DBT

Question 1

What is the BioSocial Model of BPD?

Answer 1

• Characterises BPD as a pervasive emotion dysregulation, characterised by high reactivity and slow return to baseline. Arising from the combination of:
• Biological Vulnerability:
  
  • Sensitivity to triggers
  • Intensity of reactivity
  • Slow return to baseline
• Invalidating Environment:
  
  • Intolerance of expression of private emotional experiences
  • Intermittent reinforcement of extreme expressions of emotion
  • Over-simplification of problems

Question 2

What is the Transactional Model of BPD?

Answer 2

Question 3

What are the four stages of the DBT house on fire?

Answer 3

1. Stabilisation:
   
   • Problems: Severe behavioural dyscontrol, life-threatening or self-destructive behaviours.
   • Treatment Goals: Shift behaviours to being under the client’s behavioural control using commitment and skills
2. Re-Processing:
   
   • Problems: Sense of ‘quiet desperation’, ongoing suffering from past trauma and invalidation, moderate to severe axis 1 disorders, shame, anger, interpersonal deficits.
   • Treatment Goals: shift client from emotion inhibition to non-anguished emotional experience. Exposure, PTSD work, cognitive restructuring, interpersonal skills.
3. Everyday Living
   
   • Problems: General problems in everyday living, mild axis 1 disorders,
   • Treatment Goals: Building sense of mastery, identifying and living by values, ordinary happiness and unhappiness.
4. Finding Meaning
   
   • Problems: Lack of deeper meaning, sense of incompleteness.
   • Treatment Goals: Shift towards intergrated experience of self, experiencing ‘flow’ activities, capacity for joy and freedom

Question 4

What are the five main functions in a comprehensive DBT program?

Answer 4

Question 5

What is the dialectics skill?

Answer 5

• Problem: Clients often think by oscillating in mutually exclusive extremes (I am right, I can’t get anything right)
• Dialectic Skill = learning to use “and” rather than “but” (eg. I can have my opinion and still make mistakes)
• Learning goals:
  
  • How to drop the rope (tug of war metaphor), get unstuck from conflict and standoffs
  • There can be truth to both sides
  • Developing flexibility, letting go of black and white thinking.

Question 6

What is Mindfulness in DBT?

Answer 6

• Mindfulness = the act of consciously focusing the mind in the present moment without judgement and without attachment to the moment.
• Skills:
  
  • ​Wise Mind: Sitting between the emotional mind and the reasonable/rational mind. The wise mind is a balance of intellectual decisions and respect/care for feelings.
  • “What”: Observe (cultivate a teflon mind, control attention not content), Describe, Participate
  • “How”: Non-judgementally (opinion vs fact), One Mindfully (one thing at a time), Effectively (focus on what works).

Question 7

What are the purposes of the DBT Diary Card?

Answer 7

1. Track target behaviours that clients are trying to decrease
2. Track skills that clients are trying to increase
3. A reminder to practice skills already learned and not just new ones
4. A reminder to practice skills everyday
5. Increase ability to self-identify emotions and urges
6. Exposure to sitting with and identifying emotions
7. A way to track progress over time

Question 8

What are three key dialectical dilemmas in DBT?

Answer 8

Question 9

What are some explicit assumptions of DBT group?

Answer 9

• Client Assumptions
  
  1. Clients are doing the best they can but need to try harder and do better.
  2. Clients may not have caused their own problems but need to learn to solve their own problems.
  3. Understanding and changing the cause of any particular behavior works better than judging
     and blaming.
  4. The lives of clients are unbearable as they are currently being lived.
  5. Clients want to improve.
  6. Clients cannot fail DBT
• Therapist Assumptions
  
  1. The therapeutic relationship is a real and genuine relationship between equals.
  2. Principles of behavior are universal and affect therapists as well as clients.
  3. Clarity, precision, and compassion are of the utmost importance.
  4. Care is helping clients change in ways that bring them closer to their values and goals.
  5. DBT therapists can fail.
  6. DBT can fail even when therapists do not.

Question 10

What are the three goals of distress tolerance?

Answer 10

1) Survive a crisis without making it worse
2) Accept reality to reduce being ‘stuck’ and open to moving forward
3) Become free of acting unhelpfully on urges and intense emotions

Question 11

What are some DBT Crisis Survival Skills?

Answer 11

• STOP
• Pros and Cons
• TIPP: Temperature (cold to decrease heartrate, hot to increase), Intense exercise, Paced breathing, Progressive muscle relaxation
• Distract with ACCEPTS: Activities, Contribute, Comparison, Emotions, Push away, Thoughts, Sensations
• Self-soothe
• IMPROVE the moment

Question 12

What is radical acceptance?

Answer 12

• The concept that Suffering = Pain + Non-Acceptance
• Acceptance =
  
  • Accepting reality how it is and letting go of “should be”
  • Does not mean you need to approve of how things are
  • Active and Effective, rather than resignation which is passive/noneffective
  • Requires a choice and commitment to repeat acceptance again and again

Question 13

How would DBT go about chronic risk management?

Answer 13

1. Sequence/plot out the risk event
   
   • Vulnerability –> Event –> Thought –> Emotion –> Urge –> Behaviour
   • Repeat until end of sequence (short term consequence)
2. Identify the problem the client is trying to solve
3. Collaboratively develop
   
   • Antecedent strategies (prevent escalation of distress)
   • Target Behaviour strategies (replace target behaviour)
   • Contingency strategies (reinforce skill and extinguish old beh) Why would the client choose the new solution over the old one?
4. Practice new skills in session, troubleshoot, and pair with a reminder cue

Question 14

What is the DBT model of emotions?

Answer 14

Question 15

What functions do emotions have in the DBT model?

Answer 15

(1) Emotion communicate to (and influence) others
(2) Emotions organise and motivate behaviour
(3) Emotions communicate to ourselves (and can be self validating)

e.g. sad –> urge to withdraw, connect, cry –> function to rest, heal, elicit re-connection

Question 16

What is the Opposite Action skill?

Answer 16

• When the emotion does not “fit the facts”, act in the opposite to the urge caused by the emotion
• E.g.
  
  • Fear based on physical threat = fits the fact. Therefore follow urge to escape
  • Fear based on meeting a new friendly person =/= doesnt fit. Therefore practice opposite action and reach out.

Question 17

What are the six levels of validation?

Answer 17

1. Be Present (e.g., be attentive, actively listen)
2. Paraphrase accurately (e.g., “I’m hearing you say that you are anxious about the first day of work”)
3. Guess at the emotion (e.g., “I imagine you felt hurt when your partner said that”)
4. Validate based on past history (e.g., “Given that your dad used to take off with no notice when you were young, I can understand why you started to feel anxious when you hadn’t heard from your boyfriend all morning”)
5. Normalise (e.g., “I think anyone would feel afraid if they were threatened like that”)
   
   • ONLY if genuinely normal response. Don’t normalise abnormal responding (stick to lvl 4).
6. Radical genuineness (e.g., practice equality, be non-hierarchical, don’t censor genuine reactions, don’t have a ‘therapist persona’)

Question 18

What are the goals of interpersonal effectiveness?

Answer 18

1. Ask skillfully for what I need (or say no to a request)
   
   • ( Assertiveness skills)
2. Initiating and maintaining good relationships
   
   • (Relationship skills)
3. Improve self-respect
   
   • (Self-respect skills)

Question 19

What is the DEARMAN Skill for assertiveness?

Answer 19

• D – DESCRIBE the situation
  
  • “I’ve noticed you often need to cancel our plans on the day”
• E – EXPRESS how you feel
  
  • “I feel disappointed when we can’t hang out and frustrated I’ve kept time free”
• A – ASSERT what you want
  
  • “Can you give me a day’s notice if you don’t think you’ll make it?”
• R – REINFORCE the benefits
  
  • “This will allow me to make other plans, I really value our friendship and don’t want to be resentful”
• ​M – Stay MINDFUL
  
  • Be calm, deep breathes, monitor tolerance
• A – ACT CONFIDENT
  
  • ​Sit naturally and don’t overapologise
• N – NEGOTIATE (if necessary)
  
  • Ask if they need anything in return