Dialectical Behavior Therapy
(DBT) Basics
3
2020
Presenter
• Matthew Rynkiewicz, LCSW
• Master of Social Work (2007)
• Experienced in direct clinical care as well as mental
health program coordination
• DBT group facilitator since 2013
• Received 65 hours of intensive DBT training
• Beacon Quality Management Specialist since 2017
4
Learning Objectives
• Identify the elements of comprehensive Dialectical Behavior Therapy (DBT) programs
• Describe the history and philosophy of DBT
• Explain how the functions of DBT treatment and modes of therapy are used to create
successful clinical interventions
• Demonstrate how DBT skills training works through demonstration of techniques
5
What is
Chapter
01 Dialectical
Behavior Therapy?
What is Dialectical Behavior Therapy
(DBT)?
8
• DBT is a type of cognitive behavioral therapy
• Focuses on increasing an individual’s ability to
cope with intense emotions in healthy ways
• “Emotional Sensitivity”
• Transactional theory o Invalidating environments
9
History of DBT
• Developed by Marsha Linehan in the
1980s & early 1990s
• Treatment manual published in 1993
• Originally intended to treat Borderline
Personality Disorder
• Dr. Linehan and her team added
techniques and developed a treatment
that would meet the unique needs of
these patients. Photo from University of Washington
10
What are Dialectics?
• DBT incorporates a philosophical process called
dialectics
• Everything is composed of opposites
• Change occurs when there is a "dialogue"
between opposing forces
• Dialectics makes three basic assumptions ➢ All
things are interconnected
➢ Change is constant and inevitable
➢ Opposites can be integrated to form a closer approximation of the truth
12
Wise Mind Practice
• Think of something bothering you in your life that is unresolved.
13
Goals of DBT
Cope with stress in healthy ways
Learn to regulate emotions
Improve interpersonal relationships
Live in the moment
14
What makes a good DBT candidate?
• DBT is intended to treat high risk, multiple
diagnosis individuals with pervasive, severe
emotion dysregulation
• Individuals with high emotional reactivity, engaging
in problem behaviors
• Commitment to change is not a prerequisite
Photo from WestSide DBT
15
DBT is Effective for the Following Conditions
Borderline Suicide and
Substance Use
Personality Self-harming PTSD
Disorders
Disorder Behavior
Cluster B Eating disorders
Personality ADHD Mood Disorders (Binge and
Disorders Bulimia)
16
DBT Effective in Reducing:
Outpatient Inpatient Utilization Depression
Services Stays Costs & Suicidal
Behavior
17
18
Photo from Behavioral Tech 2019
Who can perform DBT?
Therapists
Counselors
Social Workers
Case Managers
Training:
Milieu Staff • 2 week intensive courses on clinical teams
• Certification available via Behavioral Tech
19
Chapter
How does DBT 02 Work?
20
DBT Basics
• Individual takes ownership of their
recovery, - self-sufficiency.
• Homework
➢ Tracking emotions, urges, &
behaviors
• Individual and therapist work
together to:
➢ Resolve the apparent contradiction
between self-
Photo from [Link] 10/23/19 acceptance
➢ Skills Training - encourage positive behaviors
21
DBT Assumptions
Individuals are doing the best they can
Individuals want to improve
Individuals need to do better, try harder, and be more motivated to change
All behavior is caused
Individuals may not have caused their problems, but it is up to them to solve them anyway
Figuring out and changing the causes of behavior is more effective than judging and blaming
New behavior needs to be learned in all relevant contexts
22
Behavioral Skills Training
• DBT assumes that the problems exhibited by
individuals are caused by skills deficits.
• Failure to use effective behavior is often a result of
not knowing skillful behavior, or when / how to use
it
• Skills Trainings teaches the individual a set of
behavioral skills to strengthen their ability to use
those skills in their everyday lives
o Mindfulness o Emotion
Regulation o Interpersonal
Effectiveness o Distress
Tolerance
Photo from Psychiatric Times, 2016
23
Stylistic Approaches
Validation
• Acknowledging the truth in an individual’s experience
Irreverence
• Challenging patterns in the individuals perceptions & behaviors to get “unstuck”
Dialectics
• Synthesizing opposites to get closer to the truth
Use of Metaphor
• Using stories & symbols to illustrate concepts
Observing Limits vs. Setting Boundaries
• Within the therapeutic relationship; accepting what we can & can’t tolerate
24
Stages of DBT
Pre-treatment Stabilization Symptom Problems in Incomple
• Orientation to DBT Targets: Reduction living Targets:
• 1:1 meeting with • Life Threatening Targets: Targets: • Increasing
therapist Behavior • Reduce Symptoms • Improve self-worth for joy and
• Establishing • Therapy Interfering • Problem solving
commitment Behavior Interventions: Intervention
• Utilize supports
• Quality of Life • 1:1 Therapy • 1:1 Therap
Interfering Behavior
• Skills Training Interventions: • Pursuing m
and purpos
Interventions: • Phone coaching • 1:1 Therapy
• Consultation Team • Skills generalization
• 1:1 Therapy
• Ancillary Treatments
• Skills Training
• Phone coaching
• Consultation Team 25
• Ancillary Treatments
Secondary Targets for Borderline Personality
Emotional Vulnerability vs. Self-Invalidation
Dialectical
Tensions Unrelenting Crisis vs. Inhibited Experiencing
Active Passivity vs. Apparent Competence
26
Two Main Treatment • Each session lasts ~ 2 hours
• Group meets weekly for 6 months
Settings
Individual Therapy Skills Group (Group Sessions)
• Consists of one-on-one contact with a trained
• Group members share
therapist
experiences / provide mutual
• Therapist helps individual: o stay motivated o support
apply DBT skills within daily life o address • Assigned homework or exercises
obstacles that might arise over the course of
• Groups can be shorter/ longer –
treatment.
depends group members’ needs
• Group led by one trained therapist
27
Modes of DBT
Individual Skills Coaching Phone
ConsultationTherapist Treatments Ancillary
Therapy Training Calls
• Behavioral • Mindfulness Skills • Therapy for the • Medication
Targets • Interpersonal • Skills therapist Management • Diary Cards Effectiveness
Generalization • Problems in • Case
28
Management
• Behavioral Chain • Distress • Behavioral Chain therapy
• Group Therapy
Analysis Tolerance Analysis • Cheerleading
• Vocational &
• Developing • Emotion • Crisis Intervention • Providing Educational
Commitment Regulation Dialectical Balance Assistance
29
30
Skills Coaching Therapist Ancillary
Individual
Individual Training Phone Calls Consultation Treatments
Therapy
Therapy
Behavioral Chain Analysis
DBT requires evaluation of the Behavior
• How is the behavior conditioned?
• Behavioral Targets
o Classically conditioned – cue is paired with the behavior o
• Diary
Operantly conditioned - reward/ Cardsfollowing behavior
punishment
• Behavior Chain Analysis • Behavioral Chain Analysis
• Developing
Links Commitment
Unskillful Consequences/
Vulnerabilities Triggering Reinforcers
Event Behavior
• Identify
• Factors actions, body • Following the
preceding • Cues sensation, problem
problem preceding the cognitions, behavior
behavior behavior events and
feelings
31
Individual
Therapy
Diary Cards
Individual Incidents of behavioral targets, urges to engage in the
Tracks behavior (scale of 1-5)
Incidents of substance and alcohol use Review
only in
Individual
therapy
Consistency with medication regimen
Practice of skills over the last week Review in
Individual therapy
& Skills Training
32
Individual
Therapy
Diary Card Example
33
Individual
Therapy
34
Individual
Therapy
Developing commitment
• Individuals
o Commit to making changes to cues, practicing skills, using interpersonal skills with others
• Therapists
o Do not assume commitment, and do not assume that commitment to change will be uniform
across treatment
• Strategies including are used at the end of sessions to ensure commitment
o Pros & Cons o Foot in the Door
35
Mindfulness
Individual Skills Coaching Therapist Anci
Therapy Phone Calls Consultation Treatm
• Wise Mind Skills
• “What” Skills o Observe o “TeflonTraining
mind”
o Describe o Participate
• “How” Skills – Non-Judgmentally,
One Mindfully, Effectively
Photo from Psychology Compass • Mindfulness Skills
• Interpersonal Effectiveness
• Distress Tolerance
• Emotion Regulation
36
Skills
Training
Interpersonal Effectiveness Skills
Improve ability to
• Clearly communicate with others
• Say “no”
• Observe limits Objectives
Effectiveness • DEARMAN
• Head off conflict
Self Respect
• Attend to relationships Effectiveness • FAST
37
Skills
Training
EffectivenessRelationship • GIVE
38
Skills
Training
Tools for Interpersonal Effectiveness
39
Skills
Training
D Describe
E Express
G Gentle F Fair
A Assert
I Interested A Apologies
R Reinforce
V Validate S Stick to Values
M Mindful
E Easy Manner T Truthful
A Appear Confident
N Negotiate
40
Skills
Training
Distress Tolerance
• Tolerating distressing situations without engaging in problem behaviors
Improving the moment
Crisis STOP skill
Pros and cons
Survival
TIP
Distraction
Self-soothing
Reality Radical acceptance
Acceptance Turning the mind
Skills Half-smile
41
Skills
Training
Willing hands
Willingness versus willfulness
Mindfulness of current thought
PRACTICE: Radical Acceptance
• Think back to the problem you used earlier
o Is there anything about the problem – about yourself, someone else, the world around
you that you might be fighting? o Anything you’re resisting, or makes you feel tense
about the situation?
o Get comfortable and relax and open yourself to acceptance of the situation.
42
Skills
Training
• Did you feel any different?
Emotion Regulation
• Reducing the intensity of emotion states that can cue engagement in problem
behaviors
• Steps involved o Observing emotions o
Changing emotional responses
o Reduce emotional vulnerability
— Examples – ABC, PLEASE
43
Coaching
Individual Skills Therapist Ancill
Skills Generalization
Therapy Training
Coaching
Phone Calls
Consultation Treatm
• BehaviorPhone Calls
needs to be learned across all
environments
• Phone coaching
o Increases the likelihood that individuals will be able
to apply newly learned skills in all contexts o
• Skills Generalization
Provides in the moment reinforcement of skills
• Behavioral Chain Analysis Coaching
• Crisis Intervention
44
Behavioral Chain Analysis (Via Phone) Phone Calls
• In the moment evaluation of current cues, urges, emotions and reinforcers
• Therapist evaluates when the member began to experience urges
• Therapist coaches through the identification and execution of skillful means to prevent engagement
in problem behaviors
• Contingency management (if all else fails….)
• Needs to happen BEFORE the problem behavior has occurred, not after- otherwise having
your therapist on the phone becomes reinforcement of behavior (24 hour rule)
Coaching
45
Crisis Intervention (as needed) Phone Calls
• Engagement of suicide assessment
protocols/ safety protocols as needed
• Assisting by using skills to return to
behavioral chain analysis, and avoid
problem behaviors (ie. distress tolerance)
• Last Resort - Hospitalization and use of
emergency rooms
Illustration by Brittany England via [Link]
46
Individual Skills Coaching Ancillary
Therapy Training Phone Calls Treatments
Therapist
Consultation
• Therapy for the therapist
• Problems in therapy
• Cheerleading
• Providing Dialectical
Balance
47
Therap
Consult
Therapy for the
Problems in
therapist
Therapy
(weekly)
Providing
Cheerleading Dialectical
Balance
48
Image from vectors
Individual Skills Coaching Therapist
Therapy Training Phone Calls Consultation
Ancillary
Treatment
• Medication Management
• Case Management
• Group Therapy
• Vocational & Educational
49
Ancilla
Treatme
Medication Case
Management Management
Vocational &
Group Therapy
Educational
50
04
Chapter
In Summary
51
Key Takeaways
Comprehensive DBT programs can be an effective way to treat clients with high risk
behavior, multiple diagnoses and emotion dysregulation
DBT works! Studies continue to show that comprehensive programs and skills training
can be effective interventions to reduce problem behaviors
Therapists interested in providing DBT should explore training options as the
treatment is extensive and requires a degree of expertise
Use the Behavioral Tech Website to find a therapist at
[Link]
52
Thank you
Contact Us
[Link]
[Link]@[Link]
ClinicalTrainingDepartment@[Link] 55
References
• American Psychiatric Association (1998). Gold Award: Integrating dialectical behavior therapy into a community mental health program. Psychiatric Services, 49(10). 1338–1340.
• DeCou, C.R., Comtois, K.A., & Landes, S.J. (2019). Dialectical Behavior Therapy is effective for the treatment of suicidal behavior: A meta-analysis. Behavior Therapy, 50 (1), 60-72.
• Linehan, M.M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
• Linehan, M. M. (2015). DBT® Skills Training Manual (2nd ed.). Guilford Press.
• Linehan, M. M. (2015). DBT® skills training handouts and worksheets (2nd ed.). Guilford Press.
• Koerner, K. (2012). Doing Dialectical Behavior Therapy: A Practical Guide. Guilford Press.
• Meyers, L. L., Landes, S. J., & Thuras, P. (2014). Veterans’ service utilization and associated costs following participation in dialectical behavior therapy: a preliminary investigation.
Military Medicine, 179(11), 1368-1373
• Robins, C.J. (2002). Zen Principles and Mindfulness Practice in Dialectical Behavior Therapy. Cognitive and behavioral practice, 9 (50-57).
• Robins, C.J., Schmidt, H. III & Linehan, M.M. (2004). Dialectical Behavior Therapy: Synthesizing Radical Acceptacnce with Skillful Means. In S.C. Hayes, V.M. Follette & M.M. Linehan
(Eds.), Mindfulness and Acceptance: Expanding the cognitive-behavioral tradition (p. 30-44). Guildford Press.
• What is the ‘B’ in ‘DBT’? Video retrieved on 5/22/2020 from [Link]
• What is the ‘D’ in ‘DBT’? Video retrieved on 5/22/2020 from [Link]
• Behavioral Tech (2019) How DBT Helps. Retrived on 5/22/2020 from [Link]
• Schimelpfening, Nancy. (2020) Overview of dialectical behavior therapy. Retrieved on 6/2/2020 from [Link] •
Dialectical behavior therapy manual (2017) Retrieved on 6/2/2020 from [Link]
• Smith, E. (2019, August 19). Dialectical Behavior Therapy: How Does It Work?, HealthyPlace. Retrieved on 2020, June 2 from [Link]
illnessoverview/dialectical-behavior-therapy-how-does-it-work
• Harned, M.S., & Botanov, Y. (2016) Dialectical behavior therapy skills training is effective intervention. Psychiatric Times, 33 (3).
56
