a technique ­ as a precondition Acceptance leads to selfawareness and understanding of emotions, thoughts, feelings, sensations and behaviors

Acceptance strategies mindfulness

What to do Observe Describe Participate How to do it Onemindfully Nonjudgmentally Effectively

Mindfulness and meditation

Meditation is a way of practicing mindfulness because of the unique nature of meditation Anything can be done mindfully


Mindfulness Exercise ­ Awareness of the breath

Strategies validation

Definition: "The therapist communicates to the patient that her responses make sense and are understandable within her current life context or situation. The therapist actively accepts the patient and communicates this p p p p acceptance to the patient. The therapist takes the patient's responses seriously and does not discount or trivialize them. Validation strategies require the therapist to search for, recognize, and reflect to the patient the validity inherent in her responses to events".

Linehan (1993) pp. 222223

Types of validation

Listening and observing Accurate reflection Articulating the unverbalized Validating in terms of sufficient (but not necessarily valid) causes Validating as reasonable in the moment Treating the person as valid ­ radical genuineness


Why validation?

As a counterbalance to change To teach selfvalidation ­ helps people learn to trust their perceptions and experiences. To strengthen clinical progress As feedback ­ gives people feedback about themselves and their behaviour so as to assist in their understanding and evaluation of their behaviour. To strengthen the therapeutic relationship

Role Playing Exercise

Instructions: A support staff is talking to an individual in the residence while another resident who has been diagnosed with BPD and exhibits very challenging behaviours is wanting the attention of the support staff. The individual is feeling very rejected, hurt and angry at them for not paying attention to him/her. One person plays the resident while another plays staff member who is responding to the individual in a way that he/she thinks would be typical in this type of scenario.

Role Playing Exercise

Instructions: Same situation but this time the support staff responds by using validation.


Interpersonal Difficulties Battling Passivity

Validation Encourage and reward active problem solving and help seeking behavior, solving and helpseeking behavior particularly when it can prevent future problems Cheerlead and support when individual has mindfully made an interpersonal choice involving weighing options Devil's advocate

Emotion Regulation Skills

Learn to label emotions Use colours or pictures to represent emotions Identify behaviours typical of those various emotions (positive and negative emotions)

Emotion E ti Angry Happy Scared Relaxed Colour C l Red Yellow Brown Pink Examples of typical behaviours E l f t i l b h i Yelling, hitting walls, stomping feet Laughing, smiling, doing enjoyable activities Hiding, crying, trembling, avoiding Listening to music, having bath/shower, wrapping up in comfortable blanket.

Regulating emotions






Regulating emotions





Directions for Opposite Action

Identify emotion that is incompatible with the "problem emotion" if that emotion is unwanted (by the individual) and not reasonable given the circumstances. reasonable given the circumstances Identify activities typical to that emotion Use validation, cheerleading, and encouragement to get individual to try to do those activities ­ do it with them and ask them to identify any changes in emotion.

Tolerating distress

When you can't do anything to change how you are feeling, stop g, p trying to change it by accepting in the moment but do so masterfully






Distress Tolerance

Improving the moment Self soothing ­ all senses Selfsoothing basket/box Distracting Radical acceptance Maintaining an attitude of willingness as opposed to willfulness Coaching is vital and activities/items chosen by individual or with assistance from knowledgable caregivers/staff.

When Prevention Doesn't Work: Behavioural Chain Analysis (BCA)

All behaviour makes sense! BCA's help make sense of seemingly nonsensical behaviours Components of any situation: Components of any situation Circumstances (environmental ­ what is happening) Thoughts, memories, impressions, beliefs Feelings, reactions Physical Sensations Behaviours

Behavioural Chain Analysis (BCA)

These components work together to determine behaviour like a chain of events If one link in the chain is broken, the chain is broken b k Example ­ self injury after being told that the person can't go shopping


Conducting a Behavioural Chain Analysis (BCA)

Questions to ask:

1. What is the challenging behaviour 2. What happened before the behaviour occurred 3 3. What made the person vulnerable to engaging p g g g

in that behaviour?

4. What was the chain of events leading to the

behaviour (includes thoughts, feelings, sensations) 5. What were the consequences of the behaviour 6. How could the problem be solved next time so the behaviour wouldn't have occurred?

Behavioural Chain Analysis (BCA) Worksheet

Challenging Precipitating Behaviour Events Description (what happened before) Vulnerability Factors Chain of Events Consequences Positive and Negative Solutions for Initial Next Time


An ounce of genuine validation is worth a pound of change True change can only occur if balanced with acceptance Mindfulness underlies all acceptance and change Mi df l d li ll t d h strategies People with BPD can try to change emotions and, if they can't change an uncomfortable emotion in the moment, with support and encouragement they can learn to radically accept high levels of distress and tolerate distress without acting on it..



All acting out is either a habit or a direct result of high distress ­ therefore expecting that change should be immediate is an ineffective expectation to communicate Most of the time, the individual is doing the best he/she can considering his/her life situation, biology, and background


DBT can be adapted for individuals with ID but... "Clinicians should not fool themselves into thinking that they can implement a DBT program just be reading the manual or starting a skills group"*

*Lew et. al., 2006 p.12

Thank you for your time!



Microsoft PowerPoint - BPD 4 - DBT-Based Skills.pptx

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