L11: Dialectical behaviour therapy Flashcards
kenmerken dialectical behaviour therapy
- Developed by Marsha Linehan in the early 1990s.
- Based on cognitive behavioral therapy (CBT), suicide prevention, and Zen principles.
- Research shows that DBT can significantly reduce suicidal behaviors and self-injury. DBT leads to significant improvements in interpersonal functioning and emotional regulation.
DBT =
Evidence-based Treatment program developed for severely suicidal patients with or without automutilation and later extended to addiction, eating disorders, trauma, depression, antisocial pers.st. and forensic problems.
origin of dbt
- First program in the early 1990s to treat “troublesome” patients (previously Borderline personality disorder was untreatable, seen as manipulative and unmotivated).
- Marsha Linehan first developed this treatment for suicidal patients, and is based for the most part on her own experiences with CBT, suicide prevention and ZEN.
doel van dbt
build a life worth living (reducing (para) suicidal behavior, therapy-hindering behavior, and other serious, dangerous or destabilizing behaviors that stand in the way of a valuable life. but it is not a suicide prevention program!)
BPD patients do actually long for connections, people say they are unmotivated, untreatable and manipulative. but they can be very high functioning
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suicide is…
more than a symptom than a problem. as a therapist it is important that you are not afraid, because then you will treat them as vulnerable (te voorzichtig!)
if someone cuts themselves, let them show it to you. they need to feel the consequences of cutting. it has to be real
first part of DBT
relearn how to deal with stress!
DBT based on biosocial theory
when something happens we need time to process this event. everytime something happens your emotions go up. bij bpd gaat dit allemaal nog hoger, baseline arousal is higher and they respod quicker than healthy people and it takes more time to regulate. their temperament is really different. the highest point in unbearable. the only thing left to do is to try and kill themselves. hopelessness because it has just been too much. arousal is too high.
their temperament does not fit into the environment, they miss support, direction or empathy
The biosocial perspective describes that patients do not have sufficient and/or limited skills to regulate emotional problems. The DGT helps the patient by strengthening these skills or learning new skills
hoe ziet DBT er uit
The treatment contains self-chosen treatment goals based on a hierarchy and clear agreements between patient, practitioner and team. Treatment strategies based on CBT, ZEN and Suicide Prevention are used during treatment. The treatment uses a number of assumptions to support the practitioners. The program contains four components: weekly structured group training (practice and coaching), structured individual (motivating and analyse obstacles) and telephone consultation (generalizing) and a consultation team (monitoring and improving qualities and keeping therapists healthy).
the treatment starts with setting personal goals to a good life. but it is an extremely difficult therapy, both client and therapist need to work hard
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nadat mensen zijn gestopt met life threatening behaviours (self-harm), gaan ze naar stage 2:
emotie regulatie technieken, aan anxiety en depression werken
key assumptions of DBT
- The Patient is Doing Their Best: It is assumed that at any given moment, the patient is doing the best they can with the skills and resources they have. This helps to foster a non-judgmental and compassionate therapeutic environment.
- The Patient Wants to Improve: DBT operates on the belief that patients inherently desire to improve their lives and well-being. This encourages motivation and a forward-looking perspective in therapy.
- The Patient Needs to do Better, Try Harder, and be More Motivated to Change: Despite doing their best, patients must strive for improvement, increasing their efforts and motivation to achieve better outcomes.
- The Patient May Not Have Caused All Their Problems, but They Have to Solve Them Anyway: This emphasizes personal responsibility and empowerment, encouraging patients to take active steps towards resolving their issues, regardless of their origin.
- The Lives of Suicidal Patients are Unbearable as They are Currently Being Lived: Acknowledging the profound distress and pain in patients’ lives underscores the urgency and necessity of change and intervention.
- Patients Must Learn New Behaviors in All Relevant Contexts: For change to be effective and sustainable, patients must apply new skills across different areas of their lives, not just in therapy sessions.
- Patients Cannot Fail in Therapy: It is recognized that if the patient is not benefiting from therapy, it is the therapy or the therapeutic approach that needs adjustment, not the patient who is failing.
- Therapists Treating Borderline Patients Need Support: Therapists also need a supportive environment to deal with the challenges of treating complex cases, which is why DBT includes a consultation team for therapists.
3 principles of DBT
- Dialectics: recognizing the polarity in behavior and the importance of continuous change and coherence.
- Acceptance (Mindfulness): observing without judgment
- Change (Behaviorism): behavior shaping through repetition and operant conditioning.
DBT is not a talking therapy: they are working on skills. ook homework, veel bespreken, soms group therapy
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if the client does not show up in therapy
always figure out what you missed! something personal?
heel belangrijk dat je aangeeft waarom je dingen doet
no judgement but they should know the consequences
fine if you dont want to come to therapy tomorrow, but then i wont be able to treat you anymore
if you want to kill yourself, i can bring up sympathy for that. but i do not agree because i think you are worth it
skills and problem behaviours
- Mindfulness -> Addressing identity confusion and feelings of emptiness
- Interpersonal effectiveness -> Managing unstable relationships and fear of abandonment.
- Emotion regulation -> Controlling mood swings and intense anger
- Frustration tolerance -> Reducing impulsive behavior and self-harm.
in welke populaties is DBT nog meer effectief
- autism with suicidal ideation
- adolescents
- general efficacy and safety
- emotion regulation disorders
autism en suicidal ideation en dbt
- DBT is effective in reducing suicidal thoughts and attempts in adults with autism in the short term.
- A study by the Vrije Universiteit in Amsterdam showed significant reductions in suicidal ideation and attempts when compared to treatment as usual (TAU) immediately after treatment.
- However, these differences were not statistically significant at a 12-month follow-up
adolescents en dbt
- DBT has been successfully adapted for adolescents, showing positive outcomes in reducing self-harming behaviors.
- This adaptation demonstrates DBT’s flexibility and effectiveness across different age groups and issues
general efficacy and safety in dbt
- DBT continues to be a well-received and safe treatment option.
- Studies report low attrition rates and no severe adverse events, indicating good patient tolerance
emotion regulation disorders
- DBT emphasizes teaching skills to manage intense emotions, cope with challenging situations, and improve relationships.
- The incorporation of mindfulness and acceptance techniques is crucial for emotional regulation and reducing problematic behaviors
3 principles of DBT
- zen (ie. mindfulness)
- acceptance: mindfulness and distress tolerance
- change: emotion regulation and interpersonal effectiveness
welke learning technieken gebruikt DBT
- classical conditioning
- operant conditioning
- modeling
3 central principles of dbt
- wholeness (veel factoren die meespelen, niet een ding krijgt ‘de schuld’)
- polarity (reality is never in balance)
- continuous change (synthesis leads to a new set of polarities and process continues)
wanneer zijn de treatments
weekly, individual
weekly skills group
weekly consultation group for the therapists
pho coaching is needed when….
a client is in need of skills coaching, and as a way to learn and practice interpersonal and relationship skills with the therapist
dbt teaches 4 skills modules:
- mindfulness
- distress tolerance
- emotion regulation
- interpersonal effectiveness
a primary function of individual therapy is to…
enhance motivation by linking proximal behaviours to more distal goals. therapists seek to understand what makes the clients life worth living
the DBT pre-treatment contract =
explains the nature of the therapy and commitment required to benefit from dbt.
this is a written document negotiated between therapist and client durign the first three/four weeks of the treatment
the house of DBT=
allegory used to teach clients about the four stages of DBT:
(pre-treatment: build therapeutic relationship, explain biosocial theory, sign contract)
1. improving behavioural control and increasing skills use
2. improving emotional regulation and experiencing
3. bolstering overall quality of life through developing relationships
4. improving capacity for joy
chain analysis =
insight tool of dbt.
slow down the events leading to a problematic behaviour so that the client can more clearly see their patterns of thinking, feeling and acting
solution analysis=
teaches clients that when faced with a problem, they can:
- solve it
- change their emotional response
- tolerate or accept it
- do nothing and potentially make it worse
DBT is a philosophically rich, multi-stage treatment that can take months or years for a therapist to learn.
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DBT is most effective when delivered by adherent practitioners who have received comprehensive training and are adherent to the treatment model.
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which theory guides dbt
biosocial theory, states that severe emotion dysregulation emerges when a biologically vulnerable child is reared within a chronically invalidating environment. both child and parent cant get their needs met
DBT therapists often use metaphors to describe the biosocial theory in a nonjudgemental way:
coloring with the emotional equivalent of a 128 crayons
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5 functions of DBT
- improve motivation (individual therapy)
- enhance client capabilities (skills groups)
- facilitate generalization of client capabilities (phone coaching)
- enhance therapist motivation and capabilities (consultation team)
- help structure the environment to boost client and therapist capabilities (case management)
dbt contract can be changed for some elements, eg. phone hours
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24 hour rule
Clients are asked to call the therapist before a crisis to seek strategies for avoiding problem behaviors. If they engage in self-harm or other life-threatening behaviors, the client is required to wait 24 hours before phone coaching is resumed.
dialectical dilemmas of dbt
- active passivity vs. apparent competence
- emotional vulnerability vs. self-invalidation
- unrelenting crises vs. inhibited grieving
in the middle: synthesis
