Wednesday, 25 November 2015

10 Things I learnt from Fiona Kennedy's Putting DBT into your practice 2 day workshop - Dialectical Behaviour Therapy

This excellent workshop wasn't intended as a complete training in DBT, but rather as a way to understand how an experienced practitioner could take parts of the DBT model and incorporate it into their practice. It worked for me! Here are the top 10 things I learnt from the course

1) DBT is Dialectical

Dialectical means accepting and working with opposites and apparent contradictions
There is a thesis, an antithesis and then a synthes which includes  truth from both.

  • For example,  if the thesis is "I need to change!"
  • and  the antithesis is "I can't change"
  • the synthesis could be "Change is difficult. What I have tried so far hasn't worked. I need to work on skills to change, even though this will be difficult".
If  a client wants to practice midfulness (the thesis) but has a cold and says "I cant do mindfulness today because I have a cold" then as a therapist you might helpful suggest (the synthesis) "Your cold presents you with a great opportunity to practice mindfulness when its harder"

2) DBT is Behaviorial

The focus is on behaviours that need to be changed for the client to achieve their goals.  This provides a very clear focus and can make the complicated and complex much simpler
The therapy focuses on

What am I doing causing me and others problems and what can I do differently?

Below is a summary of some behavioural principles which can help guide a skilful therapist
  • Form a plan to change unhelpful behaviours
  • Get whole lot of possible solutions
    • Give them skills ask them to choose like a smorgasbord then ask which appeals most
    • Look at obstacles and how to overcome them
    • Shape and reward desired action - if they have done something positive, praise this 

    3) DBT is Skills-based

     Forming a plan is a good start, but many people don't have the skills to carry this out effectively. There is a large element of skills training in DBT and  this is usually done in Skills groups
    where participants  learn to decrease problematic and unskillful behaviours.
    Each module lasts about 6 weeks
    The modules are:
    Emotion regulation - what you can change - here are some good ideas about emotional regulation and article assessing cognitive strategies such as distraction and reappraisal
    Distress tolerance - dealing with difficult emotions and what you cant change . Here is a useful handout on distress tolerance  and here are the CCI modules on distress tolerance
    Mindfulness - learning to control your mind  - here is DBT's version of mindfulness and some free mp3 mindfulness recordings that can be used in DBT
    Interpersonal skills -learning how to get your needs met regarding other people - here is information on DEAR MAN GIVE FAST ideas and some handouts on DBT and interpersonal effectiveness skills

    There is typically a maximum of 8 in a group with  2 therapists. One talks the other "reads the room" 

    As with learning any other skills, homework is key. If people don't do it, this needs to be dealt with.
    "Did you think of it or did you forget it?". The failure to do homework is problem-solved.

    Here is a really useful free 85 page DBT Skills Booklet that can be used in a group

    4) A possibly lengthy assessment phase

    DBT is a big investment for both client and therapist. It is fitting then that some time is given for the potential client to think about whether to commit to DBT.
    A Contract usually a year involving a lot. Asssement will explore motivation and behaviours they want to change. This phase can last up to  6 weeks

    5)Telephone coaching is part of the deal

    In a DBT group, the client is offered  telephone coaching when they need it. This is specifically for help when they are in crisis. The client will form a crisis plan which they have with them
    If they ring, you go through the crisis plan with them
    "Get them to breathe then walk through plan"

    6)Validation and Acceptance of the  client

    Although change is the desired outcome, validation is an extremely important prerequisite for change

    There are 6 levels of validation

    These range from showing an interest, to validating their emotions and behaviours "It's normal to feel anxious before coming to see a therapist." You are accepting the person, but that doesn't mean you are endorsing unhelpful behaviours.

    7) Use of Chaining as a formulation method 

    This is similar but not identical to CBT's "Hot Cross Bun" or "maintenance cycle" formulation is called "Chaining" in DBT.

    Chaining is actually fairly straightforward and involves the following steps :-

    • When did you first know that  the problem behaviour would arise?
    • If you were in situation again what would you do differently?
    • What stopped you this time?
    • What made you vulnerable at this time

    • What happened when you stopped
    • What are the consequences?
    • What can we learn from this?

    Then ask them to describe the sequence as if telling an actor how to play the part. It needs to be spefific. You are finding out the chain of antecedants, behaviours and consequences in terms of thoughts, feelings, urges and behaviours.

    8) The Role of individual sessions

    A lot of the skills learning takes place in the group sessions, but individal sessions are important too. In these you make list of target unhelpful behaviours to reduce 
    In each session work through list in each area hierarchically
    They bring in diary/ Your job is to keep them "on the hook" 

    9) Wise Mind

    DBT makes the helpful distinction between Logical. Emotional  and wise mind
    Logic is great - but what it would be like to be just in logical mind, like Mr Spock?
    We would lose a large part of what it is to be human, what motivates us and what makes us individual.  Fear keeps us safe. Anger stops people treating us like a doormat
    Yet emotions can get us into a lot of trouble.

    We need emotions - but in moderation

    Wise mind can moderate emotions, its the synthesis of logical mind and emotional mind.

    Here is an exercise that might help you locate your own wise mind
    Think of a dilemma
    Start with facts and logic
    Then think about the emotions and desires connected with the dilemma
    Imagine falling  down  a well taking all the facts and feelings with you. At the bottom is
    a trap door. Through this trap door is your wise mind, which takes into account logic and feelings. Go through the trap door? What does wise mind tell you is right for you?

    Here are useful worksheets and  handouts about wise mind

    10) Use of Metaphors 

    Wise Mind is one metaphor used in DBT - there are lots of others that are used in DBT

    For example

    • Tigger and eeore
    • If you want a decent life you have to experience the pain
    • Change your home page 
    • Thoughts can be like junk mail
    • Make a lemonade out of lemons. 
    • Need to go through pain barrier to get through marathon
    Here is a link to other metaphors of use in therapy  a good article and a couple of really good books
    Oxford Guide to Metaphors in CBT
    Stories and Analogies in CBT

    Further Resources

    Free 85 page DBT Skills Booklet
    Really comprehensive site full of free DBT resources

    DBT® Skills Training Handouts and Worksheets

    There are also a number of Apps for clients to help develop DBT skills

    Wednesday, 18 March 2015

    How to do CBT (Part 3 of series)

    This is the third and final  part of a series of articles about three ways of doing CBT with a hypothetical client, "John". 

    John comes to CBT because of his depression.  He is a 40 year old who has recently been made redundant. He is worried about getting a job again and his redundancy has also  caused tension in his marriage. When questioned about how he spends his time now, he says he gets up late, intends to look for jobs but ends up doing very little. He feels demotivated, discouraged and, at times, hopeless.  He is having trouble sleeping and hints that he may be using drinking to cope with his difficulties.  At times, he says, he wonders if he will ever get a job again.  He sees his redundancy as meaning that he is a failure.  He talks in  a flat, slow monotone. As he talks, he is becoming more sad and more hopeless.

    In the first article, counsellor A had a  short car-crash session, in the second article counsellor B  if anything  did even worse.  Yet both included good evidence-based CBT ideas ... Now we will see how counsellor C takes a somewhat different approach so the session lasts a bit longer ...

    How to do CBT: Counsellor C with John

    C1: Good to see you again, John,  I can see from the PHQ9 scores you filled in whilst you were waiting that it’s been quite a tough week but there’s been some improvement. Is that how it seems to you?
    J1:  I didn’t realise there had been improvement. Still feels pretty grim at times to be honest
    C2: Sorry to hear that – shall we put that as one of the items on our agenda for today?
    J2: OK
    C3: What shall we put?
    J3: “Feeling pretty grim at times?”
    C4; OK … Just at times?
    J4: Well, probably quite a lot of the time to be honest
    C5: OK, I’ve written here under Agenda – “ 1. Addressing feeling grim a quite a lot of the time.”. OK?
    J5: Yes
    C6; Now we have an ongoing agenda item – review homework – so we’ll do that first as usual. I’d also like to add to the agenda –“pros and cons of being active” – is there anything else you would like to add?
    J5: Well, to be honest I’ve been wondering whether I’m wasting your time.
    C7: OK, that’s something we should definitely add to the agenda (writes down “Am I wasting counsellor’s time?”).  We’ll look at that more fully later,  but can you just say a little now about why you think you are wasting my time?
    J6: I still haven’t got a job. I still waste most of my time.  I’m a waste of space ….
    C8: It sounds like that’s definitely an important thing for us to look at. We’ve got 4 things on our agenda – review homework, Address feeling grim, pros and cons of being active and am I wasting counsellor’s time. I’m wondering whether that might be a good order to look at things? I’m thinking that later in the session we might have a better idea about how useful this process is for you.
    J7 : That makes sense.
    C9: So, how did you get on with the  homework?
    J8: (Gets sheet out of pocket) Here it is.
    C10: Would you like to talk me through it?
    J9:OK …Well, on Wednesday I didn’t feel great, I didn’t really feel like going out  but I had a letter to post so went into town and actually it looks like my mood did go up from a 4 to a 5. Then the rest of the day wasn’t so bad. Thursday was bad though. I woke up feeling totally lacking in energy.   I stayed in bed .. didn’t get up until 200. Then it felt like it was too late to do anything. Then later in the evening I felt even worse, thinking “I’ve wasted the day, I’m never going to get better.”
    C11: And what happened to your mood on Thursday?
    J10: It started at 3 – then went down to a 2 in the evening. Not great.
    C12: No, it doesn’t sound like a good day at all. Still, hat was a great effort to fill the forms in even though you were feeling so low. Well done. Shall we look at the two days together and see what we can learn from them?
    J11: Sure
    C12: So on Wednesday, you didn’t feel like going out, but do did and then you felt better. What can we learn from that?
    J12: Maybe that being active helps, but that sometimes we don’t feel like being active.
    C13: Exactly. So should we always do what we feel like doing?
    J13: No, because actually  I felt better after I did what I didn’t feel like doing
    C14: That’s a very important insight you’ve captured there, John. We often do feel better when we are more active. But when depressed we don’t feel like being active. So what have we got to do to lift the depression?
    J14: Be active even when we don’t feel like it?
    C15: Exactly. How would you feel about trying that as part of the homework for next week?
    J15: I’ll try.
    C16: Let’s write it down. “Last weeks’ homework suggests that it will help to be active even when I don’t feel like it.” What else do we need to record?
    J16: Maybe how I feel about being active at the time?
    C17: Right, so let’s add another column to your record sheet – “How I feel about being active”. How does that sound? Can you imagine recording this?
    J17: Yes
    C18: Do you think it might be helpful?
    J18: Yes
    C19: OK – just to make certain, let’s see how that might have panned out on Thursday. If you’d been tracking your thoughts then as well, what would you have written down?
    J19: Let me think. Probably “I’ve no energy so I’ll stay in bed?”
    C20: Bearing in mind what we’ve just learnt, what do you think now?
    J20: Even though I don’t feel like being active, if I do I’ll feel better
    C21. Great. So I’m wondering if we need another column, like this (Adds another column –“more helpful thought.”) How does that look?
    J21: Looks good – not sure though if it will work though if I am feeling as low as I did on Thursday.
    C22: Is it worth trying?
    J22: Yes, it’s worth a try.
    J23: How are you feeling now about our work today so far?
    J22: Good
    C23: Me too.. Shall we take stock. So far today we’ve reviewed the homework, and seen that on the day when you are more active, you feel better. So we have set up a homework task next week where you notice negative thoughts telling you not to be active, and do your best at answering back to them and then being active – again recording how you feel afterwards. Have I missed anything?
    J23: No
    C24: So  shall we move on to the other agenda items. We had  “wasting my time” –do you still think you are wasting my time?
    J24; No, not nearly so much
    C25: Good, neither do I. Shall we move on to the next item on our agenda?
    J25: Yes.

    What did counsellor C do differently?

    Friday, 13 March 2015

    Another song for depression : Better get to livin' by Dolly Parton

    By: Dolly Parton & Kent Wells

    People always comin' up to me and askin' 
    "Dolly, what's your secret? 
    With all you do, your attitude 
    Just seems to be so good 
    How do you keep it?" 
    Well I'm not the Dalai Lama, but I'll try 
    To offer up a few words of advice

    You better get to livin', givin'
    Don't forget to throw in a little forgivin'
    And lovin' on the way
    You better get to knowin', showin'
    A little bit more concerned about where you're goin'
    Just a word unto the wise
    You better get to livin'

    A girlfriend came to my house
    Started cryin' on my shoulder Sunday evening
    She was spinnin' such a sad tale
    I could not believe the yarn that she was weavin'
    So negative the words she had to say
    I said if I had a violin I'd play

    I said you'd better get to livin', givin'
    Be willing and forgivin'
    Cause all healing has to start with you
    You better stop whining, pining
    Get your dreams in line
    And then just shine, design, refine
    Until they come true
    And you better get to livin'

    Your life's a wreck, your house is mess
    And your wardrobe way outdated
    All your plans just keep on falling through
    Overweight and under paid, under appreciated
    I'm no guru, but I'll tell you
    This I know is true

    You better get to livin', givin'
    A little more thought about bein'
    A little more willin' to make a better way
    Don't sweat the small stuff
    Keep your chin up
    Just hang tough
    And if it gets too rough
    Fall on your knees and pray
    And do that everyday
    Then you'll get to livin'

    The day we're born we start to die
    Don't waste one minute of this life
    Get to livin'
    Share your dreams and share your laughter
    Make some points for the great hereafter
    Better start carin'
    Better start sharin'
    Better start tryin'
    Better start smiling
    And you better get to livin'

    Dolly Parton has spoken about her own history of depression   The "Better get to living"  idea is non-pharmeceutical anti-depressant.

    Thursday, 12 March 2015

    How not to do guided discovery

    From 17 min 30 secs - lasts about 4 minutes

    This link will very likely expire in which case check out  John Finnemore's Souvenir Programme
    Series 2 Episode 1

    Episode 1

    John Finnemore's Souvenir Programme,Series 2  John Finnemore, the writer and star of Cabin Pressure, regular guest on The Now Show and popper-upper in things like Miranda and Family Guy, records a second series of his hit sketch show.
    The first series was described as "sparklingly clever" by The Daily Telegraph and "one of the most consistently funny sketch shows for quite some time" by The Guardian. It featured Winnie the Pooh coming to terms with his abusive relationship with honey, how The Archers sounds to people who don't listen to the Archers and how Dr Jekyll and Mr Hyde decided whose turn it was to do the washing up.
    This episode doesn't feature any of those things, but it does feature an awkward celestial relationship, surprisingly easy contract negotiations, and a trailer for a film about the only mode of transport that hasn't had a film made about it yet.
    John Finnemore's Souvenir Programme is written by and stars John Finnemore. It also features Margaret Cabourn-Smith, Simon Kane, Lawry Lewin and Carrie Quinlan. It is produced by Ed Morrish.1 of 6

    Monday, 2 March 2015

    What songs are helpful in CBT?

    To get away from an over-clinical, unfriendly caricature that CBT is sometimes associated with, it can be helpful to make CBT more human. One way of doing this is to mention songs that reflect CBT principles or ideas. Here are a few I have used

    1. Both Sides Now (Joni Mitchell)

    An great old song, some younger folks may be familiar with it from Love Actually.

    The message here is - there is more than one way of looking at things  - the negative one isnt necessarily the only one. Perhaps I can look at this another way.

    2. Paint it, Black - The Rolling Stones

    Another old classic - illustrates "how you feel affects how you think" principle. When we are depressed, we paint everything black. This song can help the client feel understood - and perhaps provide some distancing from this unhelpful strategy

    3. Hold Your Head Up  Argent

    I've mentioned this song to clients with social anxiety - don't care what other people think, hold yuor head up. One client turned it into a helpful mantra.

    4. Fans of The Sopronos might remember with affection Tony's lamenting that he wish he was more like the Happy Wanderer of the song.  There's plenty of evidence that exercise can help overcome low mood, and this song coud link with behavioural activation in general.

    5. Here's one that you won't find in the charts -  Windy Dryden's classic renditioning of Moves Like Jagger Dryen

    I've previously posted a playlist of happy songs that might also be helpful!

    Finally, here's a competition to turn unhelpful song lyrics into helpful lyrics - give it a go!

    What songs would you add to these as helpful or relevant for CBT?

    Sunday, 1 March 2015

    How to use that dress to socialise clients into CBT

    You've probably seen the debate about "The Dress" on social media and the intenet.
    What colour do you see the dress above as now?
    Is it black and blue? Is it white and gold? Perhaps, like me, one time you see it one colour, and then when you return to it it looks different.

    So - What has the dress got to do with CBT ...

    Along with other optical illusions, like "Is it duck or rabbit?"

    these help create doubt about us being so certain that how we see things is necessarily how they really are. Thoughts are not facts. That's a useful idea to convey to the client in CBT.   For example:-

    "At the moment you think the future is hopeless"
    "You feel that you need to check those switches"
    "You believe that when your boss asked for a meeting it means you are in trouble2

    Each of these ideas are interpretations, and in CBT the client learns that they are not facts. They  may not be either the most accurate way of looking things or the most helpful.Optical illusions are a nice way of making the point; how we see things isn't necessarily how they really are.

    The interesting thing about the dress, more so than the duck rabbit, is that when we see it as black and gold, its actually hard to see it as white and gold - and vice-versa.  This is often true when people are very  depressed, ramped up through OCD. The message here is

    At the moment you see things one way and it may wekk be  hard to see it another way. As with that dress that you may have seen on the internet, could it be that there is another way of looking at your negative thoughts. 

    If the client answers "yes" you can then add - so what does that mean about how you should treat some of your negative or unhelpful thoughts?  If they answer "It means that I should treat them with some caution, as if they are just thoughts rather than the facts they claim to be"  then you have  socialised your client into an important CBT principle