Introducing Dialectical Behaviour Therapy (DBT)

Presenter: John Butters

Counselling Psychologist

Day 2

What is Dialectics?
Hierarchy of Intervention & Levels of Validation
Exploring Target Behaviours using Chain Analysis
STAGE 1 Module 1 Core Mindfulness
States of Mind / What & How Skills / Practice
STAGE 1 Module 2 Distress Tolerance
What is a Crisis? TIPP skills
“Dialectical Abstinence” (Optional skills for addictions)
 Dialectics & Therapy

• “Dialectics” in DBT refers to the stance and attitude taken

by the clinician which involves assisting the individual to
bring together or synthesise seemingly opposite
experiences.

• This is in response to the frequent occurrence of

“splitting” which can readily be seen in BPD which has
individuals “split” experiences into “good” / “bad”;
“right” / “wrong” qualities.

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Dialectics & Therapy

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 Dialectics & Therapy
When viewing the previous optical illusions: you might rst only see one
aspect of the visual: is it a cup? Are there two people? Is it a rabbit? Is it a
duck?

Dialectics is the practice of “holding multiple perspectives about a

phenomenon: or thought, feeling, or idea”. Balancing good/bad splits.

How might this apply in treatment?

Common client dilemmas in DBT include:

Does the client wish to live or die? The purpose of treatment is to assist the
individual face the pain of living; whilst at the same time bare / tolerate the
wish to die. This process will include a key dialectic:

Change (in thinking / behaviour etc) versus acceptance (as it is)

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 Skill modules as “dialectic
balance”
• The four modules (or skill sets) learned in DBT re ect a balance
that is constantly emphasised in the course of the treatment.

Acceptance Change

Core Mindfulness Emotion Regulation

Distress Tolerance Interpersonal E ectiveness

A key aim in skills practice is to ask the question, “What skill(s) will
I need to use to e ectively meet the demands of this moment”?

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 Being a skills trainer: Embodying
dialectics

Key Assumptions ~

Assuming and then organising your thinking around the following

assumptions can be useful beginning points to treatment planning. They
are also worth coming back to when you identify that you are “caught
up” in the latest crisis.

1) Clients are doing the best they can - AND - Clients need to do better,
try harder and be willing to try again

2) Clients want to improve and change their circumstances - AND -

Accept the nature of their di culties as they currently present.

3) Clients may not have caused their own problems - AND - Despite this,
they have to solve them anyway…

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 Embodying dialectics
4) Clients must learn new behaviours in all relevant contexts: especially
the taxing ones: Often the most needed skills are the most avoided by
client and therapist.

5) Clients cannot fail in therapy: therapy CAN fail the client

6)Therapists treating individuals with BPD need support and cannot do

this work in solitary: you don’t have a dialectic if you’re on your own….

7) Collaborating with the client about their goals, and assisting them in
reaching them becomes the centrepiece of treatment: “leverage”.

Watching: 1) A relationship of equality: client and therapist;

2) Distress Tolerance for client and therapist

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 Structuring Treatment:
Entering Conversations
• Five common characteristics of evidence-based treatments of BPD

1. Structured (manual directed) approaches to prototypic problems

2. Patients are encouraged to assume control of themselves (locus of control-

self). Therapist as Expert versus Therapist as Collaborator. Unhook yourself
from interventions where you dispense the skill.

3. Treatment providers help connections of feelings to events and actions

(stimulate re ective capacities). Assisting mentalizing - sense making.

4. Treatment providers are active, responsive and validating. Become mindful

of your sitting position…forward - back.

5. Treatment providers discuss cases, including their personal reactions, with others

(Bateman, Gunderson & Mulder, 2015)

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 Hierarchy of Intervention
Acceptance Change

Commitment & validation of current state

Brainstorming potential skills (w cheerleading)

Identi cation of triggering event(s) & subsequent behaviours

Agreement of Problem (identi cation of target behaviour)

Validation Skills (Start here)

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 Levels of Validation
Validation of self and others are key skills for trainers and represent the basic entry path
to any intervention. They are also key skills to be role-modelled to clients as they re ect
micro skills for ER and IE modules…From a social learning perspective, validation ‘opens’
the individual’s preparedness to learn: “epistemic trust” - seen in attachment security.

Level One:

Am I Observing and Participating in this interaction. Are my senses oriented to the broadcaster?
(Infant research highlights how sensitive the infant is to parental presence/absence in terms of
intentional stance) Am I present?

Level Two:

Once I have captured the essence or gist of what has been expressed - can I describe what I
have observed. Refraining from interpretation and stating observations in the clients own words.
Using Nonjudgemental observations and “marking” your perspective as yours - allowing the
client to correct…working with the extreme sensitivity to being told what their reality is.

Level Three:

Articulating Emotions and clarifying thoughts. Asking questions…making measured guesses

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 Validation continued….
Level Four:

Re ecting one’s understanding of an individual’s behaviours both in terms of history

(learning) and biology. Example: someone who has had a frightening experience of a dog
(prior learning) may be understandably cautious around dogs. OR someone becomes more
emotionally reactive following several days of poor sleep (physiological / biological factor)

Level Five:

Is normlising and recognising emotional reactions that anyone would have. Knowing that
anyone would have an emotional reaction in a speci c situation is both validating and
normalising - especially important for those who may have repetitively heard that they are
overly sensitive or that their reactions are invalid.

Level Six:

The other is not seen or related to as fragile or incapable…Alan Fruzzetti - “matching

vulnerability - locating the clients struggle in ourselves…I also feel at times…. “radical
openness” / “radical genuineness”

Watching DBT in action: can you pick the levels of validation?

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 Exploring target behaviours:
Chain Analysis
• Behavioral chain analyses, which are common in behavioral
and cognitive-behavioral treatments more broadly, are a
commonly used assessment and process tool in Dialectical
Behavior Therapy (DBT). Used especially when target
behaviours such as suicidal ideation or attempts or self
harm has occurred.

• As such, they are conducted in nearly every DBT session.

• Due to the emotions often associated with the target

behaviours being explored in the chain analysis - careful use
of validation TOGETHER with a gentle push toward
exploring those aspects that can cue shame/anxiety etc is
needed.

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 Chain analysis 2
1. Start "at the end”: describe the speci c behaviour (eg.
cutting, ashback, panic attack, aggressive behaviour)
A. Be speci c & detailed B. Indentify what was said,
done, doers and done to C. How intense?

2. Describe the speci c precipitating event that started

the chain or sequence leading to the target behaviour.
Look for “interpersonal changes” and speci c
meanings the client makes…eg. anniversary. (eg. who
were you with when you started feeling impulsive?)

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 Chain Analysis 3
3. Describe general vulnerability factors that were
present before the precipitating event. Areas to focus
on include: A. Untreated or unmanaged physical Illness
/ injury B. ETOH or other drugs C. Stressors (positive or
negative) D. Intense emotions

4. Describe in speci c detail the chain of events that

connect the precipitating event to the speci c problem
behaviour at point 1. What thought / feeling / action
followed the precipitating event…imagine you are
constructing a comic strip with key scenes in each link.

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 Chain Analysis 4
5. What are the consequences of this behaviour? Include: A.
How did others react immediately after / later? B. How did you
feel immediately after / later? C. What e ect did the behaviour
have on you and your environment?

6. Describe in detail di erent SOLUTIONS to the problem.

Include: A. Go back to the chain of your behaviors following the
prompting event. Circle each point or link indicating that if you
had done something di erent, you would have avoided the
problem behavior. B. What could you have done di erently at
each link in the chain of events to avoid the problem behavior?
What coping behaviors or skillful behaviors could you have used?

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 Chain Analysis 5
7. Describe a PREVENTION STRATEGY for how you
could have kept the chain from starting by reducing your
vulnerability to the chain. Identify key vulnerability factors
and potential solutions. Brainstorm.

8. Describe what you are going to do to REPAIR important

or signi cant consequences of the problem behavior.
Brainstorm.

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Exercise - Chain Analysis

• In groups of two / three

1 Therapist / 1 Client / 1 Observer

Work through a chain analysis: start with a PP (typically

some kind of self harm or other target behaviour)

Validate / identify triggers / work through some kind of

sequence from trigger to target behaviour . Model beginners
mind - “don’t know”

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Stage 1: Skills Modules

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 Introducing Mindfulness:
From Zorba to Milton
Alexis Zorba: Life is trouble. Only death is not. To be alive is
to undo your belt and look for trouble. Am I not a man? And
is a man not stupid? I'm a man, so I married. Wife, children,
house, everything. The full catastrophe.

John Milton The mind is its own place and in itself, can
make a heaven of hell, a hell of heaven.

Question: how do we participate in the ‘full catastrophe’

without turning a heaven into hell, or vice versa?

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 Why Mindfulness?
• Trauma & Attachment Insecurity = phobic avoidance of emotional
experiencing, remembering / processing. Employment of defensive
modes of managing memories via splitting, projection, repetitive
enactments with others (inc therapist)

• Mindfulness facilitates open processing of negative defences and

material excluded from awareness via process of attentional control in
a context of curiosity to current experience

• New / novel information and experience is attended to by client and

therapist: Joint attention = ‘relational learning’ / “surprise” / di erence.

• Fosters “dialectic awareness”: observer-observed; then-now; you-me;

inside-outside; similarity-di erence; certain-uncertain

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 (Module 1) Core Mindfulness

• Key to treatment is the slow accumulation of mindfulness skills:

equivalent to “opening ones eyes gradually to a world that one expects
will be lled with endless su ering”

• It is called “core mindfulness” because we use it in conjunction with

every skill taught. (Watching Video: Mindfulness / First skills module)

• Therefore this skill is taught consistently / gradually / and across varied

contexts and methods.

• The key dialectic is variety WITH consistency

• Take one aspect at a time: build an ‘exercise’: Use debrief as

opportunity for ‘joint attention to experience’ (activating social learning)

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States of Mind
Reason Mind Emotion Mind

Wise
Mind

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 WiseMind Skills

• “WiseMind” mindfulness exercise - “Minding the Gap”

between out and in-breaths

• “The Puppy in the pet store”: Reason Mind / Emotion

Mind / Wise Mind (di erences in response).

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What is Mindfulness in DBT
Watching Marsha: “The rst skills module taught in DBT”

“What Skills” or What would I be doing if I were being mindful?

Observing: Noticing / Allowing Experience / Sensing

Describing: Putting words on what you observe

Participating: Bringing all attention to experience / join in /

become-one with moment.

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 How would I do that?
The “How Skills” assist us to cultivate three ‘attitudes /
approaches’

Non-judgementally: Noticing presence of judgemental thoughts

etc. Noting link between judgements and inc emotion. Observing
judging.

One-Mindfully: Slowing observing down to an attention of the

“small and the trivial”. Returning attention when distracted:
noticing cycle of attending - distracting

E ectively: Committing to action that which meets the demands

of the present moment ONLY…”the mahout on the elephant” story

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Preparing a skills practice
Key goal of all skills in DBT is to move the skill from acquisition to
generalisation: start small - work towards greater complexity/demand
Look for “everyday practice” - remember: mindfulness NOT meditation
Steps in designing a skill for a group
1) select a speci c / simple skill
2) describe the skill and its purpose
3) outline steps / instructions clearly
4) run the skill making use of co-facilitator who will re ect on group response
5) Debrief: focussing on what is evoked / applying observe - describe skills as
a skills trainer / “there are no right answers - just experience”

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 Mindfulness - “Seeing and
Touching”
• Group Exercise - Mindful Drawing

Sitting comfortably, you will nd a paper bag with an object

in it. You will also have a pencil and a sheet of paper to draw
on. Do not open the bag. Now, slowly reach into the bag
and touch the object. Taking time to see if you can build up
a mental picture of the object…Spend time returning to the
object to build up a mental picture - and when you are
ready, begin to draw what you ‘see”…

Debrief

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 Surviving a Crisis: Distress
Tolerance (module 2)
• In DBT a crisis involves ‘intensity of experiencing which produces some
form of emotional pain”. The kinds of precipitants responsible for this
intensity may include those of hyperarousal (overstimulation) AND
hypoarousal (understimulation). Both states can produce intense
discomfort and psychic pain.

• More commonly - hyperarousal in which suicidal and parasuicidal

behaviours are more prevalent.

• In marked hyperarousal, we see an intense emotion + an action urge which

involves a search for an end to the ‘pain’.

“CRISIS” = INTENSE EMOTION + INCREASING URGE TO AVOID INTENSITY

• CRISIS ideation is engrossing and narrows ‘choices’.

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 Distress Tolerance 2
Key Components of module: “Learning Distress Tolerance is
distressing”

1) Crisis Survival Skills - surviving intense emotions in the

short term (ACCEPTS / Self soothe / IMPROVE / pros &
cons / TIPP skills)

2) Radical Acceptance: “Turning the Mind” with

“willingness” to “Reality as it is”.

3) Managing addictions: Accepting the urge to use

WITHOUT using

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 Distracts Skills 1
Characterized as a collection of skills designed to distract the mind o
current urge/state and onto something else in the here-and now. USED
WITH MINDFULNESS.

• Wise Mind ACCEPTS skills ~ distract through:

Activities, Contributing, Comparisons, opposite Emotions, Pushing

away, Thoughts, Sensations.

• SELF SOOTHE ~ distract & reduce arousal through:

Sight, Smell, Touch, Taste, & Sound.

Question: what might be a challenge or stumbling block to generating a

self soothe list with a client…

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 Distract Skills 2
• IMPROVE the Moment ~

Imagery, Meaning, Prayer, Relaxation, One-thing-in-the-

moment, Vacation, Encouragement.

• PROs & CONSs

Slowing down an urge by noting the short and long term

consequences. Engaging in “dialectic thinking” - that every
action will produce a consequence that re ects positive and
negative outcomes for the “actor”

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 Example of a Pros & Cons exercise
“Working With Self Harm Beliefs

Advantages Disadvantages

Continue
self
Harm

Stop
Self
Harm

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TIPP Skill: Distract Skills 3
• You’re at your emotional breaking point. Maybe the worst has
happened, or maybe it was just the ‘ nal straw”.This skill is
designed to bring you down from the highest level of distress to
something more manageable - and gives you time to nd “wise
mind”.

• TIPP stands for Temperature, Intense exercise, Paced breathing

and Paired Muscle Relaxation

• TIPP skills are taught early on in DT and are reinforced throughout

discussions associated with ‘crisis management’. TIPP can be used
as a ‘staging skill” to reduce hyper-arousal enough to allow for
more thorough skill usage. As a result, it is a good skill to use on
wards and other crisis-contexts during heightened exchanges or
crises.

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 Acceptance to Radical
Acceptance 4
• Movement from short term crisis survival to acceptance of
life and emotional pain as it is...

• Three interlinked concepts that relate to cultivation of a

particular stance or attitude toward “inevitable pain” versus
“optional su ering”
Willingness v
Willfulness

Radical Acceptance

Turning the Mind

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 What makes radical acceptance -
radical? 4
• The acceptance of pain AS IT PRESENTS ITSELF, without approval or
agreement, but of acceptance with body and mind.

• SUFFERING made worse through judging - through the denial / judgement of

the causes of what is or has happened. Example: “That is bad, it should not
have happened...I don't deserve this...this is not fair”. “The closing of one’s
“emotional eyes” to what is.

• To become aware of one’s aversion to the outcome...but to accept the end point
with all its causes (some of which may neither make sense or are still unknown).
To radically accept that we may not know the cause BUT accept that there is
one.

• Avoiding the Buddha’s “second arrow strike”: key treatment dialectic

• I may not be responsible for what happened to me: BUT I am responsible for
how I respond to it.

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 Dialectical Abstinence
Model (Optional Mod)
Working toward Managing Relapse/
Full Abstinence Minimising Harm

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 Dialectical Abstinence
• The constant synthesis of acceptance with change lends
itself well to the philosophical approach found in the
Twelve Step Tradition: radically accepting THIS moments
pain / urge / impulse…

• Dialectic balance in Serenity Prayer:

To my higher power: “Grant me the serenity to accept the

things I cannot change (the current urge/distress) Courage
the things I can (my reactions / behaviours) and the Wisdom
to know the di erence.”

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Mindfulness Skills for Addictions:

Sober Mind Addict Mind

Recovery
Mind

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 Skills Targets with
Addictions
• Decrease incidence / frequency / severity of usage patterns.

• Increase longer periods of abstinence (5 minutes - 5 hours - 5 days

- 5 weeks)

• Use skills (DT) to increase tolerance for usage urges / impulses.

Decrease frequency of urges.

• Decrease risk factors associated with using (“Burning Bridges” /

routes to using)

• Cultivating alternative behaviour sets to using behaviours -

matching “neurophysiological e ects of drug with alt experiences”.

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 Managing Relapse
• Using “Coping Ahead” to anticipate potential cues and rehearse / plan
responses ahead of time.

• Relapse is a problem to solve rather than as evidence of failure: what did

we learn from this?: looking for “grains of gold in defeat” (dialectic). Using
Chain Analysis on the relapse.

• Therapist moves to “Managing Relapse” side of the dialectic.

• Learning how to “fail well”: responses to relapse that enhance and

encourage re-compliance.

• Failing well - radical acceptance of healthy guilt with repair of damage

(social and or material).

• With compliance restored - therapist moves back to the abstinence side

of the dialectic.

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 References

• Shireen L. Rizvi, Lorie A. Ritschel,Mastering the Art of

Chain Analysis in Dialectical Behavior Therapy, Cognitive
and Behavioral Practice,Volume 21, Issue 3,2014, Pages
335-349 [Link]

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