Skills for DBT Training In PHP and IOP Settings

Skills for DBT Training

1. Skills Training for PHP Settings Applications In Intensive Clinical Settings

2. What is Comprehensive Skills Training? A Skills-based model of therapy emphasizing coping skills to manage life stressors Uses the DBT skills frame-work and the spirit of DBT but deviates significantly from strict DBT protocol Incorporates various CBT interventions, including behavioral activation, exposure therapy, thought tracking and cognitive restructuring, etc. Draws from mindfulness skills and exercises outside of the DBT skill-set

3. What is DBT? A research-proven cognitive-behavioral therapy developed specifically for the treatment of Borderline Personality Disorder A comprehensive treatment approach that includes individual therapy, group therapy, a consultation team, “coaching calls”, etc. that share a common theoretical framework A psychotherapeutic approach that relies heavily on the practice of mindfulness to help achieve therapeutic change

4. How is DBT different than CBT? Specific focus on Borderline Personality Disorder and self-harming and/or clients Bio-psychosocial theoretical framework for understanding clients Spirit of “dialectics” embedded throughout the therapy

5. How is DBT different than CBT ? (continued) Mindfulness drawing from a Zen Buddhist perspective Emphasis on validation and acceptance Strict hierarchy of treatment goals focused on typical BPD problem behavior: self-destructive behavior, treatment interfering behavior, and quality of life reducing behavior

6. How is DBT similar to CBT? DBT is fundamentally a cognitive behavior therapy Shares a basis in learning theory and a belief that maladaptive responses can be unlearned and/or replaced with more adaptive responses via direct teaching Emphasis on learning and practicing new behaviors Significant amount of DBT is focused on behavioral change

7. Applying DBT to different clinical settings and heterogeneous populations (continued) DBT is extremely intensive and can be quite expensive to implement making it challenging for many clinical settings DBT follows a relatively rigid treatment protocol that can also be difficult to implement Strict DBT may not be useful and/or relevant to different psychiatric populations (e.g. psychosis, developmental disorders)

8. Applying DBT to different clinical settings and heterogeneous populations Using DBT in a group or milieu setting with exclusively Borderline clients is significantly different than doing so in a heterogeneous clinical population Some skills make more sense for chronically suicidal clients and those with borderline coping but are not as relevant for those with depression, substance abuse, anxiety, etc. There are therapies that are more research-proven than DBT for specific disorders (eg. CBT protocols for anxiety and depression) It does not necessarily make sense to apply formal DBT to a diagnostically diverse population

9. Modifying DBT for a diagnostically diverse environment Keep the spirit of DBT and the coping skills, but leave the rest! Learn and apply DBT interventions when working with specific clients with Borderline Personality Disorder Eliminate some skills that aren’t more broadly relevant Add other coping skills that aren’t included inDBT (e.g. identifying cognitive distortions from CBT) when relevant Stay flexible

10. Spirit of DBT How it pertains to a PHP/IOP Setting

11. Dialectical Approach Dialectic: “arriving at the truth by stating a thesis, developing a contradictory antithesis, and combining and resolving them into a coherent synthesis” Dialectic: “any systematic reasoning, exposition, or argument that juxtaposes opposed or contradictory ideas and usually seeks to resolve their conflict” In DBT it pertains broadly to working with clients by identifying the inherent contradiction and insustainability of an extreme or “all or nothing” position Specifically in DBT it refers to the Dialectics of Change and Acceptance

12. Dialectical Approach (continued) Acceptance therapies: Rogerian or client-centered therapies, supportive psychotherapy, etc. Change therapies: Cognitive Behavior Therapy DBT seeks to balance and integrate these two opposing strategies of pushing for change and accepting the client as they are in the moment Goal is to assist the client to be able to move between these two forces (i.e. for the client to accept himself and to motivate himself for change) From a DBT perspective, one must constantly shift between these to different approaches (see-saw model)

13. Importance of flexibility Our clients frequently have rigid coping styles One must maintain a flexible posture to help the client move out of a place of rigidity When the client is being too flexible and loose, the therapist takes a more rigid stance….when the client is taking a very rigid approach, the therapist takes applies a more flexible style Another example of dialectics: maintaining flexibility while setting limits…

14. Importance of Validation DBT is based on a bio-psychosocial theory that postulates that the etiology of BPD is based in both a biological vulnerability towards extreme emotional reactions and the development experience of an invalidating environments Emotion dysregulation is fundamentally about invalidation Validation becomes a central strategy to assist the client in regulating themselves Goal is for them to eventually validate themselves as a regulatory strategy

15. Importance of Validation DBT is based on a bio-psychosocial theory that postulates that the etiology of BPD is based in both a biological vulnerability towards extreme emotional reactions and the development experience of an invalidating environments Emotion dysregulation is fundamentally about invalidation Validation becomes a central strategy to assist the client in regulating themselves Goal is for them to eventually validate themselves as a regulatory strategy

16. Ways of Validating For starter’s all emotions are on the table No such thing as an “inappropriate” emotion Dialectically speaking, of course there are inappropriate behavioral expressions of that emotion E.g. “your anger is very understandable” and “it is not ok for you to yell at me” Validating the client’s current experience Acceptance of the client as they are in the moment without preconditions (i.e. not as a change gambit)

17. Ways of Validating Observing the client’s current experience Reflecting the client’s current experience back to them Validating the client’s current experience….searching out the kernel of truth so to speak….what about the client’s response makes sense, is adaptive, is appropriate even when much of it is maladaptive and dysfunctiona

18. Validating and Accepting Another way of validating the client is to refrain from judgment Taking a non-judgmental approach is a fundamental element of mindfulness and a fundamental of DBT Behaviors are not “good” or “bad” they either have undesirable consequences or desirable consquences

19. Emphasis on behavioral practice Because of the skills training emphasis, behavioral practice is a heavy focus of DBT Research shows that it is not enough to be intellectually exposed to skills or to conceptually learn skills to affect change Practice practice practice is essential to truly learn new behaviors and use then when needed Practice is weaved into the skills training modality both as in-vivo practice and as behavioral homework

20. Emphasis on gradual change and small changes Because learning new skills can be distressing and overwhelming….focus is on “just one thing” Progress is measured as opposed to perfection Help clients to not bite off more than they can chew Homework should be small, specific, measurable...(clients frequently will pick something vague, broad or too difficult) Practicing is a success! It is not important that the client benefit from the skill in the moment….it is the choice to try a new way to cope that is important

21. Cheerleading and lavish praise Because behavioral change is daunting and fraught with potential for self-invalidation (i.e. “I failed” or “I didn’t do that right”) it is very important to praise Cheerleading even small changes is a key behavioral reinforcer that leads to further changes Watch out for invalidating the client’s work….praise the action first, regardless of the outcome…..if the coping skill worked that is a “bonus”…..the more important thing is that they tried something

22. Cheerleading and lavish praise (continued) “we can cross that one off the list” or “it may not help the first time, you might need to do this over and over again” Example: what if the client just took his Prozac on the first day it was prescribed and then said “ahh, it didn’t work” Cheerleading is also a skill that you are modeling and clients will eventually internalize

23. DBT Skills Modules

24. There are 4 categories or modules of DBT skills Mindfulness Emotion Regulation Distress Tolerance Interpersonal Skills

25. Mindfulness Mindfulness is the core of the DBT skillset It is important that more time be spent on mindfulness and that it be taught more frequently than the other skills It is the most radically different coping skills because it is a meta-process (i.e. it is a process that affects all other processes)

26. Mindfulness It is a skills that changes how people think rather than just what they think Applying mindfulness is necessary to effectively apply many of the other skills Frequently it is best to teach Mindfulness first

27. Emotion Regulation (cont’) Is about helping individuals to change how they feel It is important that they want to change how they feel…i.e. we are not here to invalidate their feelings, they must decide that they want to feel less anger or sadness Clients sometimes need help making the connection that intense emotion leads to impulsive behavior….(i.e. behavioral solution to an emotional problem)

28. Distress Tolerance Is about increasing the client’s capacity to tolerate pain Emphasis is on surviving crisis, intensely distressing situations, overwhelming affect, etc. Strategy is fundamentally about helping clients to switch from a problem-solving to a coping-with-pain mentality (i.e. you can’t problem-solve effectively when in a state of panic….first reduce the panic)

29. Emotion Regulation and Distress Tolerance are not that different In some ways the dividing line between these two skill sets is arbitrary Many emotion regulation skills have a distress tolerance component to them And many distress tolerance skills are about changing feelings

30. Interpersonal Skills These skills are focused on helping the client more skillfully interact with his/her environment It is best to cover these skills after all the self-regulation skills have been taught Frequently the environment may not respond to interpersonal skills (i.e. there are no guarantees that these will yield the desired results) and therefore it is important to have strategies to manage disappointment, feelings of helplessness, etc.

31. Last note about this dismal science There is definitely a much heavier emphasis on negative emotional states and negative events (by necessity) The only skills that explicitly focus on increasing positive experiences are pleasurable activities and self-soothing It is important to highlight positive coping whenever possible and the importance preventative maintenance

32. Issues wit implementation in a PHP or IOP Setting Skills schedule: rotation, curriculum, etc. Dealing with open enrollment: relying on Homework: importance of follow-up Increasing staff knowledge: dedication to increasing and improving skills knowledge Embedding mindfulness: using the language, routine practice time, etc.