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
