Dialectical Behavior Therapy Part 4, Las Vegas 2020 Alan E. - - PDF document

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Dialectical Behavior Therapy Part 4, Las Vegas 2020 Alan E. - - PDF document

Oct 25, 2022 102 likes •226 views

DBT Part 4, NPA Las Vegas July 2020 Comprehensive Training in Dialectical Behavior Therapy Part 4, Las Vegas 2020 Alan E. Fruzzetti, Ph.D. 1 Adherence Pyramid Adherence Mindful/Team Dialectics Acceptance & Validation Change and

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 1

Comprehensive Training in Dialectical Behavior Therapy Part 4, Las Vegas 2020

Alan E. Fruzzetti, Ph.D.

1

Adherence Pyramid

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Theory, Program & Therapy Structure, & Case Conceptualization Assessment of Targets Change and Behavior Therapy Acceptance & Validation Dialectics Mindful/Team Adherence

Revisit Dialectics in DBT

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 2

Balance Communication

  • Reciprocal communication
  • Irreverent communication
  • Dialectically balanced: speed, movement

in the service of behavioral self- management and reduced suffering

  • Dialectics: strong reciprocal and strong

irreverent communication

4

Balance Consultation Strategy With Intervening in the Environment

Consultation with the Patient:

  • Teach the patient to be effective on

his/her own behalf with

– Social network – Professional network

Environmental Intervention:

  • Intervene on her/his behalf when the

short-term gain is greater than the short-term loss + long-term loss

5

Environmental Intervention

Necessary when:

  • The patient cannot do what is needed on

her/his own behalf (or the environment will not accept it from the patient) and the

  • utcome is very important
  • The life of the patient or another is at stake
  • The patient is a minor (legal/ethical)
  • It is humane to do so and unlikely to cause

harm to the patient

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 3

Dialectical Opportunities

  • Integrate/synthesize acceptance & change
  • Use metaphors and stories
  • Balance acceptance & change as solutions

(targets and matched skills)

  • Dialectical targets (both/and, polarizations)
  • Wise mind
  • Communication strategies
  • Consultation-to-the patient/ environmental

intervention

  • Consultation team (structure & process)

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Dialectical opportunities, continued

  • Lemonade out of lemons
  • Dialectical assessment: What am I (or,

are we) missing?

  • Allow natural change
  • Notice or enter the paradox
  • Play devil’s advocate
  • Omnipotence and impotence
  • Dialectics of behavior therapy (ABCs?)
  • Movement, speed and flow (jazz,

dance)

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Dialectics is participation (mindfulness) for the therapist.

“As in the training of the samurai, the student needs a number of years to achieve expertise and many more to achieve spontaneity.”

  • Salvador Minuchin, famous DBT supervisor
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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 4

Basic DBT Family Interventions

How People Transact in Healthy Relationships: Two-Steps

1.Accurate Expression 2.Validating Responses

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Transactional Model of Emotion Dysregulation

Individual Emotion Vulnerability & Emotion Dysregulation Invalidating Responses

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 5

Judgments High emotional arousal & dysregulation Inaccurate self-expression Misunderstanding Judgments, reactivity Invalidating responses

Parent Responses to Adolescent Children (~BPD)

1 1.5 2 2.5 3 3.5 4 4.5 5 Validation* Invalidation* Parents of Clinic Children Parents of Non- Clinic Children

*p<.05

Shenk & Fruzzetti, 2014

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Judgements and anger get in the way, and are corrosive in relationships even when justified.

And, anger always hides other,

  • ften more important emotions,

in close relationships.

http://www.mindfuls c hools .org/graduate -s tories /jus t-breathe-ju lie-bay er-s alz man/

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 6

Accurate Experession Relationship Mindfulness Identify Emotion, Want, Goals, etc. Manage Emotions

Steps Toward a Accurate Expression

What is my relationship with this person? Remember I care about him/her and that she/he cares about me. Is this a good time for communication? Is the other person open? Mindfulness: Bring attention to your sensations, what happened (event), identify primary emotion What do you want? What do you care about? Mindfulness: Observe emotion Non-judgmental Be effective, not right De-escalate emotions Let go: judgments Anger as a signal Accept/allow Change: Problem solve, opposite action, exposure Describe: Your primary emotions, what you want, your goals, sensations,

  • pinions, how you

want to try to solve a problem ets. Stay descriptive. 16

Validatin g Response

Understand Relationship Mindfulness (bring attention to another) Mindfulness (manage emotions))

Steps Toward a Validating Response

Manage attention Be curious Be kind Manage own emotions to understand the

  • ther person:

What would get a person to do this? What would get me to do this? Relationship Mindfulness: Bring mindfulness to the other, your relationship Remember this is a person you love, what kind of relationship you want Mindfulness: Observe emotion Describe Participate Non-judgmental Be effective, not right De-escalate emotions Let go: judgments Anger as a signal Validate the valid Don’t invalidate valid things Don’t validate invalid things Invalidate the invalid only

  • ccasionally…

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Open your mind before you open your mouth.

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 7

Interventions

  • Family Psychoeducation

– Understanding emotion dysregulation – Transactional model → reciprocity – No judgments, no blame

  • Individual DBT Skills (self-management)
  • Family DBT Skills

– Emotion Regulation + Mindfulness → Accurate Expression – Emotion Regulation + Relationship Mindfulness → Validation

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Overall Intervention Program:

  • 1. Establish safety
  • 2. Assess/orient/commit to treatment
  • 3. Build skills (ongoing)
  • 4. Identify and reduce invalidation
  • 5. Rebuild relationships
  • 6. Accurate expression
  • 7. Increase validation
  • 8. Problem management
  • 9. Transform conflict into closeness via

acceptance & engagement

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Treatment Modes are Flexible

Parent, couple, family groups (with or without the identified patient)

  • r

Family therapy

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 8

Session Management Strategies

  • Revolving door
  • Relationship mindfulness
  • Speaking “for” (expressing accurately, or

validating) the partner

  • Involve others
  • Blocking, blocking, blocking…

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More therapeutic issues

  • Finding a way to like the client(s)

– Allows early blocking, while still liking him/her – Allows playfulness, irreverence

  • Be able to “see” the chain leading to the

present, or problem, behavior

  • Understand dysfunctional behavior IN the

model…don’t be judgmental or reactive

  • Make the partner or parent look good; don’t

undermine or show him or her up

– Speaking for the partner or parent can help – Validating the family member, his/her wise mind

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Validation Increases Positive Affect and Decreases Negative Affect

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 9

Mindfulness, description Lowered emotional arousal Accurate expression Relationship mindfulness Understanding, low reactivity Validating responses

Validating & Invalidating Responses

Validating

  • 1. Pay attention; relationship

mindfulness

  • 2. Acknowledge & describe;

reflect

  • 3. Ask questions; mind reading
  • 4. Benefit of the doubt/ valid

due to learning or biology

  • 5. Normalize (“of course”) the

normative

  • 6. Respectful, not

condescending

  • 7. Match vulnerability

Invalidating

  • 1. Not paying attention;

closed

  • 2. Judgmental, minimizing;

disregarding reality

  • 3. Closed mind
  • 4. Assume the worst;

criticize vulnerabilities

  • 5. Invalidate the

normatively valid

  • 6. Condescending,

disrespectful

  • 7. Exploit vulnerabilities

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Behavioral Chain Analysis: Dysregulated Behavior

Vulnerabilities to getting dysregulated “Links” – thoughts, emotional reactions, problematic actions

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 10

Behavioral Chain Analysis

Vulnerabilities to getting dysregulated Possibly Relevant Parent or Partner Behaviors

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Individual’s history, especially with parent or partner Individual’s history, especially with child or partner Thoughts & emotions Thoughts & emotions Situation/ Event

Negative Outcome – Attacking or Withdrawing

Judgments & secondary emotions Hurt feelings, further dysregulated emotion & behavior Verbal/public behaviors

Double Chain

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Staying Inside the DBT Model

Individual Adherence/Certification Program Adherence/Certification

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DBT Part 4, NPA Las Vegas July 2020 (c) Alan E. Fruzzetti 2020 11

Consultation: Consider

  • 1. Is the therapist adhering? Target misses…
  • 2. Is the therapist’s target for consultation

clear? Is the problem definition clear?

  • 3. How is the therapist’s motivation?
  • 4. What is getting in the way (of adherence, of

motivation, etc.)?

  • a. Lack of skills
  • b. Emotion
  • c. Judgments/cognition
  • d. Contingencies

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http://www.borderlinepersonalitydisorder.c

  • m/Conferences/Yale2011/Yale11-

demonstrations.shtml (see adherence write-up)

ADHERENCE SCALE (Linehan) Structural Strategies Problem Assessment Problem Solving Contingency Management Exposure & Response Prevention Cognitive Modification Validation Reciprocal Communication Irreverent Communication Dialectical Case Management Crisis and other protocols