1. Amy Lopez, LCSW

2. What is DBT?
 DBT is Dialectical Behavioral Therapy.
 A model of therapy that uses skills training and the
therapeutic relationship to manage strong emotions
and behavioral dyscontrol.
 Although originally created for treatment of
Borderline Personality Disorder, is now used in a
variety of treatment settings
 A bio/psycho/social model that modifies traditional
behavioral approaches
 Uses group work (skills training), individual therapy
and self-monitoring to change target behaviors.

3. DBT as Evidence Based Practice
 DBT vs TAU comparison group
 DBT had higher global functioning scales
 DBT had fewer parasuicidal behaviors
 DBT had fewer psychiatric inpatient days
 At writing, at least 13 separate Randomized Control Trials
 Two separate meta-analysis reviewed effect sizes
 Current studies including RCT of DBT vs. Treatment with “Community Expert” and aftercare models
 Replicated across treatment conditions
 Substance Abuse
 Forensics (Correctional Facilities)
 Eating Disorders
 Adolescents
 Older Adults
 Manualized Treatment Program requiring treatment fidelity
 Intensive training for practioners
 Use Individual and Skills Group model
 Consultation Team

4. History of DBT
 Created to specifically “address the needs of problem
behaviors within a diagnostic group.”
 The problem of Borderline Personality Disorders:
 Among completed suicides, 66% have BPD diagnosis
 75% have attempted suicide and 80% self-mutilate.
 Multiple hospital admissions and ER visits
 Multiple medication trials
 Multiple treatment providers
 “The most difficult patients to treat…”
 BPD theory is “re-organized” into a workable and treatable
framework.

5. Borderline Personality Disorder
 DSM IV Criteria:
 A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked impulsivity
beginning by early adulthood and present in a variety of contexts
 A pattern of intense and unstable interpersonal relationships
 Frantic efforts to avoid real or imagined abandonment
 Identity disturbance or problems with sense of self
 Impulsivity that is potentially self-damaging
 Recurrent suicidal or parasuicidal behaviors
 Affective Instability
 Chronic Feelings of Emptiness
 Inappropriate or uncontrollable anger
 Transient stress-related paranoid ideation or severe dissociative symptoms

6. BPD reorganized
 Behavioral Dysregulation
 Impulsive behaviors
 Suicidal behaviors
 Interpersonal Dysregulation
 Chaotic relationships
 Fears of Abandonment
 Cognitive Dysregulation
 Non-pyschotic paranoid ideation
 Emotional Dysregulation
 Affective Lability
 Problems with Anger
 Self Dysregulation
 Identity Disturbance
 “I don’t know who I am or what I can expect from myself”

7. Borderline Personality Disorder –
Biosocial theory
Emotional Chronic
Invalidating
Sensitivity Emotion
Environment
Dysregulation
Emotional Sensitivity:
High Sensitivity and Immediate Reaction
High arousal and intense body response
Slow return to Baseline
Invalidating Environment:
Lack of appropriate response from parents
Emotion Dysregulation:
Person never learns to accurately experience and express emotions,
creating confusion both internally and externally

8. Behavior Modification Theory
 All behaviors have meaning
 If a behavior does not serve a purpose, it will no longer
exist
 All behaviors are motivated by rewards and consequences
 Change to behavior is directly linked to
rewards/consequences
 Theory is focused on outcomes, less on motivation
 Behavior changes first, attitudes change second
 Act “AS If”
 Can’t wait to feel better, behavior is what simulates mood
change

9. What is Dialectics:
 The idea that two opposite or contradictory ideas
can exist simultaneously.
Emotions
Behaviors Thoughts
 Similar to CBT and behavior modification with
addition of recognition of emotion on thoughts and
behaviors (and VALIDATION of emotion)

10. Who is appropriate for DBT?
 Strong Emotions  Previous Treatment
 Difficulty with “Failures” (note –
relationships patients cannot “fail”
 Behavioral problems
DBT).
 High users of system
 Difficulty managing own
thoughts resources
 Inpatient stays
 ER visits
 A desire to have a life
worth living

11. Commitment Strategies
 DBT is MOST effective when  Prior to engaging client in
used as the full model treatment, client must be:
 Individual treatment  Ready and willing to make
 Skills training changes
 Crisis intervention  Agree to year long
 Therapist consultation commitment
 Willing to engage in a
partnership with therapist
 Full model requires a big  Willing to do things differently
commitment: than they have always done.
 6-12 months of  Able to define problems
 Weekly individual sessions behaviorally
 Weekly skills training  DBT stages of treatment as a
 Homework house
 Daily diary card use  Pre-treatment – still standing
outside

12. Stages of Treatment
 Stage I Treatment
 Life Threatening Behavior
Stage IV
 Therapy Interferring
Incompleteness
Behavior
Stage III  Life Interferring Behaviors
Problems in Living  Quiet Desperation
 Inhibited Grieving
Stage II  Re-Learning to Experience
Quiet Desperation Emotions
 Problems in Living
Stage I
 “Ordinary Unhappiness”
Life In Hell
 Incompleteness
 Capacity for Joy (Existential)

13. Individual Treatment Strategies
 Every session follows the stages of treatment:
 “Let’s start with your diary card.”
 “Any life threatening behaviors this week?”
 Diary cards
 Ways to record impulses and behaviors
 Rewards for using skills
 Transitional Object – continues relationship outside office
 Behavior Chains
 Maps out rewards/consequences of certain behaviors
 Focused way for therapist and client to think about behaviors
 Can serve as negative reinforcement…
 Skills Review and in-session practice for life situations
 Role play skills for life situations
 Problem solving
 Therapist as participant
 Observes and addresses violations of personal boundaries
 Offers opinion, disappointment, uses relationship as both reward and consequence
 Allows patient to express all emotions, re-teach appropriate emotional response through relationship
 Middle ground solutions to dialectical dilemmas

14. Defining Problems Behaviorally
 When developing target goals, define problem behavior that is to be changed:
 A Behavioral Excess?
 Too much of a behavior
 Drinking, cutting, stealing, acts of violence
 A Behavioral Deficit?
 Too little of a behavior
 Social isolation, exercise
 Faulty Stimulus control?
 Appropriate behavior, but wrong context
 Anger outbursts
 Describe the Behavior Specifically
 How often
 In what context
 Intensity
 Duration
 Will be used to develop diary cards

15. Dialectical Dilemmas
Borderline Personality Adolescents
Excessive
Emotional Leniency
Vulnerabilities
Force Normalize
Unrelenting Active
Crises Passivity Autonomy Pathological
Midd Behavior
le
Grou
nd
Pathologize
Apparent Inhibited Foster
Competence Grieving
Normal
Dependency
Behaviors
Self- Authoritarian
Invalidation Control

16. Group Skills Training
 Skills Training – NOT Group therapy
 In CONJUNCTION with individual therapy – the two
compliment each other.
 Serves purpose of:
 Skill Acquisition
 Skills Strengthening
 Skills Generalization
 Builds relationship with skills groups leaders through
therapist modeling and reinforcement of skills.

17. Skills Group Training –
Acceptance Change
 Mindfulness Skills  Interpersonal Effectiveness
 Cognitive Dysregulation Skills
 Self-Dysregulation  Interpersonal Dysregulation
 Distress Tolerance Skills  Emotional Regulation
 Behavioral Dysregulation  Emotional Dysregulation

18. DBT Group Skills
Mindfulness Skills Distress Tolerance Skills
 Wise Mind  Wise Mind ACCEPTS
 The intersection of Emotion  Improve the Moment
and Rational Mind
 Self-Soothe
 The What and How Skills
 Pros/Cons
 Observe
 Breathing Exercises
 Describe
 Half-Smile
 Participate
 One mindfully
 Radical Acceptance
 Effectively  Willingness vs. Willfulness
 Non-Judgementally  Turning the Mind

19. DBT Group Skills
Interpersonal Effectiveness Emotional Regulation
 DEAR MAN  Model for Describing
 To make requests Emotions
 GIVE  Check the Facts
 To maintain relationship  ABC Please
 FAST  Mindfulness of Emotions
 To maintain self-respect  Opposite Action
 Intensity and Options for  Brainstorming and Problem
Asking solving
 Provides Middle Ground for
when, how and if to ask