Dialectics & Patient Conceptualtization
Define dialectics
A philosophical concept that includes several assumptions:
All things are connected
Change is inevitable and continual
Opposites can be integrated to develop a closer approximation of the truth
What is an invalidating environment?
Ongoing pattern of unsatisfactory responses on the part of the primary caregiver to the emotional expressions of the emotionally dysregulated individual
What are the 3 core treatment strategies of DBT?
Change
Acceptance
Dialectical
What are the 4 basic components of DBT?
Individual psychotherapy
Skills training (group)
Intersession patient coaching (phone consultation)
Team consultation
Who created DBT?
Marsha Linehan
What is one of the 8 DBT Assupmtions about patients?
1. Patients are doing their best
2. Patients want to get better
3. Patients need to work harder and be more motivated for change
4. Patients didn’t cause all of their problems but have to solve them anyways
5. The lives of suicidal patients are unbearable
6. Patients need to learn how to act skillfully in all areas of life.
7. Patients cannot fail psychotherapy
8. Therapists treating patients with emotional dysregulation need support too
What is the biosocial theory?
Emotion dysregulation results from a transaction between an inborn emotional vulnerability and an emotionally invalidating environment
Identify 1 DBT change strategy (general)
Skills training
Exposure therapy
Contingency management
Cognitive modification
Commitment strategies
What are the 4 skills modules?
Mindfulness
Distress tolerance
Emotion regulation
Interpersonal effectiveness
What is a solution analysis?
Essentially: A strait-forward conversation about what patient could have done differently
Identify desired behaviors/outcomes and identify specific steps required to achieve those behaviors/outcomes
Who is DBT indicated for?
Initially developed for those with suicidal and self-injurious behaviors
Commonality between such patients = BPD
Became more broadly considered a treatment for severe emotional dysregulation (core feature of BPD)
According to the biosocial theory, what are the 3 components of the biologically-based vulnerabilities to developing BPD?
High sensitivity (Minor perturbations result in intense reactions)
High reactivity (Intense, quick reaction to stimuli in the environment)
Prolonged activation (Long recovery time following emotional arousal, often includes physiological component)
Define validation
Empathy + communication that the patient’s perspective is valid in some way
What are the 3 components of the DBT hierarchy of goals? (Targets)
Target 1: Reduction of life-threatening behaviors
Target 2: Reduction of therapy-interfering behaviors
Target 3: Reduction of quality of life interfering behavior
What is the definition of non-suicidal self-injury?
Intentional self-destructive behavior performed with no intent to die
What are the two dialectical communication strategies?
Reciprocal and irreverent communication
According to DBT, what purpose does dysfunctional behavior serve and why does it persist?
DBT hypothesis: dysfunctional behavior (cutting) is a solution. It is the patient’s attempt to solve the problem of emotional pain and discomfort
It persists because it WORKS: it provides short-term relief
Identify 2 commitment strategies
Pros and cons
Foot-in-the-door
Door-in-the-face
Freedom to choose, absence of alternatives
Linking prior commitment to current commitments
Devil’s advocate
What are 3 appropriate reasons for a patient to utilize phone consultation?
Relationship repair
Good news
Solution-focus problem solving
What are the basic goals for your first DBT session next week week?
Establish rapport
Explore their goals of therapy
Weave DBT Targets into their goals
Get commitment to:
- Stop life-threatening behaviors now
- Go to all group and individual sessions
- Caution them about 3 miss rule
What are the five categories of dysregulation that the diagnostic criteria for BPD diagnosis has been reorganized into?
Emotion Dysregulation (affective lability, problems with anger)
Interpersonal dysregulation (Chaotic relationships, fear of abandonment)
Self dysregulation (identity disturbance/difficulties with sense of self, sense of emptiness)
Behavioral dysregulation (intentional self-harm behavior, impulsive behavior)
Cognitive dysregulation (dissociative responses/paranoid ideation)
You have just diagnosed Mark Schlotterback with borderline personality disorder. Briefly psychoeducate him on his diagnosis and the biosocial theory. Don’t forget to validate him!
Subjective scoring per Mark Schlotterback
What are the 6 levels of validation?
Listen with complete awareness, be awake
Accurately reflect the patient’s communication
Articulate nonverbal emotions, thoughts, or behavior patterns
Describe how the patient’s behavior makes sense in terms of past learning history or biology
Actively search for the ways that the patient’s behavior makes sense in the current circumstances
Radically genuine
“Treat patients as sunsets rather than math problems”
What is the typical (very general) structure of a DBT session? (First do this, then this, then this...)
Review diary card
Establish hierarchy of goals
Conduct chain analysis
Outline the basic components of a chain analysis
Vulnerabilities
Triggering event
Thoughts/emotions/behavior
Problematic behavior
Consequences