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LOOKING THROUGH THE TRAUMA LENS AT DIALECTICAL BEHAVIORAL THERAPY

Anita Mandley, LCPC

Fundamental Elements of Trauma

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Powerlessness Disconnection Devaluing

Out of Control

Four Levels of Stress Reactivity

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Judith Hermann ,MD. Trauma and Recovery

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Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. When the force is that of nature, we speak of disasters. When the force is that of other human beings, we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people control, connection, and meaning.

Consequences of Trauma
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Underdeveloped affect regulation skills Disruptions in attention and consciousness Somatic disturbances Distortions in self-perception Distortions in perception of the offender(s) Relational disturbances Disruptions is systems of meaning

The Trauma Mind

Inability to Trust

Self-Harm

Storm of Affect
Pseudo-Competency
Rage Fear

Eating Problems Guilt

THE EYE
Shifting Sense of Self

Anger

Unsafe Physical Behaviors

Stealing Depression

Terror

Lying

Sexual Behaviors Low SelfEsteem

Property of The Center For Contextual Change, Ltd.

Damaged Goods
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DBT for Pervasive Emotion Dysregulation

Complex PTSD, Disorders of Extreme Stress, or BPD are all names of disorders of pervasive dysregulation across both negative and positive emotions DBT is a comprehensive treatment for emotion dysregulation across diagnostic lines Each DBT skill set is designed for the purpose of emotion regulation

Characteristics of PED

Excess of aversive emotional experiences Inability to regulate intense physiological arousal Problems turning attention away from emotional stimuli Cognitive distortions Failures in information processing Insufficient control of impulsive behaviors

PED Characteristics cont'd

Difficulties organizing and coordinating activities to achieve non-mood-dependent goals when emotionally aroused Tendency to freeze or dissociate under very high stress Occurs across the entire emotional system, including the behavioral, physiological, cognitive, and experiential subsystems of emotional responding

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Five Functions of Comprehensive of Treatment Model

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Enhance client capabilities Improve client motivation for treatment Structure the environment Generalization to the environment Enhance therapists motivation to provide effective treatment

Center for Contextual Change 2010

Five Functions of Treatment

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Enhance Client Capabilities

Behavioral Control Interpersonal Stability Stabilization of Core Sense of Self Cognitive Stability

The Orchid Hypothesis

This is a transformative, even startling view of human frailty and strength. For more than a decade, proponents of the vulnerability hypothesis have argued that certain gene variants underlie some of humankinds most grievous problems: despair, alienation, cruelties both petty and epic. The orchid hypothesis accepts that proposition. But it adds, tantalizingly, that these same troublesome genes play a critical role in our species astounding success. The Atlantic Magazine, 2009

Anita Mandley, LCPC, Center for Contextual Change

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Emotion Regulation Targets

Focuses on targeting specific emotion components with a simultaneous emphasis on targeting specific time points in the emotion-generative process All DBT skills target emotion regulation in some way or another

Five Subsystems of Emotions

Emotional Vulnerability to Cues Internal and external events that serve as
emotional cues, including attention to and appraisals of the cues Emotional responses: physiological, cognitive, experiential, and action urges Nonverbal and verbal expressive responses and actions Aftereffects of the initial emotional firing including secondary emotions

Five Functions of Treatment

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Improve Client Motivation for Treatment

Therapeutic Relationship Phased Collaborative Treatment Plan Interventions that Help Quickly

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Dialectics of the Therapeutic Relationship

Constant attention to combining acceptance with change Flexibility with stability Nurturing with challenging Focus on capabilities with a focus on limitations and deficits Change is facilitated by emphasizing acceptance and acceptance is facilitated by emphasizing change.

Schwartz and Southern

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Some individuals seem to be saved by novel experiences with a loving caretaker, teacher, friend, or therapist. These experiences prove transformative, influencing them to compensate with new cortical structures and learn relative to healthy attachments. Indeed, the purpose of psychotherapy is fundamentally to facilitate these transformations. Since, as Schore emphasized, it is affect not cognition- that is the means of exchange in relationships, the client will not remember events, rather, emotions will be the primary form of communication.

Collaborative Stages of Treatment

Stage I: Level 1 CREATING A CONTEXT FOR CHANGE A. Creating a safe Therapeutic Relationship Safety Inside and Outside of the office 1. Safety Plan 2. Psychoeducation about Model, Treatment, Cycle, etc. B. C. Pretreatment Planning & Treatment Planning Contextual Assessment 1. Vulnerability Factors 2. Resiliency Factors Level 2 A. B. C. Level 3 A. B. Stage 2: Level 1 Negative and Positive Consequences of Change Introduction to symptom reduction interventions Address Denial Goal Setting Pre-Acknowledgement Sessions

CHALLENGING PATTERNS AND EXPANDING REALITIES A. Patterns and Exceptions Identified and Mutually Agreed 1. Review of Stage I 2. Identify Old Patterns & Challenge Them 3. Continuing to Address forms of Denial 4. Determine Therapeutic Process

Level 2

A.

Alternate Realities and Behaviors Mutually Explored 1. In and out of session tasks and enactments 2. Negative Behavior Cycle and or Victim/Survivor Cycle 3. Imaging Alternatives 4. Symptom Reduction Interventions

Level 3 III.

A. CONSOLIDATION A. B. C.

Acknowledgement Sessions centered on Impact Punctuate Changes Look at future problem areas Change - Changes M.J. Barrett, C. Sykes and W. Byrnes, 1985. T. Trepper & M.J. Barrett, 1989

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Five Functions of Treatment

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Structure the Environment

Systemic Interventions Coaching Client to Advocate for Self Direct Interventions

Five Functions of Treatment

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Generalization to the Environment

Through homework assignments and practice in between sessions.

Center for Contextual Change 2010

Five Functions of Treatment

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Enhance Therapists Capabilities to Provide Effective Treatment

Stage Oriented Integrated Treatment Model Interventions that Increase Mastery Interventions that Decrease Helplessness Interventions that Decrease Extreme Behaviors and Crisis Supervision and Consultation

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Therapist Treatment Interfering Behaviors

Imbalance of change versus acceptance Imbalance of flexibility versus stability Imbalance of nurturing versus demanding change Imbalance of reciprocal versus irreverent communication Behaviors showing lack of respect for the client Blaming the victim

Dialectics in Treating the Therapist

Functions as a dialectical counterweight to treatment of the client Allows the therapist to be the recipient of acceptance and change strategies even as he or she is applying those same strategies with the client Transactions between client and therapist are brought into a dialogue among the therapist and the team Therapy is modeled from the client up and from the team down, both being affected by the other Team works to keep the therapist in therapy with the client and the therapist works to keep the client in therapy Helps the therapist maintain balance in the therapeutic relationship

Treating the Therapist(contd)

Balance can be achieved by getting closer to therapist which allows therapist to gain distance from client or move away from therapist which allow therapist to move closer to the client Provide a context for DBT, reminding the therapist of DBT principles or providing a dialectical balance to the individual, subjective viewpoint Regular attendance and a willingness to engage in open exploration of difficult situations through a non-defensive application of DBT principles Part education, part support, and part challenge to widen their perspective or balance their view Humility is a necessary ingredient for those who instruct today will be taught tomorrow, and those whose sight is clear now will discover their own blindness at some point Reminders to remain grounded and supportive

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The Dialectical Therapist

DBT holds in dialectical tension two different models of behavioral dysfunction: motivation versus capability (unwilling versus unable) Motivation affected by diverse factors, i.e., fear, guilt, shame, a reinforcement history that reinforced maladaptive responses, or dysfunctional beliefs Capability model asserts that clients do not have the necessary skills DBT works with clients to change motivation and provide them skills and new behavioral options Clinicians must attempt to change clients motivation while accepting the client as she is, regardless of level of skillfulness Middle Path between clients history and fear of being invalidated again and the clients own knowledge that change is necessary to end the misery Therapist can be in danger of invalidating client by either demands to change or acceptance of them as they are. Must do both simultaneously or quickly move from one to the other

HELL IS TO DRIFT, HEAVEN IS TO STEER GEORGE BERNARD SHAW

Affect Regulation Triangle

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Therapist Self Regulation

Co-Regulation

Client Self Regulation

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Hegel and Dialectical Materialism

Within each beginning is necessarily found an endpoint, for the beginning is posited only on the assumption of some process that is unfolding toward an end; there is no beginning without an explicit reference to a process and conclusion.

Steps of Self Regulation

Stages
I. Creating a Context for Change

Steps
Pause & Ponder

Tasks
Observe Describe Validate Acknowledgment

II(A). Expand the Reality

Create a New Possibility

Turn the Mind Dialectical Thinking Pros & Cons Willingness Focus on Effectiveness Mindfulness Distress Tolerance Skills Opposite Action Network for Safety Interpersonal Skills

II(B). Challenge Patterns

Take Action

III. Consolidation

Take Notice

Observe & Describe the Impact of Action Create New Meaning

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5 Myths About DBT

1. If a client engages in self-harm behavior, all contact with the therapist stops for 24 hours. If a scheduled appointment is within 24 hours, (any mode), keep the appointment and use it for a chain analysis. 2. Chain Analysis was designed to be aversive. The analysis is a means of gathering information on the controlling variables around behaviors. The depth and clarity of chains allows them to be used to determine behavioral patterns and replace the dysfunctional ones with new behaviors 3. If the client is in Stage 1 DBT and is sexually assaulted , it is not dealt with until Stage 2 DBT. Focus on what is the most humane and respectful process and treat the assault. 4. Skills training is DBT. Absolutely no evidence that Skills Training alone is effective treatment. 5. It is alright for consultation teams to meet biweekly or once a month when structuring their DBT program

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DBT STAGES OF TREATMENT

1.
i. ii. iii. iv.

Increasing Capacities for Coping and Tolerance (includes

pre-commitment strategies)

Decreasing tissue-damaging behaviors Decreasing therapy-interfering behaviors Decreasing quality of life interfering behaviors Increasing behavioral skills

2.

Transforming Post-Traumatic Stress Disorder

3. Increasing Self Respect And Mastery While Achieving Individual Goals

DBT and Affect Regulation

Defines affect as emotion, brain and physiological changes, cognitions, environment( people and the world), and action urges Emotion is the core element of personality and is an evolutionarily important response and motivator in the interaction between person and environment Includes environmental stimuli, cognitive interpretations, facial expressions, action urges DBT helps clients to sharpen their capacity to attend to the environment, widen their attentional focus, discriminate between relevant and irrelevant stimuli, and improve the quality and variety of actions available To change the behavior is to change the emotion

Affect Regulation (contd)

The dialectic in treatment is to have the client experience the emotion and to block the clients typical response patterns to that emotion (change strategies) Balanced with an acceptance of emotional experiencing modeled by the therapist, and with acceptance of the clients previous strategies to regulate their emotions as the best that they could do at the time While blocking the typical action patterns through contingencies, the therapist is also providing a warm, accepting environment to keep the client in treatment, and is directing behavior through skills training homework and phone strategizing (coaching) Resolution through the new behaviors coached by the therapist to improve adaptivity of response

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Affect Regulation (contd)

a) b) c)

Clients are moved slowly from attempts to rigidly control phenomena (internal and external), into a dialectical manner of interacting with the environment, developing patterns of emotional responding that are: Flexible More situation-person specific Maintains clients contact with environmental stimuli while they regulate and modulate their own emotional experience. Clients become better able to use information from the environment previously lost through poor attending and loss of control as clients withdrew or exploded while attempting to eliminate unwanted emotions Flexibility and environmental contact are necessary for a more dialectical lifestyle and fundamental for the development of long term adaptive interaction strategies

Skills Training
1. 2. 3.

4.

DBT modes: Individual therapy to address motivation Group skills training to address skills acquisition Telephone consultation and coaching to address skills generalization Supervision/consultation aimed at keeping therapists within the therapeutic frame and balancing clients behaviors that might pull them out of that frame Other modes of treatment Goal is to balance skills of accepting life and events as they are in the moment, with skills for changing oneself and the environment

Skills Training

Skills training groups developed because, despite the best intentions to train clients in skills that they desperately needed, individual therapy could not seem to get beyond dealing with the need to manage crises there was never a lull in the process into which skills training could be introduced. Groups are open as a way to model and to teach acceptance and accommodation of change Concept of acceptance of change now a part of individual therapy, and therapy is more focused on learning to deal with the natural fluctuations of events both within therapy and in their home environment

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DBT SKILLS TRAINING GROUP

Stage 1 Mindfulness Practice Diary Card Review Stage 2 Homework Review Lecture/Presentation Stage 3 Mindfulness

Biosocial Theory
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Biological Dysfunction in the Emotion Regulation System

Invalidating Environment

Pervasive Emotion Dysregulation

Dialectics and BPD

BPD and its accompanying emotional dysfunction, is the result of transactions between a constitutional vulnerability to emotional dysregulation, and an environment that is prone to invalidate the expression of private experiences, beliefs, and actions. DBT suggests that the individual and the environment are coactive in providing conditions for the development of the dysfunction.

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Dialectics and BPD

On the one hand, the individual elicits the environment that creates dysfunction, and, on the other hand, the environment exacerbates vulnerabilities that, in a more benign environment, might not have developed. Similar to Millons biosocial learning theory of personality disorders, where patterns of interactions crystallize into personality.

The Individual-Environment System

Individual functioning and environmental conditions are mutually and continuously interactive, reciprocal, and interdependent. The environment and the individual adapt to and influence each other.In reality they cannot be distinguished.
Linehan 1993

Emotional Vulnerability

Enhanced Sensitivity Enhanced Reactivity Prolonged Activation

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Overview of ERS

Taught in the context of mindfulness skills Progression from mindfulness to distress tolerance skills to emotion regulation skills DTS target reducing maladaptive behavioral reactivity by building tolerance for emotions without evaluation or attempting to change or control emotions ERS target the reduction of emotional distress through exposure in a nonjudgmental atmosphere and with skills

Invalidating Environments
Characteristics of Invalidation

Communication of private experience met with exaggerated, inappropriate, extreme response. Communication of private experience not validated, often punished and/or trivialized. Painful emotions and factors causing them are disregarded. The individuals interpretations of his/her behaviors and motivations for behaviors are dismissed. Tells the individual he/she is wrong in both the description and analysis of the experience particularly what is causing the emotion, belief or action. Attributes the experience to socially unacceptable characteristics or personality traits. Failure to live up to expectations brings disapproval, criticism, sarcasm, or attempts to change the individuals attitude.

Invalidating Environments
Consequences of Invalidation

Individual does not learn to label private experiences and emotions in normative manner. Individual does not learn to modulate emotional arousal. If problems are not recognized, problem-solving skills are not learned. Extreme problems or emotional displays become necessary to provoke a response. Inhibition or extreme emotional states occur. Individual does not learn to tolerate distress or form realistic goals and expectations. Individual does not learn to trust his/her own emotional response. Self-invalidation and shame.

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Middle Path Skills

Dialectics

Validation

Behaviorism

The Middle Path

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The Middle Path is an alternative to the sort of thinking that becomes locked in extremes....Rather than offer a compromise between such opposing views, the Middle Path posits that neither extreme represents reality. When one rejects attachment to the extreme, what remains is the true nature of things.

The Middle Path

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Therefore, the Middle Way is not a passive state of middle of the road thinking. Rather, while recognizing and rejecting limiting or biased views, it is an active state of developing the wisdom to perceive the true nature of things and to act accordingly. Daisaku Ikeda, contemporary Buddhist teacher

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DIALECTICS
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Everything is Transient and Finite Everything is Made Out of Opposing Forces Gradual Changes Lead to Turning Points Where One Force Overcomes the Other Change Moves in Spirals, Not Lines of Circles

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Function of Validation

Creates safety (verbal, emotional, physical and sexual) Establishes the environmental context for constructive, useful, effective behavior (verbal and nonverbal; with self and others) Enhances connections in relationships Teaches trust and helps it to evolve Strengthens empathy Generates feeling understood and supported Generates comfort through emphasis on naturalness of responses Generates encouragement and effectiveness

VALIDATION

Type 1:
i.

ii.

iii.

Finding the value and wisdom of the clients feelings, urges, thoughts, and actions Looking for responses that have context specific validity Providing a consistent source of validation

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Validation (contd)

Type 2:
i.

ii. iii.

Believing and noticing the clients capacity to exit states of suffering Focusing on strength, not fragility Believing and Believing In, the client

Why Validate?

Validate as Acceptance to Balance Change Validation to Teach Self-Validation Validation to Strengthen Clinical Progress Validation as Feedback Validation to Strengthen the Therapeutic Relationship

The more a neural system is activated the more that system changes to reflect the pattern of activation This is the basis for development, memory and learning
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www.childtrauma.org

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Emphasize Practice!

(vs. perfection)

Behavioral Tech, LLC

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Accepting Life As It Is In The Moment

Mindfulness and Tolerance Mindfulness is the backbone of skills Core Skills and Distress Tolerance skills addresses observing and participating in ones environment so that one may collect accurate feedback and make predictions about consequences of actions. It is the segment of the dialectic that deals with planning actions and observing effects Trains clients to engage more fully and to observe more clearly and improve both by removing judgments, in order to interact more harmoniously and effectively with the environment Addresses the interplay between states of mind, and resolution involves moving to wise mind. Along with logic and emotion, wise mind includes other knowledge like intuitive mind(sensing) and trauma mind, intense emotional experiencing without containment, or a sense of power and control, and often without reality based context

Five Facets of Mindfulness Practices

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1. Decreased reactivity to inner experiences

2. Increased capacity to remain present even with painful emotions and sensations

3. Increased capacity to react with awareness and intention

4. Increased capacity to describe/label with words

5. Non-judgmental of experiences
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CORE MINDFULNESS SKILLS

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What Skills - the doing

Observe Describe Participate

How Skills - the being

Non-judgmental Effectiveness One thing at a time

Trauma as a

Certain psychiatric disorders can be conceptualized as state change

disorders, in that a major patho-physiological component of the disorder comes from dysregulation of the state change process. Trauma disorders can be seen as problems in maintaining states relevant to context, and in smooth state shifting.

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Frank Putnam (1994)

1. In normal development, state changes are co-regulated with changes in state becoming smoothed out over the course of development. -Putnam 2. States become traits: if the neurobiology of a specific response, Hyper-arousal or Dissociation, is activated long enough, there will be molecular, structural and functional changes in those systems. -Perry

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Mind State Features

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Adaptive Functional Evolutionary Not Always Clearly Differentiated Mutual Possession

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States of Mind
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Rational Mind Emotion Mind Intuitive Mind

Dominated by reason, logic Dominated by emotional reactivity Perceptions in the absence of perceptible cues, non-verbal encoding and decoding. Extreme distress, high emotional reactivity, vacillating between hyper-arousal and numbness, negative self view, fight, flight and freeze Dominated by intrapersonal coherence and internal attunement of body, brain, mind and relationship. Safety, coherence 62 and effectiveness.

Trauma Mind

Wise Mind

STATES OF MIND PARADIGM

THOUGHTS

Sense Of Self

URGES

Emotion
INTERNAL MODEL OF OTHERS AND THE WORLD Somatic Experiences BEHAVIORS

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INTUITIVE MIND PARADIGM

Observer Evaluator

Ambiguous To Unsafe Anxious Curious On alert

I have a gut feeling somethings not right

Increased Energy Uneasy Assess explicit cues Proceed with caution Effective fight or flight

Distance Develop an action plan

TRAUMA MIND PARADIGM

Im bad Incompetent IM SO STUPID BAD THINGS HAPPEN BECAUSE IM BAD Fear Helplessness Shame NAUSEAUS SHAKY CUT HIDE SEXING Binge Overmedicate Sleep

Dangerous Disconnected Out of Control

WISE MIND PARADIGM

Integrated Present in the moment Balancing Internal locus of control

Negotiable Neither self nor others are less than human

I need to create a pause and bring the anger down

Anger
Warm Increased heart rate
Self-observing Assessing Needs Enact a goaldriven action plan

Focus on safety and effectiveness

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Distress Tolerance
Crisis Survival Strategiestolerating short term pain (doing) Guidelines for Accepting Reality -tolerating long term pain(being)

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Behavioral Tech, LLC

Distress Tolerance
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The Doing

Improve the Moment Self-soothing Distractions The Being

Turning the Mind Willingness over Willfulness Radical acknowledgement/acceptance

Addressing Deficits in Capacity to Regulate Self and Environment

Interpersonal effectiveness skills address capacity to interact effectively with environment and increase probability of positive reinforcement. Other skill sets needed to ensure successful application of interpersonal skills. Interpersonal skills to be advanced only as quickly as the other skills improve Emotion regulation skills are taught as a means of regulating emotional responses through identifying and labeling emotions, decreasing emotional vulnerability through self-care, increasing pleasure, and regulation of emotional responses through opposite action.

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Situations for Interpersonal Effectiveness

Attending to Relationships Balancing Priorities vs. Demands Balancing the Wants-to-Shoulds Building Mastery and Self-Respect

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Emotion Regulation
Goals of Emotion Regulation Module Understand emotions Reduce emotional vulnerability Decrease emotional suffering Change by acting opposite to painful emotions

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The DBT Model of Emotion

Teaching clients about emotions and emotion regulation is a necessity and requires some definition of emotion. Emotions are complex, brief, involuntary, patterned, fullsystem responses to internal and external stimuli. Patterned actions associated with emotional responses are part of the emotional response rather than consequences of the emotion. Viewed as a sequence interrelated, synchronized changes in the states of all organismic subsystems Modifying any component of the emotional system is likely to change the functioning of the entire system

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Five Subsystems of Emotions

Emotional Vulnerability to Cues Internal and external events that serve as emotional cues, including attention to and appraisals of the cues Emotional responses: physiological, cognitive, experiential, and action urges Nonverbal and verbal expressive responses and actions Aftereffects of the initial emotional firing including secondary emotions

DIARY CARD
DATES___________________________________________NAME___________________________________________ DAY DESRIBE THE TRIGGER SITUATION FEELING & INTENSITY URGE DBT SKILL NAME: RATE (SEE BELOW) WHAT YOU DID?
AFTERMATH: DISTRESS LEVEL 0-10 IMMEDIATE 1 HOUR

RATING SCALE
012345DIDNT THINK ABOUT OR USE THOUGHT ABOUT; DIDNT USE BECAUSE DIDNT WANT TO THOUGHT ABOUT; DIDNT USE BUT WANTED TO TRIED; BUT COULDNT USE TRIED; COULD USE BUT DIDNT HELP TRIED; COULD USE; HELPFUL

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Behavioral Analysis Checklist

1.

T helps C define the problem Choose a focus Formulate the problem in terms of behavior Describe the problem behavior specifically, i.e., frequency, duration, intensity, topography T weaves validation throughout

2.

T (and C) conduct a Chain Analysis T and P select one instance of problem to analyze T attends to small units of behavior with attention to defining the behaviors beginning, middle and end, in terms of emotion, bodily sensations, thoughts, images, overt behaviors, and environmental stressors, overt behaviors and environmental stressors Conduct in session analysis T maintains Cs. and owns, cooperation T helps C monitor her behavior between sessions, diary cards are essential

3. T generates hypotheses with C about variables influencing or controlling behaviors in question

T and C use the results of previous analyses to guide the current one T is guided by DBT theory

Anti-DBT Tactics

T colludes with C in avoiding behavioral analysis or targeted behaviors T unduly biases information gathering to prove Ts own theory of Cs behavior

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Behavior Analysis
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Basic Treatment Strategies

Strategies -Both a plan of action and finesse in carrying out the plan

Dialectical Strategies- pervasive, inform the entire treatment Core Strategies-problem solving and validation Stylistic Strategies- compatible interpersonal and communication styles Case Management Strategies-how the therapist interacts with and responds to the clients social network

Treatment Strategies

Keeping the client off balance Entering the paradox Using metaphors Making lemonade out of lemons Allowing for natural change Extending Activating Wise Mind

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Summary Points

Understanding and application of dialectics to treatment process continues to evolve in DBT Dialectics guides the therapists actions and inquiry Dialectics furthers the process of behavioral change No therapist without a client, no beginning of treatment without end goals, no theory devoid of practice Therapists are consistently engaged in some dialectical process, operating out of some theory of behavior change, responding to client responses generated by past interventions in determining the next move A focus on dialectics shifts attention to the process occurring rather than to the endpoint toward which one is moving

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