DBT Course Flashcards
DBT is a stronger therapy for which kind of clients?
BPD; complex clients with emotion regulation; suicidal
DBT is not as strong for which kind of clients?
Less complex, just bipolar, just substance use, just depression.
How is DBT like a shotgun?
For someone with a less complex presentation, like ‘just depression’ or ‘just bipolar’ DBT would be like using a shotgun where an arrow would be sufficient.
What are the four treatment components of DBT?
1) Individual therapy
2) Group skills training
3) Telephone consultation
4) Consultation team
What are the two main functions of individual therapy in DBT?
1) Improvements in motivation and generalization; solve life problems; build life worth living 2) structure the environment
What is meant by ‘generalization’ in DBT?
The ability to transfer skills learned in therapy to everyday life.
What is meant by ‘structure the environment’ in DBT?
Figuring out how to structure client’s environment to support the change they want to make?
Within the DBT framework, how do we see ‘client resistance’?
Due to great suffering. It can be just as uncomfortable to get out of it as to stay in it.
What is an analogy that captures how a DBT client is faced with a choice between the suffering of their condition vs the suffering of trying to get out of it?
They are in a burning pit of fire, and the only way out is an aluminum ladder that will hurt them on the way up.
What is the format of DBT group skills training, and what 4 key skills it it trying to increase?
It is a class format (rather than therapy). It is trying to increase mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.
What is the function of the telephone consultation in DBT?
To generalize skills to everyday life.
What is the function of the consultation team in DBT?
To support and improve therapist motivation and capability to help complex clients.
What is a possible negative experience of a focus on change for clients?
It can feel invalidating. Client may want to move in the opposite direction. Change and invalidation can make arousal levels go up.
What is a major difference between CBT and DBT approaches to change.
CBT is focused on change, while DBT balances change with acceptance.
Early in the development of DBT, why did treatment efforts fail?
She focused on change, which led to arousal, a sense of being out-of-control, which impaired client cognitive processing and resulted in an intense effort to control.
What is the D in DBT referring to?
Dialectical. It refers to the dialectic, or the tension / synthesis between the polar opposites of acceptance and change. Reality changes when opposites synthesize.
What are four qualities of a dialectical view of treatment in DBT?
1) Balance of treatment strategies, skills, and styles.
2) Search for what is left out (e.g., a 2nd suicide plan?)
3) Search for synthesis (if there is a winner, there is a loser)
4) Movement, speed, and flow
What is a dialectical suggestion to a person who is fighting with their spouse?
What do you want when you are fighting? (to win) If you are the winner, who are you married to? (the loser)
What is an analogy that could help with someone who is refusing to give up their suicide option?
The suicide door. You are in a painful, hot, sickening room, and there is a bright light coming from a door, a way out. This is a suicide door. What if I told you there are other doors, you just can’t see them because the light of the suicide door is so bright. And these other doors lead to happier life, more contentment. But to see them you need to step away from the suicide door.
What is an irreverant response to a DBT client says they are going to kill themselves?
“Dear, I thought we agreed you were not going to quit therapy.”
According to Linehan, what is the advantage to irreverant responses?
“We process more deeply information that is not expected”
According to Linehan, what is one of the most effective emotion regulation strategies?
Distraction
What is the DBT approach in regards to behavioural reinforcement of parasuicidal behaviour?
Call before you attempt, but not for 24 hours after. This is to prevent reinforcement of parasuicidal behaviours.
What does the T in TIP skills refer to?
Tip the temperature. The Mamalian dive reflex when putting head below heart and submerging face in ice water or on ice packs for 30 seconds, or as long as you can tolerate. Water should cover temples. Will slow heart rate and calm dysregulated emotions. Practice this a few times first, before you are dysregulated.
What is the rule around missing sessions in DBT?
4 consecutive misses is a drop out. If you miss 4 consecutive individual or group sessions, you are considered to have dropped out of therapy and must renegotiate coming back.
What is the purpose of a diary card in DBT?
To provide structure and target behaviours.
To track
To assess for effectiveness
To remind us of skills we need to practice
To track suicidality
How might one introduce a diary card?
Introduce it; indicate its purpose; ask the client why they agreed to do it; ask them what might get in the way; troubleshoot those problems.
How long would you spend on a diary card?
5-10 minutes
What would you do if a client has not completed their diary card?
Fill it out in session, and reinforce by reading it. Ask them what got in the way of completing it. Troubleshoot.
DBT is flexible, but what 5 functions must it fulfill?
1) Enhance capabilities
2) Improve motivational factors (follow through)
3) Assure generalization to natural environment
4) Structure environment
5) Enhance therapist capabilities and motivation to treat effectively
What are a couple of problems with signed safety contracts for suicidal behaviour? What is a good compromise?
1) They can give the therapist a false sense of security
2) Do not limit liability
It is good to get verbal commitment, to work on safety planning. Commitments are good.
What are the 3 levels of commitment in DBT?
1) Participate in treatment, no suicide, no self-harm
2) Collaborate in treatment, apply skillful behaviour
3) Other specific strategies identified in session
What are some (8) DBT commitment strategies?
Pros and Cons Devil's Advocate Foot in the Door Door in the Face Freedom to Choose / Absence of Alternative Link Present Commitments to Previous Commitments Shaping Generating Hope: Cheerleading
What are the components of DBT pros and cons? In what order do you ask them.
Pros and cons grid includes listing pros and cons for both problem behaviours and for DBT skills. The order would be:
1) Pro for problem behaviour
2) Con for DBT skill
3) Con for Prob behaviour
4) Pro for DBT skill
How might a therapist use the Devil’s Advocate commitment strategy?
Pose an argument against making the commitment to therapy, but the counter-argument is slightly weaker than commitment. For example: “Why not kill yourself? Why are you still alive?” (This is extreme example - play around with easier stuff first)
What are the pretreatment targets in DBT?
Orientation, agreement on goals and commitment
What are the 4 first stage targets of DBT?
1) Decreasing suicidal behaviours
2) Decreasing therapy interfering behaviours
3) Decreasing quality of life interfering behaviours
4) Increasing behavioural skills
What are the 4 behavioural skills we seek to increase in first stage of DBT?
1) Core mindfulness skills
2) Interpersonal effectiveness
3) Emotion regulation
4) Distress tolerance
What is the 2nd stage target of DBT?
Decrease posttraumatic stress
What are the two 3rd stage targets of DBT?
1) Increasing respect for self
2) Achieving other individual goals
What is the ratio of suicide attempts to deaths
1/30
What are the gendered prevalence rates of suicide attempts and deaths?
Deaths 4x more prevalent in men (hanging)
Attempts 3x more prevalent in women (pills)
What portion of BPD commit suicide?
8%
What are 5 categories on the spectrum of suicidal behaviour?
1) Accidental injury
2) NSSI (non-suicidal self injury)
3) Ambivalent suicide attempt (Intent to self-harm, unclear about death)
4) Suicide attempt
5) Suicide
What is the most straightforward way to determine suicide probability?
Ask patient directly
According to Franklin et al. (2017) meta-analysis of suicide research, how well do risk factors predict suicide and attempts?
Slightly above chance guessing
What are the 3 main factors in Joiner’s interpersonal model of suicidal behaviour?
A) Being capable of suicide
B) Desiring suicide (1) thwarted belongingness and (2) perceived burdensomeness
How is suicide a solution?
One solution to an intolerable problem. (Other solutions are observed or seem out of reach)
What is the biggest miss in suicide assessment?
Not spending enough time problem solving
How do you problem solve in suicidality?
Chain analysis. How did you get from feeling anxious to suicidal?
What is a fire analogy to suicidal problem solving?
Suicidal behaviour is the fire, the problem. We need to throw buckets of water on the fire.
What are buckets of water you can throw on the fire of suicide? (9)
1) Crisis plan
2) Troubleshoot plan
3) Commitment
4) Follow up care
5) Solve problems
6) Reasons for living
7) Clarify negative consequences
8) Remove lethal means
9) Instruct to to kill self
According to Frankl, how did he deal with 2 suicidals who expected no more from life?
Convinced them that life still expects something from them
How might you communicate hope and belief in client who is suicidal?
“I believe in you.”
“Between you and I, I believe we can figure this out”
What are four main negative consequences of suicide to dissuade people from killing selves?
1) Impact on family, friends (a) research has shown they will carry it for rest of their lives (b) their chance of suicide increases significantly
2) You won’t achieve your life goals
3) You could end up disabled or a vegetable
4) Death might suck more than life does
How would you remove lethal means for someone who plans to jump in front of car or off a bridge? Stab w knife?
A) Let’s keep you away from cars and bridges
B) Duct tape around knife, or freeze it
What is an important aspect of having client remove lethal means?
Get corroborating info, from caregiver, family members etc.
How would you instruct someone to not kill themselves? What if they resist?
“It is important that you not kill yourself. Given your level of distress it is too difficult to weigh all the factors for such an important decision. Therefore, I do not want you to kill yourself.” If resistance: validate distress, highlight contingencies (uncertainties, unknown future events), instruct again.
What are some things you could include in a crisis plan? (4)
A) Distraction, get out of house, go to a coffee shop, get around people
B) T.I.P.
C) Crisis line, 1-800-Suicide
D0 Alert others to their plan (Family, safety network)
What is the problem with written suicide contracts?
Creates a false sense of security, and doesn’t reduce liability
How would you get a commitment to no suicide?
1) Verbal agreement
2) Foot in the door, door in the face
“If you do a week, how about a month.”
3) Get commitment to treatment, which means no suicide
How do you trouble shoot a suicide safety plan?
A) “What might get in the way of this working?”
B) “What happens when (sadness, loneliness, fear) comes back?”
How and why would you arrange follow up contact for a suicidal client?
Make follow up appointment, enable phone contact to give client a continued sense of presence.
What might a post card to a client say?
“Dear John, it has been some time since I’ve seen you at the office and I hope things are going well for you. If you wish to drop me a note sometime, it would be great to hear from you.”
When should a client be hospitalized?
A) Moderate to high risk for imminent suicide -> next day or so
B) Refuses treatment or getting rid of means
C) Co-Morbid conditions like psychosis or substance use
D) Psychotic / delusional
What are some irreverant strategies to address someone suicidal?
“You can’t finish treatment if you’re dead”
“This is a ‘life worth living program’ - it doesn’t work if you knock yourself off.”
What are 3 things you can say to reframe suicide as the problem?
“Watch your suicidal thoughts and say ‘problem’”
“Say ‘I don’t have to kill myself, I just have to solve the probelm’”
“Suicidal thoughts are like a bell ringing saying ‘problem’”
How might you validate suicidal thinking?
Research shows suicide is associated with relief from bad feelings.
I’m asking you to give up a short term solution that works, but for longer term value.
What are the 3 levels of the DBT treatment heirarchy?
1) Life threatening behaviours (Suicide and parasuicide) (Stay alive)
2) Therapy interfering behaviours (Stay in therapy)
3) Quality of life (get to work)
How might you sell diary card or other homework?
“The more you do out of session, the more bang for your buck.”
What are two common DBT strategies that happen to also be forms of exposure?
Chain analysis and diary card
What are 2 simple ways of explaining dialectics?
A) Black and white doesn’t make grey. It makes panda / zebra
B) I want to say all of the things, but I’ll choose this one
What is the 24 hour rule in DBT?
Wait 24 hours after self-harm / suicide attempt before calling to avoid reinforcing that behaviour
What happens in the first 4 sessions of DBT? (8)
1) Assessment (standard)
2) Introductions
3) Treatment goals
4) Assess for suicide, parasuicide, chain analysis, safety plan
5) Orient to treatment -> collaboration, skills biosocial theory, dialectical targeting heirarchy, treatment modes, telephone consults, 24 hour rule, 4 miss rule
6) Commitment to stop suicide and self harm, go to all sessions, schedule
7) Introduce diary card
8) Generate interest and hope
What are DBT pretreatment targets (3)
Orientation, agree on goals, commitment
What are 1st stage targets (4)
1) Decrease suicidal behaviour
2) Decrease therapy interfering behaviour
3) Decrease quality of life interfering behaviours
4) Increase behavioural skills (mindfulness; interpersonal effectiveness; emotion regulation; distress tolerance)
What is DBT 2 stage target?
Decrease posttraumatic stress
What are DBT 3rd stage targets (2)?
1) Increase self-respect
2) Achieve other individual goals
What’s something you can say irreverantly re self harm to get commitment?
“It’s gonna be hard to get you out of depression if you are cutting yourself.”
How would you intro a diary card? (5)
1) Intro
2) Purpose
3) Ask why they agreed
4) Ask what could get in the way
5) Troubleshoot
Why use a diary card (5)?
1) Provides structure, helps us target
2) Tracking can be helpful
3) Assess effectiveness
4) Reminds you of skills
5) Tracks suicidality
What are some useful questions to ask to elicit suicidal ideations? (4)
1) Sometimes when people are struggling with difficulties like your own, they will have thoughts about killing themselves. Have you had any such thoughts?
2) Are you currently having such thoughts?
3) When was the last time you had such thoughts?
4) How persistent are such thoughts?
What are some useful questions to ask to elicit suicide plan (inlc intent and access to means)? (7)
1) Have you ever thought about how you would kill yourself?
2) Do you currently have a plan for doing so?
3) What are your plans?
4) Have you taken any initial actions to carry the plan out?
5) Do you currently have the means available to do so?
6) How difficult would it be for you to obtain those means?
7) How likely are you to follow through with those plans in the next week (month, year) etc.?
What are some useful questions to ask to elicit suicide attempts (and intent)? (5)
1) Have you ever tried to commit suicide int he past?
2) WEhat did you do? (Person, place, time, etc)
3) What happened as a result?
4) Were you discovered or did it go untreated?
5) Were you trying to kill yourself at the time? (Clear ambivalence vs no intent to die)
What are some useful questions to ask to elicit non-suicidal self-injury? (6)
1) Have you ever engaged in any other self-harming behaviour, such as cutting yourself, banging your head against a wall, etc.?
2) Tell me a little bit more about what you do?
3) How frequently do you do so?
4) When was the last time that you did so?
5) Were you intending to kill yourself during any of these episodes?
6) Has this ever required medical care or should you have received medical care (ie stiches, etc)
Roughly how long should you spend reviewing a diary card?
5-10 minutes
What do you do when a client doesn’t bring in their diary card?
Have them fill it out. Reinforce by reading it. Ask what got in the way of them doing it.
When is it useful to use Pros and Cons? (3)
1) When selling commitments
2) When rehearse the positives of adaptive solutions
3) To develop challenges to reservations and other negatives
Describe the freedom to choose an absence of alternatives commitment strategy.
Therapist highlights both the freedom to choose and the consequences of the action, especially in relation to goals. This both enhances choice in terms of goals and consequences of that choice.
Describe the linking present commitment with past strategy?
When commitment seems to be fading, especially in crisis: “I thought you had committed to not hurting yourself.”
Describe the shaping commitment strategy?
Link commitments to smaller, more limited goals which can be expanded over time.
Describe the generating hope: cheerleading commitment strategy?
Provide encouragement within realistic range of client’s capabilities.
What is dialectical abstinence?
Balance between complete abstinence (never engage in problem behaviour again) vs harm reduction: if you slip, minimize the harm and get back to abstaining. Like when I’m on a diet, I slip one day. Minimize the harm and get back to diet the next day.
What is one of the first things to be assessed (though not assumed) when problems arise in therapy?
A failure in commitment
What could you do to troubleshoot commitment?
Is the therapist asking for more than the client can give?
Is therapist asking for too many things at once?
Are client and therapist in agreement regarding treatment goals?
Is therapist reviewing and assessing homework?
Is therapist imposing own expectations and goals?
Is therapist overemphasizing the client’s freedom to choose?
Is therapist own emotions interfering with their (therapist’s) commitment?
What 3 things should be avoided in using commitment strategies?
Being demanding or rigid.
Assuming client is motivated to change
Being mean spirited or punishing
When a client has difficulty with assertiveness, what is a helpful strategy in terms of modeling assertive behaviour?
Model them first, and have them model the person they’re trying to be assertive with. Then they can see what it looks like, and you can see what they are up against.
What 4 things are we trying to differentiate in emotion regulation?
Perception, emotion, urge, and action
What are somethings that emotion regulation can help with?
Identify emotions and their function
Reduce vulnerability to negative emotions
Manage emotions more effectively
Manage extreme emotions effectively
How do you validate an unjustified emotion for a client?
An emotion may be unjustified, but understandable. “Given your past experience with neglect, your rage at being ignored is totally understandable, but we would call it unjustified as it doesn’t fit the facts of the current situation”
When are emotion regulation skills needed / not needed?
Needed: in presence of an unwanted emotion
Not needed: when there is no unwanted emotion
What is the first step in emotion regulation, when noticing an unwanted emotion?
Check the facts / use wise mind to determine whether the emotion is justified AND has an effective urge, or whether it isn’t justified, or there isn’t an effective urge, or if there is simply just too much emotion.
In emotion regulation, after feeling an unwanted emotion, and having checked the facts / using wise mind and having determined there is a justified emotion, and an effective urge, what are the short and long term actions?
Short term: act on urge
Long term: problem solving
In emotion regulation, after feeling an unwanted emotion, and having checked the facts / using wise mind and having determined there is either an unjustified emotion, or an ineffective urge, what are the short and long term actions?
Short term: do not act on urge
Long term: opposite action
In emotion regulation, after feeling an unwanted emotion, and having checked the facts / using wise mind and having determined there is too much emotion, what are the short and long term actions?
Short term: crisis survival
Long term: reality acceptance
What are the 5 primary emotions?
Anger Sadness Disgust Fear Joy
What factors might increase our vulnerability to emotions?
Being hungry
Lacking sleep
Stress
Intoxicants
What tension does sadness relieve?
The tension between what we wanted and what we got
What are the 6 steps in the process of emotion? When do secondary emotions come into play?
1) Prompting event
2) Interpretation (lightning fast)
3) Biological changes (heart rate, breathing, etc)
4) Expression in face, body language, words, actions
5) Emotion name
6) Secondary emotions can happen at any point after the initial interpretation of the primary emotion.
e. g., 1) Someone looks at you in a strange way; 2) That person is a threat; 3) Heart rate increases, pupils dilate; 4) Defensive posture and words; 5) You are feeling fear whether you realize it or not
What are the 10 major emotions?
1) Anger - assertion
2) Sadness - grief
3) Joy - Happiness
4) Disgust - Contempt
5) Fear - Terror
6) Guilt
7) Shame
8) Interest - Excitement
9) Envy
10) Jealousy
What does anger communicate?
Interference, obstruction, intrusion, neglect (boundary violation)
What does fear-terror communicate?
Danger (physical or emotional)
What does Sadness-grief communicate?
Loss or things not as hoped
What does guilt communicate?
Act against values
What does shame communicate?
Perception of self as inferior / unacceptable, by self or others
What does disgust-contempt communicate?
Something noxious, or someone obnoxious
What does interest-excitement communicate?
Something cared about
What does happiness-joy communicate?
Things are as desired
What does envy communicate?
Another has something desired
What does jealousy communicate?
Another threatens my relationship with something/someone
What are some inhibiting emotions?
Anxiety, guilt, shame, contempt
What are some activating emotions (move towards)?
Anger-assertion, joy, interest, grief, positive feelings about the self
According to Michael, what do most clients come to therapy for?
They are experiencing unjustified inhibiting emotions and are using ineffective coping. Therapy should enable access to blocked emotions.
What are some examples of ineffective coping strategies to deal with inhibiting, unjustified emotions?
Suicidal self injury, substance use, sex, eating disorder, isolationism, perfectionism
What are 4 steps of check the facts?
1) Describe event non-judgmentally
2) Identify interpretations, and generate alternative interpretations
3) Likely outcomes for different interpretations
4) Identify likely worst case scenario - fact based terms, and it’s likelyhood
What would you do if a likely worst case scenario is estimated to have a greater than 50% probability?
Problem solve, coping ahead, radical acceptance
What is the action for justified anger?
Assert oneself
What is the action for justified fear?
Get away from danger
What is the action for justified Sadness?
Grieve, replace what was lost
What is the action for justified guilt?
Apologize, repair, accept consequences
What is the action for justified shame?
Hide, appease, avoid disapproving groups, find approving groups
What is the action for justified disgust?
Avoid object of disgust
What is the action for justified interest-excitement?
Attend to interesting thing
What is the action for justified love?
Be with loved one, touch, hold, avoid separation
What is the action for justified envy?
Improve life, devalue desired thing (sour grapes)
What is the action for justified jealousy?
Protect what you have, end relationship, work at being more desireable
How can you improve the statement “good enough”?
Be specific. “Good enough for what?”
When would shame be justified?
When valued group disapproves
What’s a question to get at core values?
What gets you out of bed in the morning?
What’s the acronym for reducing vulnerability?
ABC Please
Accumulate positive experiences (short term: fun; long term: values based)
Build mastery: progressively increase challenge level
Cope ahead: rehearse, visualize
Physical illness (treat) Lather, rinse, repeat (personal hygiene) Eat (balanced diet) Avoid intoxicants Sleep (balanced) Exercise
How are goals related to values?
Goals should be in service of values. Example - value = excitement, goal = travel
What would you do if values conflict?
Higher value prevails; values based ethical decision making model
What is Michael’s ‘quick and dirty’ check the facts?
1) Identify unwanted emotion
2) Is it justified by facts?
3) Wise mind -> seriousness of emotion matches seriousness of event?
4) Flow chart for unwanted emotions
What is the pole-vault analogy when we’ve been hurt?
We can pole-vault to assumptions when we’ve been hurt and our brain wants to protect us.
What is the ‘two hands’ analogy for check the facts?
One hand holds feelings, one hand holds situation. Look back and forth and weigh them. “Do they match?”
What are the 7 steps in problem solving?
1) Observe and describe facts
2) Check facts
3) Identify goal
4) Brainstorm actions
5) Pros / cons, choose a way
6) Take action
7) Evaluate, perhaps try something else
Modify the statement for guilt and shame “how could I have done that?”
Guilt: How could i have done THAT?
Shame: How could -> I
What is shame a fear of?
Rejection from others
What is the difference between a feeling and an urge?
Have you ever wanted to pee in the car? The pressure on your bladder is the feeling. Wanting to pee in the car is the urge.
What strategy would you recommend if the emotion does not fit the facts of the situation in quality, intensity, and duration?
Opposite action. It must be done 100%
What is a hand analogy for emotions that start out fitting but may move out of synch with a situation?
On hand over the other… each finger represents “gross,” “dangerous,” something lost”, “something I like”
How should you do opposite action?
After identifying urges associated with the action, check the facts, note whether emotion fits the situation in intensity, duration, and quality, ask whether acting on it would be effective. If no to effective, act opposite to the urge, and keep doing it as often as possible until unjustified emotion ceases to be a problem. Do opposite action 100%, in body language, in behaviour.
What are the four, trauma-related emotions for which opposite action is particularly tough?
Anger-assertion, fear-terror, sadness-grief, shame
What is the opposite action for anger assertion?
Gentle avoidance, common courtesy, validation, physical relaxation. “You need to be able to let go of your stuff, long enough to see their stuff”
What is the opposite action for fear terror?
Approach the thing prompting the fear-terror. Physical relaxation. Slow breathing.
What is the opposite action for sadness-grief?
Be active, socialize, physical activity
What is the opposite action for guilt?
Do the thing prompting the unjustified guilt, physical relaxation, eye contact
What is the opposite action for shame?
Do the thing prompting the shame, publicly, physical relaxation, eye contact
What is the opposite action for disgust-contempt?
Approach, validate the thing prompting the disgust, contempt, physical relaxation
What is the opposite action for interest-excitement?
Avoid the thing prompting the interest-excitement, think about why interest is unjustified, focus attention elsewhere
What is the opposite action for love?
Get rid of reminders, avoid loved one, think of why love is unjustified
What is the opposite action for envy?
Get your own thing or think of why other should have it, validate other, count your blessing
What is the opposite action for jealousy?
Let go, share, stop trying to control or snoop
When might interest-excitement be an unjustified emotion?
If interest were in arson, or something else illegal or dangerous.
What is a good term to use as an example of how PLEASE components significantly affect levels of emotional vulnerability (has to do with balanced eating)?
Hangry (a state of anger caused by lack of food causing a negative charge in emotional state)
What skills would you use before and after breaking point?
Before: emotion regulation
After: crisis survival
What are crisis survival skills to use at breaking point? (6)
STOP TIP Distract Self-soothe Improve the moment Mindfulness of current emotions
What does being mindful of current emotions look like?
Being aware of the feeling, both as it comes up and goes down; being willing to tolerate the peak of the emotion; getting out of your words and into your body.
What might you have to do with someone who is at their breaking point before you go into mindfulness of emotions?
Distress tolerance
What is a helpful comment for someone who hates their emotions, is afraid of their emotions?
Try to love your emotions. They are trying to help you. They can be very wrong sometimes, but they are trying.
According to Michael, what is the corridor of emotional experience?
Most of emotional experience occurs within the corridor from bottom of stomach to head
What is the emotion of the body trying to protect itself?
Fear (maybe anger?)
What do the following words have in common? Should, good, bad, right, wrong, this sucks…
They are all judgments, and can have an impact on how we feel.
What is contingency management?
Operant conditioning.
Contingency management (CM) is most-widely used in the field of substance abuse, often implemented as part of clinical behavior analysis. CM refers to the application of the three-term contingency (or operant conditioning), which uses stimulus control and positive reinforcement to change behavior.
In operant conditioning, what difference between positive and negative?
Positive = something added Negative = something taken away
Positive and negative refer to the action taken
In operant conditioning, what is difference between reinforcement and punishment?
Reinforcement increases likelyhood of behaviour
Punishment decreases likelyhood of behaviour
These refer to the result on behaviour
In behaviourism, what is shaping?
Reinforcing small steps that lead to an ultimate goal, like in dolphin training
In behaviourism, what is extinction?
Reducing likelyhood of a behaviour by removing the reinforcer
In behaviourism, what is an extinction burst?
A temporary increase in a behaviour following the removal of a reinforcer
In behaviourism, what is satiation?
Providing relief or what is wanted before the behaviour occurs.
In behaviourism, how do you strengthen behaviour?
Add reinforcer, remove aversive
In behaviourism, how do you weaken behaviour?
Withhold reinforcer, maintain aversive
In behaviourism, how do you suppress behaviour?
Add aversive, remove positive
Which is more effective, immediate or delayed reinforcement?
Immediate is more effective. However, delayed gratifycation is associated with maturity.
When are continuous vs intermittent reinforcement schedules typically used?
Continuous tends to be used when learning a behaviour, and intermittent when maintaining it.
What is the difference between natural and arbitrary reinforcement?
Natural reinforcement occurs as part of the behaviour - studying leads to the reward of feeling more competent. Arbitrary reinforcment in this case would be a parent giving the student a cash gift for having done well on the exam.
What is an example of the need for heterogeous reinforcement?
Praise may be reinforcing for some, punishing for others.
What kinds of behaviours in the therapeutic relationship can be reinforcing?
Praise (verbal or body) Expressions of approval Validation Active listening Smiling Telephone calls Therapy sessions
How do you extinguish a maladaptive behaviour?
Remove the reinforcer.
Determine what reinforcers are Create an extinction schedule Watch for extinction bursts Reinforce alternative behaviours Be mindful of shaping Soothe, validate, educate
What is pairing a behaviour with an aversive?
Punishment
When is punishment appropriate in DBT, and what might it look like?
Only when no other stronger reinforcers are available, and no other behaviours occur that can be reinforced. You can confront, or withdraw warmth. Use this cautiously and in low doses. Always assess its effectiveness.
What is a latch ditch effort to change a problem behaviour?
When nothing else works, use aversives of vacation from therapy: identify behaviour that must be changed. Give client a chance to make change. Acknowledge limits of therapist. Clarify client can return when change has been made. Made intermittent contact, encouraging change. Provide referral.
If this doesn’t work, terminate therapy only as a very last resort.
What should be avoided in contingency management?
Reinforcing maladaptive behaviour (giving sympathy immediately following suicide attempt) Reinforcing before change is made Punishing adaptive behaviour Inconsistent use of contingencies Overusing praise Overusing aversives Communicating disrespect or judgments Overusing vacations Imposing arbitrary limits Premature termination
How could a DBT client fail?
They cannot. Only the therapy can fail.
What is more effective, reinforcing positive behaviours or punishing negative ones?
RPB is more effective
What is recommended timing of reinforcement?
Immediately
What works better, natural or arbitrary reinforcement?
Natural - smiles, praise, etc.
What should you check about standard reinforcers before using them?
Does it actually reinforce for that person, in that context?
What would be a contingency management approach to the following: You make suggestions about skills, solutions, or strategies, and she often says ‘yes, but’ to suggestions.
Elicit suggestions from her
What would be a contingency management approach to the following: Your client often shows up late for session and apologizes profusely. You find yourself extending your session time so that the client can have a 50 min session.
Stop reinforcing behaviour
What is the function of therapist observing their limits?
Preserve a sense of self
Remove aversive contingencies for continuing as therapist
Increase interpersonal skills and distress tolerance of client vis-a-vis observing and respecting other’s limits and tolerance for distress
What are 5 principles of observing your limits
Monitor your limits Be honest about your limits Temporarily extend limits when needed Be consistently firm Soothe, validate, and problem solve
How do you monitor your own limits as a therapist?
Notice own emotions, body sensations, thoughts, urges, and actions
Non-judgmentally describe client’s behaviour
Identify how these responses might make sense given past, present or future
In DBT, what word do we use instead of ‘boundaries’?
Limits
How can you, as a therapist, be honest about your own limits?
Watch out for implying it’s for client’s own good
Remember people sometimes want what others are unwilling to give
Take responsibility by using self-involving disclosure
Use I statements to do so
How might you, as a therapist, self-disclose about a limit?
Notice your reaction: “I notice myself feeling worried and thinking it’s going to make overall matters worse…”
Note what it’s in response to: “… when you ask me to tell…”
Note your limit
What are some important principles of temporarily extending your limits?
It’s not a license to be uncaring or unresponsive
Giving someone what they want is sometimes the most effective way of reducing problems
Short term vs long term consequences
Let them know it is temporary (use specific timelines)
Develop solutions for addressing problems
What are some principles in being ‘consistently firm’ when observing your limits as a therapist?
Pacifying or acceding to someone’s demands often increases future behaviours
Be careful not to intermittently reinforce behaviours
Calmly and clearly state your position
What is an example of a limit around phone time in DBT?
You will get 15 min of free time per week. Then its $15 per 5 minute rate after that.
What is helpful to remember when combining being firm with soothing, validation, and problem solving?
Not getting a desired outcome is generally painful
Use validation: “I understand that it is quite frustrating…”
What is the function of telephone calls in DBT?
Skills training, not therapy.
Remove calls as reinforcer for suicidal and crises behaviours (your have to return suicidal calls anyways)
Generalize behvarioural skills to daily life
A bit of extra counselling time when sessions are insufficient, but extra sessions not warranted
Trains client to ask for help appropriately
Repair relationship alientation
What are good reasons for calling in DBT?
Decrease self-harm, suicidal behaviour
Increase general skills use
Decrease alienation and distance
Reinforce skills use / progress
How do you modify therapy interfering phone call behaviours? (ie, calling too much)
Define the behaviour
Do a chain analysis during session
Generate a solution
Reinforce desired call behaviour on phone and in session
Be completely clear on what behaviours you don’t want (no judgments)
Reduce frequency or duration of accepted calls as contingency
Phone call vacations as a last resort
What might you say to someone who calls and says “I’m going to kill myself”
“Yes, that’s the thought you’re having.”
What might you do with a non-productive phone call?
“I’m having trouble understanding you. I’m going to recommend TIP and give me a call if maybe I can understand you better.”
Try again another time
What are three questions to ask about the quality of suicidal ideations?
1) Is the suicide to move away from something or towards something?
2) If you didn’t have the symptoms, would you still be suicidal?
3) If you notice suicidal thoughts, ask what’s the problem?
What is an arson related analogy for suicide?
It’s like burning your house down because you have termites.
What are four types of therapy interfering behaviours? Which is the most common?
1) Non attentive behaviours
2) Non-collaborative behaviours
3) Noncompliant behaviours (most common)
4) Behaviours that interfere with other patients
What are 3 types of behaviours that burn out therapists?
Pushing therapists’ personal limits
Push organizational limits
Behaviours that decrease therapists motivation
What might a therapist suggest to a patient with therapy interfering behaviours?
“Act in a such a way that I want to work with you”
What are some therapist’s interfering behaviours?
Imbalance of change vs acceptance
Imbalance of flexibility vs stability
Imbalance of nurturing vs demanding change
Imbalance of reciprocal vs irreverent communication
What are the 6 stages of the transtheoretical model of change and roughly when do they occur?
1) Precontemplation (more than 6 mo away)
2) Contemplation (under 6 mo away)
3) Preparation (next month)
4) Action (now)
5) Maintenance (at least 6 mo)
6) Relapse or Termination (anytime)
What are some examples of quality of life issues that therapy can help with?
Substance use Problematic sexual behaviour Extreme financial problems Criminal behaviours Dysfunctional interpersonal behaviours Job or school related problems Illness related problems Housing related problems Mental-health related problems Mental disorder related problems
What are the 6 core mindfulness skills in DBT?
What skills:
Observe (aware of what happens)
Describe (able to describe it)
Participate (be in the moment)
How skills:
Non-judmentally (neither good nor bad)
One-mindfully (focused)
Effectively (ultimately it should be effective)
What are the components of ‘improve the moment’
Imagery Meaning Prayer Relaxation One thing at a time Vacation Encouragement
What are the components of interpersonal effectiveness?
Describe Express Assert Reinforce Mindful Appear confident Negotiate
What are the components of relationship effectiveness?
Gentle
Interested
Validate
Easy manner
What are the components of self-respect effectiveness?
Fair
Apologies / no apologies
Stick to value
Truthful
What are the 3 states of mind?
Reasonable mind
Emotion mind
Wise mind
What can be a way to keep someone present while telling a difficult trauma story?
I want you to tell the story on one leg
What are the goals of PTS treatment in DBT?
Acceptance of the fact of the trauma/abuse
Reduce stigma, self-invalidation, self-blame
Reduce denial and intrusive stress response
Synthesize the abuse dichotomy
Increase respect for self
What does “synthesizing the abuse dichotomy” mean?
A dialectical synthesis of the black and white split of “either the abusers are all bad for abusing them or they are all bad for being abused”. Forgiveness is NOT the only possible synthesis here.
What might you do in DBT with a client who is dissociating?
“I’m going to clap really loud in front of your face”
When processing complex or multiple traumas, where do you start?
Worst trauma first
In what order would you target emotions in trauma work?
1st: Guilt, shame, fear, disgust (doesn’t fit facts)
2nd: Anger, sadness
3rd: Sadness
4th: Acceptance
If there was a common phobia in DBT, what would it be?
Emotion-phobia
What is the typical way to formulate a problem in DBT?
In terms of specific behaviour, described by frequency, duration, intensity, and topography.
When is a chain analysis appropriate?
When looking at a specific example of a problem behaviour (e.g., self-harm)
How would you do a chain analysis? What kind of information fills in the links?
1) Choose a specific instance of a problem behaviour
2) Attend to the links in the chain (beg, mid, end)
3) Fill in the links (emotions, bodily sensations, thoughts and images, behaviours, environmental factors)
4) Generate hypothesis (don’t just leave it at the chain)
How would you use a domino analogy with chain analysis?
If the event was a chain of dominos, what was the first domino and the last domino? What were the positive and negative consequences?
What is the function of DBT insight strategies?
To provide insight into dysfunctional patterns and behaviours
What are four principles of DBT insight strategies?
Focus insights on DBT target behaviours and precursors
Explore current, observeable, public behaviours
Use DBT assumptions about patients and biosocial theory to structure insights (ie, they are doing their best)
Favour non-pegorative and empathic interpretations
What is a tool analogy for suicide?
If the only tool you have is a hammer, everything looks like a nail. If the only tool you have is suicide…
What is an alternative to focusing on the breath for those who can’t tolerate it?
Music, or other external things.
Can you get rid of fear through exposure? How important is it to get rid of the fear?
No, but you can make other networks stronger. It’s not important to get rid of it - rather you are trying to learn to tolerate emotion and reduce avoidance.
What is the exposure-related lesson in regards to negative stimulus?
Negative stimulus does not predict bad consequences
What is the intervention for motivational deficit?
Enhance motivation
What is the intervention for skill deficit?
Improve / teach skills
What is the intervention for faulty contingencies?
Contingency management and behavioural activation
What is the intervention for pathalogical fear, unwanted emotional states, inhibited grieving
Exposure interventions, acceptance, mindfulness
What is the intervention for problem cognitions?
Cognitive restructuring, acceptance, mindfulness
What is the intervention for problem environments?
Problem solving
How would you address a therapy interfering behaviour?
- Call it out
- Explain why it doesn’t work (effect on therapist)
- Perhaps model that other behaviour
What was a solution for a client who had extremely ashamed body language in session?
Mirrored it: how about I take the same posture for the rest of the session. You could also video tape behaviour.
What are the 3 primary targets for exposure?
1) Pathalogical fear / anxiety
2) Situations related to threat
3) Inhibited / avoided emotions
How could you use exposure in treatment for anger?
Anger barbs. Practice effective coping in the face of anger-provoking verbal barbs.
What does exposure teach us about safe situations?
That they are safe
How can mindfulness help us in exposure to feared emotions?
Helps us ride the wave of emotion without acting on it.
How important is context in exposure to feared situations?
Very important, because safety is context specific, and fear is generalized. Clients must learn safety in all applicable contexts.
What is the best evidenced-based exposure therapy for fear?
“Cognitive Therapy for Panic Disorder” David M Clark
What is the best treatment for OCD?
Exposure
What are the common steps for exposure? (6)
- Assessment
- Orient to details and rationale
- Conduct non-reinforced exposure
- Prevent avoidance / safety signals / behaviour
- Conduct ongoing assessment (SUDS, etc)
- Ensure client has control
What is non-reinforced exposure (vs reinforced exposure)?
The exposure situation does not reinforce the response being targeted (anxiety, etc.)
When you construct an exposure hierarchy, where should it start?
Where the client is willing to
What can you associate with exposure treatments?
Tones on phone, smells like peppermint
Describe what informal exposure would look like when a client is trying to avoid an emotional experience, going in circles, looking away…
Briefly orient
Present or maintain cue
Block avoidance / escape
Check SUDS
“Let’s come back to what we were talking about and just sit and be with that feeling. Feeling the rise and fall of sadness, or the rise and fall of the fear of sadness. If sadness is justified, it makes sense to feel sad (notice and experience it) and then throw yourself into an activity / distraction
How would you work with emotional suppression in therapy?
Spend time looking at what they should be feeling something about. Figure out all the ways they suppress the emotion, and stop those behaviours.
