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