Wk 6 - DBT

Question 1

Which group of clients is DBT most often used for?

Answer 1

Self-harming and suicidal clients with Borderline Personality Disorder (BPD)

Question 2

Describe the BioSocial Theory of Development.

Answer 2

Posits that emotional dysregulation is a result of an interaction between biological and social processes.

Biological Aspect - different people have different sensitivity to emotions. some people are more reactive and sensitive (thin emotional skin). They experience strong emotions really quickly and don’t calm down easily with a slow return to baseline. Hence, experiencing these emotions can be very distressing for them.

Social Aspect - invalidating environment growing up. emotional experiences are not taken seriously, neglected, or ridiculed by early caregivers

Interaction results in poor emotional regulation skills. child does not learn how to understand and regulate emotions. Hence, they self-regulate through suicidal and self-harming behavior to escape from the distress.

Question 3

How do we decide on the target hierarchy in DBT?

Answer 3

Put risky behaviors first

Question 4

How does DBT use behavioral theories?

Answer 4

All behaviors have a meaning/function, they have ABCs (trigger and reinforcer)

Question 5

What is the underlying philosophy behind DBT?

Answer 5

Dialectics - achieving a synthesis of opposites in therapy; the flexibility of going back and forth between validation and change. should not focus too much on either extreme as this is not beneficial for the client.

Question 6

Describe how dialectics may work in DBT.

Answer 6

Start with the empathy work first and validate the client’s difficulties. (“yes the pain of relapse is real. but you coming back for therapy shows the strength in your character in which you keep trying”). Then move on to the problem-solving part. (“let’s think about what we can do differently now to make sure you don’t come back a 4th time)

Question 7

How is targetting emotion dysregulation like?

Answer 7

It’s about getting them out of automatic tendencies to self-harm in response to strong emotions, but to bring them into more manual gear by strengthening more helpful regulation methods.

Question 8

Besides self-harming to escape strong distressing emotions, what other possible reasons are there of self-harm? (4)

Answer 8

1) too numb –> self-harm to produce some kind of feeling
2) punishing themselves –> response to that invalidating voice. repenting for what they did wrong
3) gain attention –> signalling a need for help
4) vengeful –> show others how much people were hurting him.

Question 9

What is considered healthy and dysfunctional in DBT?

Answer 9

Health

• no biological disposition of vulnerability to strong emotions
• parents appropriately responded to child’s needs (validating and secure environment)

Dysfunction

• biological disposition to vulnerability of strong emotions
• invalidating early environment. inner emotional experience is ignored or discounted.
• unhelpful ways of coping as individual lack the skills to regulate their own emotions

Question 10

DBT is a ___-based therapy

Answer 10

skills

Question 11

Why do we have to provide skills in DBT?

Answer 11

The current skills they use to cope is maladaptive in the long run, but very effective in the short term. We want to provide them with skills that are more functional in the long term, although they may be less effective now. When they cut themselves or drink excessive alcohol etc., there is secondary emotions of guilt and shame, which is self-defeating in the long term. They are not punished by the shame and guilt later on because it is too far away and doesn’t influence behavior that much. Immediate relief is more reinforcing.

Question 12

What are the 4 therapy components in DBT?

Answer 12

1) consult group for therapist
2) group therapy (teaching of skills)
3) individual sessions (how to apply the skills in their lives specifically)
4) 24h phone support (not an emergency SOS hotline - therapist meant to do prevention work, not remedial.)

Question 13

What is a crucial part of assessment we have to do when working with BPD patients.

Answer 13

Risk assessment!

• make sure that people around them/ closed ones know that they are living with this risky situation.
• make sure that client knows who to call and what to do in times of crisis

Question 14

Describe what you should do in the first 2 sessions of DBT. (4)

Answer 14

1) assessment of client’s clinical history
2) explain biosocial theory to client
3) agree/contract how long and frequent are the sessions
4) agree/contract that client will not kill themselves

Question 15

How frequent are sessions supposed to be?

Answer 15

weekly individual sessions

weekly group sessions (1 year)

Question 16

In what cases should you and should you not intervene for risky behavior?

Answer 16

if behavior is non life-threatening (eg. just small cutting on the wrist), don’t need to ask them to stop UNTIL you teach them new skills to manage their distress.
BUT if it’s life critical (eg. cutting downwards, cutting inner thights), you MUST make a contract with them to stop

Question 17

How do you make a contract with a suicidal client?

Answer 17

1) start off with acceptance and validation work. there is a function and meaning to every behavior. understand that their suicidal behaviors are reasonable from their perspective.
2) as a therapist, you cannot guarantee they will recover because you really don’t know
3) “how many miss rule” - if you don’t commit, you are out. you must register again if you want to come back
4) better do a recontract before the end of the contract.t

Question 18

Describe the 4 stages of DBT.

Answer 18

Stage 1 
- life threatening behaviors 
and intentional self-injury
- therapy interfering behaviors 
- quality of life interfering behaviors 
- skills deficits 
stage 2 
- trauma processing work; helping client experience distressing emotions
stage 3 
 - client is helped to make a greater connection to the world, while decreasing behaviors that hinder achievement of life goals
stage 4 
- address any leftover feeligns of incompleteness

Question 19

What are some skills that is taught in DBT?

Answer 19

• methods to regulate distress
• mindfulness
• interpersonal skills

Question 20

Why is it that you cannot start doing trauma processing work so early?

Answer 20

because the pressure cooker is still very high when they just got referred for therapy. (ie. they experience very strong emotions and don’t know how to cope with them yet). if you take away their coping mechanisms and flood them with strong emotions, they cannot regulate it and the pressure cooker will explode.

Question 21

Describe Behavioral Chain Analysis as a formulation technique.

Answer 21

Extended version of ABCs. Target behavior is identified. Client and counselor collaborate to determine what triggers it and its consequences.
Two kinds of As
1) Precipitating events - specifically invalidation
2) Vulnerability factors (eg. stress at work, lack of sleep) that makes client susceptible to precipitating events
For Bs
- Track progression of thoughts, emotions, behavior
Two kinds of Cs
1) immediate consequences
2) delayed consequences

Question 22

In a behavioral chain analysis, why do we need so much detail?

Answer 22

Because every single one of these bubbles can be a target for intervention. Can focus on what can be done differently in each step

Question 23

Describe the 6 levels of validation.

Answer 23

1) Active listening
2) Accurate reflection of client’s words
3) Accurate reflection of client’s UNEXPRESSED thoughts, feelings, behavioral patterns
4) Help clients make sense of current experience with regard to their HISTORY
5) Help clients make sense of current experience with regard to Current Circumstance (behaviors are reasonable and has a function)
6) Radically genuine: respecting the client as an equal, recognizing their strengths and weaknesses

Question 24

What are diary cards?

Answer 24

Similar to CBT thought records but more detailed. Clients will track the frequency of target specific behaviors everyday (eg. cutting, thoughts about suicide, feelings of misery, use of substances, use of behavioral skills, going productive activities). Progress is tracked each week.

Question 25

What are the 4 types of skills taught in DBT?

Answer 25

1) Core Mindfulness (CM) skills
2) Emotional Regulation (ER) skills
3) Interpersonal Effectiveness (IE) skills
4) Distress tolerance (DT) skills

Question 26

Describe the teaching of Mindfulness skills in DBT.

Answer 26

What Skills - Learning just to observe and describe experience as it is. Noticing our own behavioral chain. The experienced is to be talked about rather than reacted to or avoided.
How Skills - 1) non-judgmental stance 2) focus on one thing at a time 3) doing what is effective

Question 27

What is Wise Mind?

Answer 27

Rational Mind + Emotional Mind. Wise mind refers to a balance between the reasonable and emotional halves of minds. It is able to recognize and respect their own feelings, while responding to them in a rational manner.

Question 28

The wise mind reflects a ______ position.

Answer 28

Dialectical position

Question 29

What is Rational Mind and What is Emotional Mind?

Answer 29

Rational Mind - when people approach a situation intellectually
Emotional Mind - when feelings control a person’s thoughts and behavior.

Question 30

Describe the techniques of distract tolerance skills. (5)

Answer 30

1) Distracting - take part in activities, think of smth else
2) self-soothing - 5 senses, calming activities, imagery, prayer, self-encouragement
3) improving the moment
4) think of pros and cons
5) acceptance (genuine radical acceptance, choosing and willing to accept)

Question 31

What are some techniques for Emotional Regulation? (ie. used BEFORE a crisis)

Answer 31

1) identify and label emotions. identify things that prevent you from changing your emotions.
2) addressing vulnerability factors
PLEASE - physical health, eat well, avoid mood altering substances, sleep, exercise
3) check the facts; be objective (does my emotions match the facts)

Question 32

What are the 3 main techniques for interpersonal effectiveness?

Answer 32

1) Objective effectiveness (DEAR MAN)
2) Relationship effectiveness (GIVE)
3) Self-respect effectiveness (FAST)

Question 33

What are the techniques of objective effectiveness? (DEARMAN)

Answer 33

Describe the Situation
Express your feelings
Assert your needs
Reinforce ppl who respond
Mindful of goal of interaction
Appear confident
Negotiate

Question 34

What are the techniques of relationship effectiveness? (GIVE)

Answer 34

Gentle
Interest in other person
Validate the other person’s thoughts and emotions
Easy light hearted interaction

Question 35

What are the techniques of self-respect effectiveness (FAST)

Answer 35

Fair to self and others
Apologies only when it is warranted
Stick to your values
Truthful

Question 36

What is the purpose of telephone consultations?

Answer 36

1) decrease self-injurious behavior
2) help clients generalise skills across situations
3) address problems in the therapy relationship
* meant to be brief

Question 37

What are the 4 different types of validation?

Answer 37

1) Emotional Validation
2) Behavioral Validation
3) Cognitive Validation
4) Cheerleading

Question 38

Name the 2 dialectical strategies used.

Answer 38

1) Making lemonade out of lemons
- sadness and pain leads to greater understandings of self and others
2) Entering the paradox
- therapist emphasizes the contradictory aspects of the client’s situations. lets client know that there are many sides to a story.

Question 39

What are some cultural benefits of DBT?

Answer 39

1) emphasizes client values. clients can determine culturally consistent goals for themselves
2) assumes that identity is relational. may be good for those in collectivistic cultures.