Using ACT and DBT in Response to Self-Injury and Other Target Behaviors

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2 Using ACT and DBT in Response to Self-Injury and Other Target Behaviors Stephanie Bonier, LCPC, CADC Danielle Kiehler, PsyD Clinical Therapists in the Discoveries Program 2

3 Objectives Identify self-injury and other target behaviors that impact functioning in the school setting. Increase understanding of Acceptance and Commitment Therapy and skills to implement within the school setting. Increase understanding of Dialectical Behavioral Therapy and skills to implement within the school setting. Identify barriers to behavior change and appropriate interventions. 3

4 Target Behaviors In Acceptance and Commitment Therapy, the term target behaviors is not directly used; however, the individual and treatment team are looking to increase behaviors that are in like with the individual s stated values. In Dialectical Behavioral Therapy, target behaviors are behaviors that the individual and treatment team are trying to increase or decrease. 4

5 Target Behaviors to Decrease Within the School Setting Self-injury behaviors Substance use behaviors Skipping class Not completing homework Avoiding presentations 5

6 Target Behaviors to Increase Within the School Setting Attending class Completing assignments Presenting in front of class 6

7 Acceptance and Commitment Therapy (ACT) ACT is a contextually based intervention designed to create psychological flexibility by helping clients connect on an experiential level. Seeks to balance mindfulness and acceptance processes with commitment and behavior change processes. 7

8 Acceptance and Commitment Therapy (ACT) Acceptance does not mean to agree with or approve of something, it is simply the act of acknowledging that something that cannot be changed has occurred. Commitment comes in when the client begins to take committed action towards living a values based life. ACT is more concerned with increasing the quality of life of the client than with symptom reduction. 8

9 Acceptance and Commitment Therapy (ACT) Built on the principles of relational frame theory (RFT), which explores how language functions to keep human beings stuck in painful psychological material, and how this leads to increased suffering and misery. ACT aims to undermine the verbal difficulties that trap people in their own suffering, such as when we try to force ourselves not to think or feel a certain way only to find that is all we can think or feel anymore. 9

10 Acceptance and Commitment Therapy (ACT) Psychopathology, or human unhappiness, comes from a core pathological process known as Experiential Avoidance. Experiential Avoidance leads to psychological inflexibility. The use of language tools in a way that is ineffective, unhelpful, or problematic. 10

11 Acceptance and Commitment Therapy (ACT) Psychological Inflexibility is caused by: Experiential Avoidance Cognitive Fusion Limited Self-Knowledge Attachment to the Conceptualized Self Lack of Values Clarity/Contact Inaction, Impulsivity, or Avoidant Persistence 11

12 12 Acceptance and Commitment Therapy (ACT)

13 Acceptance and Commitment Therapy (ACT) In order to restore psychological flexibility ACT focuses on: Acceptance Cognitive Defusion Being Present Self as Context Defining Valued Directions Committed Action 13

14 14 Acceptance and Commitment Therapy (ACT)

15 ACT: Willingness People, in general, work to avoid painful experiences (experiential avoidance). This process can become so ingrained that people don t even notice they engage in it anymore (cognitive fusion, conceptualized self). Pain and suffering are increased through trying not to think about an unpleasant experience or by living outside of values (lack of values, avoidance persistence). 15

16 ACT: Willingness Willingness can be thought of as being open to ones whole experience while choosing to live life in a valued direction. Being open and present with whatever is being felt, sense, or witnessed. NOT the same as wanting. Do not have to want something to be willing to experience it. 16

17 ACT: Developing Willingness Cannot move forward without first being willing. Developing willingness has two focuses: Helping the person become aware of the ways they attempt to control or avoid their experience. Discuss the consequences of these strategies and long vs short term impact. 17

18 ACT: Developing Willingness When discussing past attempts to control or avoid, remember past attempts are always understandable and reasonable All discussion of the behaviors should be met with validation. Remember you can validate without agreeing or encouraging behavior. Recognize that all movement towards values is important and sometimes small steps are healthier than large ones. 18

19 ACT: Acceptance Helps the person to become active and aware of private experiences without attempts to change them. Not an end, but a beginning, to foster values based action. Exercises in acceptance look like exposure exercises with the additional purpose of increasing willingness and flexibility. 19

20 ACT: Cognitive Defusion The process of creating nonliteral contexts in which language can be seen as a relational process. Decreases attachment to thoughts. Helps person to have a more mindful perspective on thoughts and increases flexibility linked to values. Ex: Twinkle, twinkle little.. 20

21 ACT: Being Present Helps the individual learn to selectively attend to existing internal and external experiences. Ongoing, nonjudgmental contact with psychological and environmental events. Want to help the student work towards a defused, nonjudgmental, on going description of thoughts, feelings, and internal events. 21

22 ACT: Self as Context Learning to view one s self as the context of their inner experiences and not being distracted by the content. View the self and an arena for experience. A continuous and secure I from which all events are experienced. Helps to develop a more solid sense of self. Ex: The sky vs the weather 22

23 23 ACT: Defining Valued Directions

24 ACT: Defining Valued Directions Asks us to step back from everyday problems and take a look at what gives life meaning. Provide life direction and serve at motivation for change. Ask yourself: In a world where I can choose to have my life be about something, what would I choose? Actions are evaluated based on if they are helpful or not in pursuit of a valued life. 24

25 ACT: Committed Action Taking steps to live towards ones values, larger and larger patterns of effective behavior are linked to chosen values. Protocols are always focused on short, medium, and long term behavior change goals. SMART goals Behavior change leads to contact with psychological barriers. 25

26 ACT: SMART Goals Specific What will you do, when, where, and who else is involved? Meaningful Is it guided by your values? Adaptive Does this goal help you improve your quality of life? Realistic Can you achieve this goal realistically? Time-bound Set a day, date, and time for it. 26

27 27 Time for a Break!

28 Dialectical Behavioral Therapy (DBT) Developed by Marsha Linehan, PhD, ABPP in the 1980s to treat individuals that struggled with borderline personality disorder (BPD). Currently DBT is recognized as the gold standard for treating BPD. Empirically proven to be successful to reduce: Suicidal behavior, non-suicidal self-injury, psychiatric hospitalization, treatment dropout, substance use, anger, and depression. Empirically proven to improve social, and overall, functioning.

29 Dialectical Behavioral Therapy (DBT) Used for individuals who struggle with controlling emotions and behaviors. Aims to reduce target behaviors and increase use of more skillful behaviors. Helps to create a life worth living.

30 Dialectical Behavioral Therapy (DBT) Third wave form of Cognitive Behavioral Therapy. DBT DOES NOT have a constant focus just on change. By adding acceptance components to the strategies focused on change, it allowed individuals to feel that their therapists understood them more. 30

31 Dialectical Behavioral Therapy (DBT) Biosocial Theory of BPD Theory has therapists focus on emotions and emotion regulation in treatment. Individuals with BPD are more likely to experience emotion vulnerability due to their biology. Invalidation during childhood, combined with biology, leads to an increased likelihood of a child developing BPD. 31

32 DBT: Emotion Vulnerability Emotional Intensity Time Before DBT After DBT 32

33 DBT Target Behaviors Hierarchy is used in order to prioritize which target behaviors to address first. Target behaviors, in order of priority: Life-threatening behaviors Therapy-interfering behaviors Quality of life behaviors Skills acquisition 33

34 Stages of Treatment in DBT Stage 1 Individual is miserable and behaviors are out of control. Goal: Gain behavioral control. Stage 2 Behaviors are more under control and individuals still are feeling that they are suffering. Goal: Experience emotions fully. 34

35 Stages of Treatment in DBT Stage 3 Individuals are learning to live again. Goal: Experience ordinary happiness and unhappiness. Stage 4 Made for individuals who are seeking an increased spiritual connection. Goal: Continued movement toward experiencing joy and freedom. 35

36 Dialectical Behavioral Therapy (DBT) Skills taught fall into one of five modules: Mindfulness Distress Tolerance Emotion Regulation Interpersonal Effectiveness Walking the Middle Path In addition to skills it is important to utilize: Diary/Skills cards Behavior chain analysis Acceptance Skills Change Skills 36

37 37 DBT: Mindfulness

38 DBT: Mindfulness Function is to increase our awareness of our thoughts, feelings, and urges in the moment to promote more effective decision making. Pay attention with intention, to the present moment while noticing and letting go of judgments. Is at the core of ALL DBT skills and needs to be taught first before moving on to other modules. 38

39 DBT: Mindfulness Mind States Influence decision making No good or bad mind state Three states of mind Rational mind Emotional mind Wise mind 39

40 DBT: Mindfulness States of Mind Rational Mind Wise Mind Emotional Mind 40

41 41 DBT: Mindfulness How and What

42 DBT: Mindfulness How and What How Observe: Watch wordlessly, or just notice your experience in the moment. Describe: Use facts; not interpretations. Talk about what you are observing as if you are someone who has never seen that thing before. Participate: Throw yourself into the present moment; full immersion in an activity. What One-Mindfully: Do one thing at a time. Non-Judgmentally: Acknowledge effective and ineffective, helpful versus harmful instead of good and bad and positive and negative. Effectively: Doing what works, even if it is not what we want to do. Acting skillfully versus acting solely on emotions. 42

43 DBT: Mindfulness Time for a Mindfulness Exercise! 43

44 44 DBT: Emotion Regulation

45 DBT: Emotion Regulation Set of skills to improve our ability to decrease mood swings, emotional intensity, and mooddependent behaviors. Work toward taking charge of our emotions by: Understanding our experienced emotions Reducing emotional vulnerability to unwanted emotions Reducing frequency of unwanted emotions Stop or reduce unwanted emotions once they start 45

46 DBT: Emotion Regulation Skills include: ABC PLEASE Ride the Wave Opposite Action to Change Emotion 46

47 DBT: Emotion Regulation ABC PLEASE Accumulating positive experiences. Build mastery. Cope ahead. Treat PhysicaL illness Balance Eating. Avoid mood-altering substances. Balance Sleep. Get Exercise. 47

48 DBT: Emotion Regulation Ride the Wave Experience your emotion. Observe your feeling and notice it. Practice mindfulness of emotional body senses. Notice where in your body you re feeling the emotional sensations. Remember: You are not your emotion. You don t need to act on the feeling or emotion. Don t judge your emotion. Practice willingness. 48

49 DBT: Emotion Regulation Opposite Action to Change Emotion All emotions come with action urges that direct us to behave in certain ways. Often, we tend to escape uncomfortable emotions in unhelpful ways. This skill directs us to do the opposite of our action urges under two circumstances: When the emotion doesn t fit the facts. The emotion, its intensity, or its duration is not effective. 49

50 DBT: Emotion Regulation Opposite Action to Change Emotion Emotion Fear Anger Sadness Shame Guilt Jealousy Love Common Action Urges Escape or avoid Attack Withdraw, isolate, increase passivity Hide, avoid, attack others Overpromise you won t hurt the person again, disclaim responsibility Accuse others, attempt to control Say I love you, show affection 50

51 DBT: Emotion Regulation Opposite Action to Change Emotion Fear/Anxiety Escape/ Avoid Approach Run/Retreat 51

52 52 DBT: Interpersonal Effectiveness

53 DBT: Interpersonal Effectiveness Goal of these skills is to increase effective, assertive, communication in order to build and maintain healthy relationships. Three types of effectiveness are focused on: Objective Relationship Self-respect 53

54 54 DBT: Interpersonal Effectiveness

55 DBT: Interpersonal Effectiveness Skills include: DEAR MAN - Getting someone to do what you want GIVE - Building and maintaining positive relationships FAST - Maintaining your self-respect THINK - Interpretations 55

56 DBT: Interpersonal Effectiveness DEAR MAN Describe the situation. Express feelings and opinions. Assert be asking what you want/need or by saying no. Reinforce or reward the person you are talking with. (Be) Mindful. Say focused on your goals. Appear confident. Negotiate. 56

57 DBT: Interpersonal Effectiveness GIVE and FAST (Be) Gentle. Don t attack. Be aware of your tone of voice. (Act) Interested. Listen! Don t interrupt. Make good eye contact. Validate. (Use an) Easy Manner. Smile. Use humor. Leave your attitude at the door. (Be) Fair. (No) Apologies. Don t over or under apologize; and apologize if you have wronged someone. Stick to values. Don t sell out. (Be) Truthful. Don t lie. Don t make excuses or exaggerate. 57

58 DBT: Interpersonal Effectiveness THINK Think about it from the other person s perspective. Have empathy. What may the other person be feeling or thinking? Interpretations. Can we identify other interpretations or explanations for the other person s behavior? Notice ways the other person has been trying to make things better, or show that they care. Or, notice how the other person may be struggling with their own problems. Use Kindness. 58

59 59 DBT: Distress Tolerance

60 DBT: Distress Tolerance Set of skills to decrease impulsivity. Skills help us tolerate painful/crisis experiences. Pain is part of life that cannot be avoided. - Suffering is an option. Prevents us from acting on impulsive urges by using our skills. Reality acceptance and crisis survival skills. Function of these skills is to get us to a place where we can access, and use, wise mind. 60

61 DBT: Distress Tolerance We will only use the crisis survival skills when we are in crisis! Using these skills when we are not in crisis will make them less effective when we are actually in crisis! If we use these skills when we are not in crisis, we are teaching ourselves: We are in crisis when we are not. We cannot tolerate painful, intense emotions CRISIS 61

62 DBT: Distress Tolerance Crisis survival skills include: ACCEPTS - Distraction IMPROVE the Moment Self-soothe Pros and Cons 62

63 DBT: Distress Tolerance ACCEPTS Activities. Do something. Contributing. Contribute to (do something nice for) someone. Comparisons. Compare yourself. Emotions. Create different emotions. Pushing Away. Push the painful situation our of your mind temporarily. Thoughts. Replace your thoughts. Sensations. Intensify other sensations. 63

64 DBT: Distress Tolerance IMPROVE The Moment Imagery. Imagine your happy place, things going well, and painful emotions leaving your body. Meaning. When live gives you lemons, make lemonade. Prayer. Ask for strength. Relaxation. Progressive muscle relaxation. One thing in the moment. Use mindfulness and pay attention to only what you are doing. Vacation. Give yourself a brief break. Encouragement. Be your own cheerleader. 64

65 DBT: Distress Tolerance Self-Soothe Touch Taste Smell See 65 Hear

66 DBT: Distress Tolerance Pros and Cons Self-Injury Behaviors Pros Cons Being skillful No scars Pride in using skills Experience discomfort longer Don t like using skills Acting on urges and not using skills Instant relief Easy Comfortable Scars Shame and guilt Consider short-term and long-term pros and cons. Before a crisis occurs, write out your pros and cons. When in crisis, review your pros and cons and imagine any possible consequences of either action. 66

67 DBT: Distress Tolerance Reality acceptance skills include: Radical Acceptance Turning the Mind Willingness 67

68 DBT: Distress Tolerance Reality Acceptance Skills Radical Acceptance Accepting things that you cannot change. Turing the Mind Making the choice to accept something after noticing that you are not accepting reality. Willingness Allowing the world to be what it is and participating fully, being effective, and listening to Wise mind to make a decision. 68

69 DBT: Walking the Middle Path Set of concepts that focuses on replacing either-or with both-and thinking. Increases the ability to see the gray area. Helps us make room for compromise and see different perspectives of situations. Developed to address common struggles that teens and their parents encounter. 69

70 DBT: Walking the Middle Path Concepts include: Dialectics Validation Behavior change 70

71 DBT: Walking the Middle Path Dialectics Acceptance Change 71

72 DBT: Walking the Middle Path Dialectics Dialectics are two opposite things that are true at the same time. To be more dialectical we have to: Move away from using extreme words such as always and never. Look at all sides of the situation. Remember that no one has the absolute truth. Use I feel statements. Accept that different opinions can be valid. Check assumptions. Don t expect others to know what you re thinking. 72

73 DBT: Walking the Middle Path Validation Validation communicates that one s feelings, thoughts, and actions make sense and are understandable to you in a particular situation. Validation Agreement We can validate an emotion and not validate the behavior that the individual engaged in. 73

74 DBT: Walking the Middle Path Behavior Change Looking to increase, and decrease, certain behaviors. Increasing behavior Provide rewards for effective behavior Notice use of negative reinforcement when trying to avoid discomfort Decreasing behavior Withhold previous reinforcement. Provide a consequence for a behavior. 74

75 DBT: Diary/Skills Cards Card utilized on a day-to-day basis to track urges and actions of target behaviors. Card usually tracks the following: Date/Time and location Vulnerabilities to emotion mind Prompting event Feelings Intensity of urge and if action was taken What the urges are telling you Skills that were used, if any 75

76 DBT: Behavior Chain Analyses Step-by-step breakdown of thoughts, feelings, and behaviors associated with urges, or actions, related to target behaviors. How to: Start with identifying vulnerabilities to emotion mind Prompting event Thought à Feeling à Behavior Once completed this activity allows the student to see possible patterns that lead to urges or engagement in target behaviors. As well as when, and how, to use more effective skills. 76

77 DBT: Behavior Chain Analysis Example Vulnerabilities to emotion mind: Tired, Lonely, Storms outside, Didn t eat dinner Prompting event: Best friend stopped talking to me Thought: What did I do wrong? Feeling: Worthless, sad, anxious Behavior: Paced in bedroom Thought: Why do I always ruin things? Feeling: Worthless, angry, sad Behavior: Looked for self-injury tools Thought: I just need to feel better. Feeling: Sad, worthless, angry Behavior: Self-injured Thought: Oh, that s better. Feeling: Relief Behavior: Cleaned up tools Thought: Oh no, why did I do that? Feeling: Guilt and shame Behavior: Began crying Thought: I keep messing things up Feeling: Worthless, hopeless Behavior: Isolated self 77

78 Implementing ACT in the School Setting ACT can be used individually or with a group. Many group based activities can be altered to accommodate only one person. ACT with an individual student may include: Individual sessions to work on developing willingness, defining values, or learning defusion techniques. Homework assignments associated with committed action and mindfulness can be assigned and discussed. ACT in group may include engaging in group activities associated with the different areas or psychological flexibility. 78

79 Implementing ACT in the School Setting In the classroom, ACT could look like: Encouraging students to focus on values, when they begin to engage in unhealthy or ineffective behaviors. Validating the student is struggling and remind them of the steps they have taken in committed action, without pointing out past mistakes. 79

80 Implementing DBT in the School Setting DBT is traditionally a combination of group-based education and individual therapy. DBT with an individual student may look like: Processing diary/skills cards Review of homework assignments focused on application of skills Balancing acceptance and change in behaviors DBT in a group includes: Weekly group-based skills training focused on a specific skills module. 80

81 Implementing DBT in the School Setting DBT in the classroom may look like: Allow students to utilize self-soothe kits. Provide students with the opportunity to meet with staff when in crisis. Provide validation and offer ways to problem solve when target behaviors are engaged in. 81

82 Barriers to Change within the School Setting School policy Lack of knowledge regarding skills to use For both students and staff Severity of behaviors Limited time For skills training, acquisition, and follow-up 82

83 Treatment of Self-Injury at Linden Oaks Hospital 83

84 Discoveries Program at Linden Oaks Treatment program focused on the treatment of self-injury behaviors in conjunction with other mental health diagnoses IOP and PHP levels of care are offered Program earned The Gold Seal of Approval from The Joint Commission 84

85 Discoveries Program at Linden Oaks Program consists of: Daily group therapy Daily skills groups Daily expressive therapy Individual therapy (once or twice per week) Family therapy (once per week) Multi-family group (once per week) Body image group (once per week) Regular psychiatric support provided by nursing staff, psychiatrists, and physician assistants/advanced nurse practitioners 85

86 Ways to Provide Reassurance During Treatment Explain that the path to recovery is bumpy, and not to get discouraged Try avoiding the abstinence violation effect Validate that it is okay to miss self-injury Discuss the beliefs about the skills because they matter as much as the skills What are the student s attitudes about the skills?

87 87 Questions?