DBT Training Notes

Introduction

  • Caitlin Baxter Musser will lead the Dialectical Behavior Therapy (DBT) training, spanning three days.
  • Participants are primarily from California or on West Coast time.

Important Considerations

  • Participants must use the training material responsibly, within the scope and boundaries of their own professional practice and licensure.

Caitlin's Background

  • Caitlin is from Maine, originally from Massachusetts, also lived in Washington DC and Arizona.
  • She has a background in private practice and state agencies, working as a child and family therapist and trauma therapist.
  • She has experience with victims of domestic violence, sexual assault, and hate crimes, and has worked on Native American reservations.
  • Caitlin currently uses DBT across the board with all her clients.

Training Logistics

  • First break: approximately 10:00 AM.
  • Lunch: 11:50 AM to 1:00 PM (1 hour and 10 minutes).
  • Second break: approximately 3:00 PM or 3:15 PM.
  • End time: 4:40 PM each day.

Questions and Tech Support

  • Clinical or material-related questions: use the Q&A feature to reach Caitlin.
  • Tech-related questions: use the chat to ask Sid from Pesi.
  • Caitlin will address questions during breaks.

DBT Certification

  • To become a certified DBT professional, clinicians must:
    • Attest to having used DBT as a theoretical orientation for at least 500 practice hours.
    • Attest to reading at least two practitioner books on DBT.
    • Read the APA policy on evidence-based practice of psychology.

Training Goals

  • Learn and understand the theory, rationale, and development of DBT.
  • Understand the different formats and ways that DBT can be offered to clients (standard DBT, DBT-informed, certified vs. informed clinicians).
  • Learn the components of DBT and how to integrate it into clinical practice.
  • The training will be very practical, teachable, and effective.

Resources

  • PowerPoint slides and a handout packet will be provided.
  • The handout packet includes expanded slides and worksheets for clinical sessions.
  • A list of recommended readings and resources is available at the end of the presentation.

Mindfulness Activity

  • The training will incorporate mindfulness activities at the start of each morning and after lunch.
  • Participants should get into a comfortable and relaxed position, and can leave their eyes open or closed.
  • Various mindfulness videos will be used, which are all available on YouTube.

Mindfulness Definition

  • Mindfulness is present moment attention without judgment.
Guided Meditation Instructions
  • Observe your feet and how they feel on the ground.
  • Notice the pressure and temperature.
  • Let go of any distractions or thoughts.
  • Shift attention to your abdomen and observe your breath.
  • Notice the rising and falling of your abdomen.
  • Ride the waves of your breath.
  • Return to your breath when distracted.
  • Transition out of the meditation with movement in your toes.

Introduction to DBT

  • Dialectical Behavior Therapy (DBT) is a broad-based cognitive-behavioral therapy (CBT) originally developed for chronically suicidal clients and people diagnosed with borderline personality disorder.
  • The first population studied using DBT techniques was women with borderline personality disorder.
  • A standard DBT program has four distinct components:
    • Individual therapy
    • Skills training
    • Phone consultation
    • Consultation team for the therapist
  • DBT can be used with a variety of disorders and age groups.
  • It is rooted in the development of mindfulness and emotion regulation skills.
  • The goal is to teach clients adaptive, effective ways of regulating emotions to replace maladaptive or impulsive behaviors.

Why Use DBT?

  • Applicable across diverse settings and populations
  • Variety of therapeutic interventions
  • Teachable and practical
  • Accessible to all levels of clinicians
  • The ultimate goal is to increase resilience and build a life worth living by helping individuals change behavioral, emotional, cognitive, and interpersonal patterns that cause problems in their everyday life.
  • DBT stresses the importance of learning a new set of skills that replaces the old skills and behaviors that don't work.
  • It balances acceptance with change.

Conceptualizing DBT Skills

  • Challenges lead to usual ways of coping, which provide brief relief but ultimately cause misery.
  • DBT skills provide a new way of coping and interacting with stressful life situations, helping clients build a life worth living.
  • Mindfulness is a foundational skill that enables slowing down and choosing how to respond adaptively.

Metaphors for Teaching DBT

  • Analogies and metaphors help clients understand the use of skills.
  • Example: If you don't accept that your tire is flat, you're not ever going to be able to change your tire.
  • Another example: You can't change the wind, but you can adjust your sails.

Core Skills of DBT

  • DBT emphasizes four sets of core skills:
    • Mindfulness
    • Emotion regulation
    • Interpersonal effectiveness
    • Distress tolerance
  • DBT is rooted in the development of skills, but it's really a set of assumptions, principles, and strategies that help clients build what Marshall Linehan calls a life worth living.

Defining a Life Worth Living

  • Clients often come into sessions feeling demoralized, confused, abandoned, useless, and emotionally dysregulated.
  • Building a life worth living gives clients something to hope for and helps them identify treatment goals.
  • By identifying what a life worth living looks like for our clients, we can help our clients start to understand what we're working towards and how to get there.

Marsha Linehan's Perspective

  • The purpose of DBT is not just to help keep clients alive, but to help them build a life worth living.
  • It involves work, skills, and application of those skills to help people learn that they can improve their own lives.
  • DBT also involves this idea of acceptance.
  • There may be constraints on what your life can look like, but there are no constraints on whether your life is worth living.
  • Building a life worth living is hard, and it does require this belief that change is possible.

Identifying Goals for a Life Worth Living

  • What are your goals for therapy?
  • What defines your life worth living?
  • Are there things that they used to dream about in childhood that they still feel like they have a calling or an urge to do?
  • What brings you joy?

Personal Reflection on DBT

  • Throughout the course, share with you some different ideas and ways to actually teach.
  • When teaching DBT skills to clients, it's important to have some ideas or ways that you have actually used the skills in your own life.

Video: Impact of DBT

  • The skills helped to empower her.
  • These skills are skills that we use over and over; they're ongoing skills that we use over the course of our life.

Development of DBT

  • Developed in the 1980s by Marsha Linehan at the University of Washington in Seattle.
  • Linehan recognized that CBT skills were not enough to help suicidal and self-harming clients.
  • She developed a new series and set of skills to meet the needs of these clients.

DBT and Emotion Regulation

  • Anybody struggling to regulate emotions can benefit from DBT skills.
  • 75% of mental illnesses in the DSM-5 have components of emotion dysregulation.
  • DBT skills can work across caseloads, from trauma histories to self-esteem problems to relational issues.
  • DBT helps clients accept life as it is and change despite that reality and because of it.
    From a behavioral perspective, people can learn new behaviors, and change can have a top-down effect on altering their emotions.
  • The only way to begin to facilitate change was to acknowledge that clients' behaviors made sense given their situation.

Marsha Linehan's Personal Experience

  • Marsha Linehan disclosed that she met the criteria for borderline personality disorder herself.
  • At age 17, she was hospitalized for 26 months and diagnosed with schizophrenia.
  • In 1967, she had an epiphany that led her to graduate school and the development of DBT.
  • Clinically appropriate to share story to give clients hope.

Diagnostic Criteria for Borderline Personality Disorder

  • The term "borderline" was developed with the creation of the DSM-III in the late 1970s to define clients on border between psychotic and neurotic disorders.
  • Research supports that the term "borderline personality disorder" carries stigma.
  • Borderline personality disorder is a pervasive pattern of instability in interpersonal relationships, self-image, and affect, with marked impulsivity, beginning at early adulthood, indicated by five or more of the following:
    • Excessive and unstable, poorly regulated emotional responses
    • Impulsive behaviors that are harmful to the self or others
    • Inaccurate perceptions of self and others
    • Frantic efforts to avoid abandonment

Borderline Personality Disorder Diagnostic Overlap

  • Borderline personality disorder symptoms overlap with symptoms of PTSD, complex PTSD, and major depressive disorder.
  • The difference between borderline personality disorder and histrionic personality disorder is that, in borderline personality disorder, there's impulsivity and instability, and in histrionic personality disorder, there's this excessive emotionality and attention seeking behavior piece as well.
  • Personality disorder can coexist overlap with bipolar disorder.
  • Men with BPD more likely to have substance abuse disorders, while women with BPD more likely to have comorbid PTSD or eating disorders.

Abrupt Shifts in Interpersonal Relationships

  • One minute everything seems fine, and then the next minute, there's a lot of hurt and anger, and even rejective, over something that to the person on this side of the equation might seem like a nonissue or might seem like something that's really small.
  • A painful event causes an emotional response, and others resist that, leading to validation and fears of abandonment.
  • Black and white thinking is activated. This leads to Self Hatred that we start to see risk-taking behavior come into play.

Recommendation: Book about Borderline Personality Disorder

  • The book ''Buddha and the Borderline'' can help compassion fatigue and re-ignite clinical enthusiasm.
  • Reading it help provide great way to concept the life for somebody with borderline personality disorder

Assessing for Borderline Personality Disorder

  • Cautious when diagnosing personality disorder because there's lots of stigma
  • When diagnosing any personality disorder and then I'm looking just beyond the client's presenting issue and really looking into that client's interpersonal history
  • Clinical Assessment and Diagnosis in Social Work Practice can help the questions for assessing BPD can be from.

General Concepts and Ideas of DBT

  • The focus in DBT is to learn skills to replace the behaviors that don't work.
  • Need to address problems that cause difficulties in how we function in life, and the emphasis is on the therapist having an accepting, nonjudgmental, and validating approach to clients.
  • DBT takes an eclectic approach, and DBT is guided by the dialectical and biopsychosocial theory.
  • DBT addresses safety issues and therapy interfering behavior before anything else.
  • The goals of DBT are to help people live in the moment, regulate their emotions, develop coping mechanisms for their stress, and improve interpersonal relationships as well.

Biosocial Theory

  • Emotions are patterned responses to our internal and external environment; they are brief, involuntary, and full-system.
  • Linehan's constructs of emotions is pretty broad, including biochemistry, physiology, facial and muscle relationship, action urges, and thought processes.
  • When we modify any component of our emotional system, we can actually change the function of the entire system as well.

Emotion Dysregulation

  • The inability to change or regulate emotional cues, experiences, actions, verbal responses, or nonverbal expression.
  • Characteristics include an excess of painful emotional experiences, the inability to regulate intense arousal, and the inability to turn away from emotional cues.
  • Emotion dysregulation has been linked to mental health problems like eating disorders, substance abuse disorders, and trauma.
  • There is two things produced this which is emotional vulnerability including a high negative affectivity at a baseline.

Emotion Regulation

  • the ability to inhabit impulsive behavior related to ether strong your positive negative emotions
  • ability to organize oneself for coordinated actions that we can meet an external goal.
  • Ability to self sue any strong emotional responses.
  • That really will make a lot of positive effects and we also want to increase positive emotions too.

Polyvagal Theory to reduce shame.

  • It gives clients a good understanding of how their systems responds to trigger in their environment.
  • The movement through their nervous system is actually more extreme and can be seen in the lack of their ability to regulate emotions and manage relationships.
    Steven Porges the nervous system is functionally a triangle upside down with a point which is the brainstem.
    If you're in a constant dangerous environment, your nervous system is going to find it difficult to detect safety.
  • Polyvagal Theory explains how and why clients move through this continuous cycle of mobilization, disconnection, and engagement.
  • nervous system picks up information in the environment and evaluating that information not on a cognitive level but on a subconscious level.

Polyvagal theory video

  • Polyvagal theory provides an understanding of three neural circuits that support different types of behavior; one is social engagement behaviors in safe environments. two is fight three and Mobilization behaviors, and 3 is shutting down, a second level of defense.
  • nervous system reads the environment around us it is sending out and searching for his cues of safety and danger.
  • How we begin to interact with the world starts with us our autonomic nervous system.
  • Polyvagal perspective effective and healthy interpersonal relationships rely first on a stable sense of self to ability to express motions in a healthy way and the ability to operate and regulate distressing in the painful stimuli.

Invalidation Environments video.

  • Babies this young are extremely responsive to emotions reactivity social interaction.
  • Is something that we started studying 30-40 years ago when people didn't think that infants could engage in social interaction now.
  • In what the mother did was she sits down and she's playing with her baby.
  • She gives a greeting to the baby and the baby.
  • The mother is trying to engage her and play with her and are working to coordinate the emotions in her intentions what they want to do in the world.
  • the mother stop responding and how the child and then quickly picks up the sound and she uses all of the abilities to try and get the mother back in.
  • I was still faced from two minutes then they don't get the normal action they react with negative emotions.
  • They turn away they're feeling the streets of the reaction may lose control during 2 minutes because of the streets that they are experiencing.
  • A little bad is when something bad happens, but the infant can overcome it.

The Connection Between Adverse Childhood Experiences (ACEs) and Trauma

  • Between 1995-1997 over 17,000 participants competed personal and a medical history
  • It was create to create and combined with results from the physical examination to form the baseline data
    We know that there were adverse childhood experiences such as trauma for example can also have lifelong impacts on people and these are the people that were seeing there everyday office.
  • An invalidating environment is a place where there's a tendency to deny, respondunprectably, extremely or radically or an appropriately too childhood or child's private experiences.

A questionnaire or a resilience questionnaire and that I used with my clients.

  • it just going awareness I've used with clients just get an idea of what somebody believes about themselves in any relationship to what they've experienced.

Environmental Transection 2

  • The environmental impact of where people grow up and what they experience children then impacting them later in years of adulthood.
  • A validating really means that caregivers are failing to treat.
    The child expression of emotions with attention which respect, or with understanding and those private experiences.
    There several ways they can tell that if children has several experiences in their life some things they are used about to get there is no crying, and the goal for somebody it says to see all of therapy to know this for yourself 2 in relationship, okay, they learn to be so sensitive.
  • People that are generally working with are having a really hard time tolerating any emotions that they're experiencing, often come into I can't even is to be able to regulate her emotions that comes to somebody that is or high negative affect is baseline and those emotional stimuli a longer time to actually return emotional Baseline.

General Aspects/thoughts

  • there 3 people in your sessions and I can get our amygdala and our prefrontal cortex back online .
  • People or very good the lead to the emotions with others of the day.
  • What happens is actually mess with neutrol faces a faces of anger.
    • People that they respond to it's important what there saying right if you see their brain responding in all of a sudden okay if this is a how mindfulness again help get our back on.
    • People has experience all the time they put on is good relationship that you like people around what is the to have so you come over here and that's there