LOOKING THROUGH THE TRAUMA LENS AT DIALECTICAL BEHAVIORAL THERAPY. Fundamental Elements of Trauma. Four Levels of Stress Reactivity 2/18/2013

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1 1 LOOKING THROUGH THE TRAUMA LENS AT DIALECTICAL BEHAVIORAL THERAPY Anita Mandley, LCPC Fundamental Elements of Trauma 2 Powerlessness Disconnection Devaluing Out of Control Four Levels of Stress Reactivity 3 1

2 4 Judith Hermann,MD. Trauma and Recovery Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. When the force is that of nature, we speak of disasters. When the force is that of other human beings, we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people control, connection, and meaning. Consequences of Trauma 5 Underdeveloped affect regulation skills Disruptions in attention and consciousness Somatic disturbances Distortions in self-perception Distortions in perception of the offender(s) Relational disturbances Disruptions is systems of meaning Inability to Trust The Trauma Mind Storm of Affect Self-Harm Pseudo-Competency Eating Problems Rage Fear Guilt THE EYE Shifting Sense of Self Anger Unsafe Physical Behaviors Stealing Terror Lying Depression Sexual Behaviors 6 Damaged Goods Low Self- Esteem Property of The Center For Contextual Change, Ltd. 6 2

3 DBT for Pervasive Emotion Dysregulation Complex PTSD, Disorders of Extreme Stress, or BPD are all names of disorders of pervasive dysregulation across both negative and positive emotions DBT is a comprehensive treatment for emotion dysregulation across diagnostic lines Each DBT skill set is designed for the purpose of emotion regulation Characteristics of PED Excess of aversive emotional experiences Inability to regulate intense physiological arousal Problems turning attention away from emotional stimuli Cognitive distortions Failures in information processing Insufficient control of impulsive behaviors PED Characteristics cont'd Difficulties organizing and coordinating activities to achieve non-mood-dependent goals when emotionally aroused Tendency to freeze or dissociate under very high stress Occurs across the entire emotional system, including the behavioral, physiological, cognitive, and experiential subsystems of emotional responding 3

4 10 Five Functions of Comprehensive of Treatment Model Enhance client capabilities Improve client motivation for treatment Structure the environment Generalization to the environment Enhance therapist s motivation to provide effective treatment Center for Contextual Change Five Functions of Treatment Enhance Client Capabilities Behavioral Control Interpersonal Stability Stabilization of Core Sense of Self Cognitive Stability The Orchid Hypothesis This is a transformative, even startling view of human frailty and strength. For more than a decade, proponents of the vulnerability hypothesis have argued that certain gene variants underlie some of humankind s most grievous problems: despair, alienation, cruelties both petty and epic. The orchid hypothesis accepts that proposition. But it adds, tantalizingly, that these same troublesome genes play a critical role in our species astounding success. The Atlantic Magazine, 2009 Anita Mandley, LCPC, Center for Contextual Change 4

5 Emotion Regulation Targets Focuses on targeting specific emotion components with a simultaneous emphasis on targeting specific time points in the emotion-generative process All DBT skills target emotion regulation in some way or another Five Subsystems of Emotions Emotional Vulnerability to Cues Internal and external events that serve as emotional cues, including attention to and appraisals of the cues Emotional responses: physiological, cognitive, experiential, and action urges Nonverbal and verbal expressive responses and actions Aftereffects of the initial emotional firing including secondary emotions Five Functions of Treatment 15 Improve Client Motivation for Treatment Therapeutic Relationship Phased Collaborative Treatment Plan Interventions that Help Quickly 5

6 Dialectics of the Therapeutic Relationship Constant attention to combining acceptance with change Flexibility with stability Nurturing with challenging Focus on capabilities with a focus on limitations and deficits Change is facilitated by emphasizing acceptance and acceptance is facilitated by emphasizing change. Schwartz and Southern 17 Some individuals seem to be saved by novel experiences with a loving caretaker, teacher, friend, or therapist. These experiences prove transformative, influencing them to compensate with new cortical structures and learn relative to healthy attachments. Indeed, the purpose of psychotherapy is fundamentally to facilitate these transformations. Since, as Schore emphasized, it is affect not cognition- that is the means of exchange in relationships, the client will not remember events, rather, emotions will be the primary form of communication. Collaborative Stages of Treatment Stage I: CREATING A CONTEXT FOR CHANGE Level 1 A. Creating a safe Therapeutic Relationship Safety Inside and Outside of the office 1. Safety Plan 2. Psychoeducation about Model, Treatment, Cycle, etc. B. Pretreatment Planning & Treatment Planning C. Contextual Assessment 1. Vulnerability Factors 2. Resiliency Factors Level 2 A. Negative and Positive Consequences of Change B. Introduction to symptom reduction interventions C. Address Denial Level 3 A. Goal Setting B. Pre-Acknowledgement Sessions 18 Stage 2: CHALLENGING PATTERNS AND EXPANDING REALITIES Level 1 A. Patterns and Exceptions Identified and Mutually Agreed 1. Review of Stage I 2. Identify Old Patterns & Challenge Them 3. Continuing to Address forms of Denial 4. Determine Therapeutic Process Level 2 A. Alternate Realities and Behaviors Mutually Explored 1. In and out of session tasks and enactments 2. Negative Behavior Cycle and or Victim/Survivor Cycle 3. Imaging Alternatives 4. Symptom Reduction Interventions Level 3 A. Acknowledgement Sessions centered on Impact III. CONSOLIDATION A. Punctuate Changes B. Look at future problem areas C. Change - Changes M.J. Barrett, C. Sykes and W. Byrnes, T. Trepper & M.J. Barrett,

7 Five Functions of Treatment 19 Structure the Environment Systemic Interventions Coaching Client to Advocate for Self Direct Interventions Five Functions of Treatment 20 Generalization to the Environment Through homework assignments and practice in between sessions. Center for Contextual Change 2010 Five Functions of Treatment 21 Enhance Therapists Capabilities to Provide Effective Treatment Stage Oriented Integrated Treatment Model Interventions that Increase Mastery Interventions that Decrease Helplessness Interventions that Decrease Extreme Behaviors and Crisis Supervision and Consultation 7

8 22 Therapist Treatment Interfering Behaviors Imbalance of change versus acceptance Imbalance of flexibility versus stability Imbalance of nurturing versus demanding change Imbalance of reciprocal versus irreverent communication Behaviors showing lack of respect for the client Blaming the victim Dialectics in Treating the Therapist Functions as a dialectical counterweight to treatment of the client Allows the therapist to be the recipient of acceptance and change strategies even as he or she is applying those same strategies with the client Transactions between client and therapist are brought into a dialogue among the therapist and the team Therapy is modeled from the client up and from the team down, both being affected by the other Team works to keep the therapist in therapy with the client and the therapist works to keep the client in therapy Helps the therapist maintain balance in the therapeutic relationship Treating the Therapist(cont d) Balance can be achieved by getting closer to therapist which allows therapist to gain distance from client or move away from therapist which allow therapist to move closer to the client Provide a context for DBT, reminding the therapist of DBT principles or providing a dialectical balance to the individual, subjective viewpoint Regular attendance and a willingness to engage in open exploration of difficult situations through a non-defensive application of DBT principles Part education, part support, and part challenge to widen their perspective or balance their view Humility is a necessary ingredient for those who instruct today will be taught tomorrow, and those whose sight is clear now will discover their own blindness at some point Reminders to remain grounded and supportive 8

9 The Dialectical Therapist DBT holds in dialectical tension two different models of behavioral dysfunction: motivation versus capability (unwilling versus unable) Motivation affected by diverse factors, i.e., fear, guilt, shame, a reinforcement history that reinforced maladaptive responses, or dysfunctional beliefs Capability model asserts that clients do not have the necessary skills DBT works with clients to change motivation and provide them skills and new behavioral options Clinicians must attempt to change clients motivation while accepting the client as she is, regardless of level of skillfulness Middle Path between client s history and fear of being invalidated again and the client s own knowledge that change is necessary to end the misery Therapist can be in danger of invalidating client by either demands to change or acceptance of them as they are. Must do both simultaneously or quickly move from one to the other HELL IS TO DRIFT, HEAVEN IS TO STEER GEORGE BERNARD SHAW Affect Regulation Triangle 27 Therapist Self Regulation Co-Regulation Client Self Regulation 9

10 Hegel and Dialectical Materialism Within each beginning is necessarily found an endpoint, for the beginning is posited only on the assumption of some process that is unfolding toward an end; there is no beginning without an explicit reference to a process and conclusion. Steps of Self Regulation Stages Steps Tasks I. Creating a Context for Change Pause & Ponder Observe Describe Validate Acknowledgment II(A). Expand the Reality Create a New Possibility Turn the Mind Dialectical Thinking Pros & Cons II(B). Challenge Patterns Take Action Willingness Focus on Effectiveness Mindfulness Distress Tolerance Skills Opposite Action Network for Safety Interpersonal Skills III. Consolidation Take Notice Observe & Describe the Impact of Action Create New Meaning 29 5 Myths About DBT 1. If a client engages in self-harm behavior, all contact with the therapist stops for 24 hours. If a scheduled appointment is within 24 hours, (any mode), keep the appointment and use it for a chain analysis. 2. Chain Analysis was designed to be aversive. The analysis is a means of gathering information on the controlling variables around behaviors. The depth and clarity of chains allows them to be used to determine behavioral patterns and replace the dysfunctional ones with new behaviors 3. If the client is in Stage 1 DBT and is sexually assaulted, it is not dealt with until Stage 2 DBT. Focus on what is the most humane and respectful process and treat the assault. 4. Skills training is DBT. Absolutely no evidence that Skills Training alone is effective treatment. 5. It is alright for consultation teams to meet biweekly or once a month when structuring their DBT program 10

11 DBT STAGES OF TREATMENT 1. Increasing Capacities for Coping and Tolerance (includes pre-commitment strategies) i. Decreasing tissue-damaging behaviors ii. Decreasing therapy-interfering behaviors iii. Decreasing quality of life interfering behaviors iv. Increasing behavioral skills 2. Transforming Post-Traumatic Stress Disorder 3. Increasing Self Respect And Mastery While Achieving Individual Goals DBT and Affect Regulation Defines affect as emotion, brain and physiological changes, cognitions, environment( people and the world), and action urges Emotion is the core element of personality and is an evolutionarily important response and motivator in the interaction between person and environment Includes environmental stimuli, cognitive interpretations, facial expressions, action urges DBT helps clients to sharpen their capacity to attend to the environment, widen their attentional focus, discriminate between relevant and irrelevant stimuli, and improve the quality and variety of actions available To change the behavior is to change the emotion Affect Regulation (cont d) The dialectic in treatment is to have the client experience the emotion and to block the client s typical response patterns to that emotion (change strategies) Balanced with an acceptance of emotional experiencing modeled by the therapist, and with acceptance of the client s previous strategies to regulate their emotions as the best that they could do at the time While blocking the typical action patterns through contingencies, the therapist is also providing a warm, accepting environment to keep the client in treatment, and is directing behavior through skills training homework and phone strategizing (coaching) Resolution through the new behaviors coached by the therapist to improve adaptivity of response 11

12 Affect Regulation (cont d) Clients are moved slowly from attempts to rigidly control phenomena (internal and external), into a dialectical manner of interacting with the environment, developing patterns of emotional responding that are: a) Flexible b) More situation-person specific c) Maintains clients contact with environmental stimuli while they regulate and modulate their own emotional experience. Clients become better able to use information from the environment previously lost through poor attending and loss of control as clients withdrew or exploded while attempting to eliminate unwanted emotions Flexibility and environmental contact are necessary for a more dialectical lifestyle and fundamental for the development of long term adaptive interaction strategies Skills Training DBT modes: 1. Individual therapy to address motivation 2. Group skills training to address skills acquisition 3. Telephone consultation and coaching to address skills generalization 4. Supervision/consultation aimed at keeping therapists within the therapeutic frame and balancing clients behaviors that might pull them out of that frame Other modes of treatment Goal is to balance skills of accepting life and events as they are in the moment, with skills for changing oneself and the environment Skills Training Skills training groups developed because, despite the best intentions to train clients in skills that they desperately needed, individual therapy could not seem to get beyond dealing with the need to manage crises there was never a lull in the process into which skills training could be introduced. Groups are open as a way to model and to teach acceptance and accommodation of change Concept of acceptance of change now a part of individual therapy, and therapy is more focused on learning to deal with the natural fluctuations of events both within therapy and in their home environment 12

13 DBT SKILLS TRAINING GROUP Stage 1 Mindfulness Practice Diary Card Review Stage 2 Homework Review Lecture/Presentation Stage 3 Mindfulness Biosocial Theory 38 Biological Dysfunction in the Emotion Regulation System Invalidating Environment Pervasive Emotion Dysregulation Dialectics and BPD BPD and its accompanying emotional dysfunction, is the result of transactions between a constitutional vulnerability to emotional dysregulation, and an environment that is prone to invalidate the expression of private experiences, beliefs, and actions. DBT suggests that the individual and the environment are coactive in providing conditions for the development of the dysfunction. 13

14 Dialectics and BPD On the one hand, the individual elicits the environment that creates dysfunction, and, on the other hand, the environment exacerbates vulnerabilities that, in a more benign environment, might not have developed. Similar to Millon s biosocial learning theory of personality disorders, where patterns of interactions crystallize into personality. The Individual-Environment System Individual functioning and environmental conditions are mutually and continuously interactive, reciprocal, and interdependent. The environment and the individual adapt to and influence each other.in reality they cannot be distinguished. Linehan 1993 Emotional Vulnerability Enhanced Sensitivity Enhanced Reactivity Prolonged Activation 14

15 Overview of ERS Taught in the context of mindfulness skills Progression from mindfulness to distress tolerance skills to emotion regulation skills DTS target reducing maladaptive behavioral reactivity by building tolerance for emotions without evaluation or attempting to change or control emotions ERS target the reduction of emotional distress through exposure in a nonjudgmental atmosphere and with skills Invalidating Environments Characteristics of Invalidation Communication of private experience met with exaggerated, inappropriate, extreme response. Communication of private experience not validated, often punished and/or trivialized. Painful emotions and factors causing them are disregarded. The individual s interpretations of his/her behaviors and motivations for behaviors are dismissed. Tells the individual he/she is wrong in both the description and analysis of the experience particularly what is causing the emotion, belief or action. Attributes the experience to socially unacceptable characteristics or personality traits. Failure to live up to expectations brings disapproval, criticism, sarcasm, or attempts to change the individuals attitude. Invalidating Environments Consequences of Invalidation Individual does not learn to label private experiences and emotions in normative manner. Individual does not learn to modulate emotional arousal. If problems are not recognized, problem-solving skills are not learned. Extreme problems or emotional displays become necessary to provoke a response. Inhibition or extreme emotional states occur. Individual does not learn to tolerate distress or form realistic goals and expectations. Individual does not learn to trust his/her own emotional response. Self-invalidation and shame. 15

16 Middle Path Skills Dialectics Validation Behaviorism 47 The Middle Path The Middle Path is an alternative to the sort of thinking that becomes locked in extremes...rather than offer a compromise between such opposing views, the Middle Path posits that neither extreme represents reality. When one rejects attachment to the extreme, what remains is the true nature of things. 48 The Middle Path Therefore, the Middle Way is not a passive state of middle of the road thinking. Rather, while recognizing and rejecting limiting or biased views, it is an active state of developing the wisdom to perceive the true nature of things and to act accordingly. Daisaku Ikeda, contemporary Buddhist teacher 16

17 DIALECTICS 49 Everything is Transient and Finite Everything is Made Out of Opposing Forces Gradual Changes Lead to Turning Points Where One Force Overcomes the Other Change Moves in Spirals, Not Lines of Circles 49 Function of Validation Creates safety (verbal, emotional, physical and sexual) Establishes the environmental context for constructive, useful, effective behavior (verbal and nonverbal; with self and others) Enhances connections in relationships Teaches trust and helps it to evolve Strengthens empathy Generates feeling understood and supported Generates comfort through emphasis on naturalness of responses Generates encouragement and effectiveness VALIDATION Type 1: i. Finding the value and wisdom of the client s feelings, urges, thoughts, and actions ii. Looking for responses that have context specific validity iii. Providing a consistent source of validation 17

18 Validation (cont d) Type 2: i. Believing and noticing the client s capacity to exit states of suffering ii. Focusing on strength, not fragility iii. Believing and Believing In, the client Why Validate? Validate as Acceptance to Balance Change Validation to Teach Self-Validation Validation to Strengthen Clinical Progress Validation as Feedback Validation to Strengthen the Therapeutic Relationship The more a neural system is activated the more that system changes to reflect the pattern of activation This is the basis for development, memory and learning

19 Emphasize Practice! (vs. perfection) Behavioral Tech, LLC 55 Accepting Life As It Is In The Moment Mindfulness and Tolerance Mindfulness is the backbone of skills Core Skills and Distress Tolerance skills addresses observing and participating in one s environment so that one may collect accurate feedback and make predictions about consequences of actions. It is the segment of the dialectic that deals with planning actions and observing effects Trains clients to engage more fully and to observe more clearly and improve both by removing judgments, in order to interact more harmoniously and effectively with the environment Addresses the interplay between states of mind, and resolution involves moving to wise mind. Along with logic and emotion, wise mind includes other knowledge like intuitive mind(sensing) and trauma mind, intense emotional experiencing without containment, or a sense of power and control, and often without reality based context Five Facets of Mindfulness Practices Decreased reactivity to inner experiences 2. Increased capacity to remain present even with painful emotions and sensations 3. Increased capacity to react with awareness and intention 4. Increased capacity to describe/label with words 5. Non-judgmental of experiences 57 19

20 CORE MINDFULNESS SKILLS 58 What Skills - the doing Observe Describe Participate How Skills - the being Non-judgmental Effectiveness One thing at a time Trauma as a Certain psychiatric disorders can be conceptualized as state change disorders, in that a major patho-physiological component of the disorder comes from dysregulation of the state change process. Trauma disorders can be seen as problems in maintaining states relevant to context, and in smooth state shifting. 59 Frank Putnam (1994) 1. In normal development, state changes are co-regulated with changes in state becoming smoothed out over the course of development. -Putnam 2. States become traits: if the neurobiology of a specific response, Hyper-arousal or Dissociation, is activated long enough, there will be molecular, structural and functional changes in those systems. -Perry 60 20

21 61 Mind State Features Adaptive Functional Evolutionary Not Always Clearly Differentiated Mutual Possession 61 States of Mind 62 Rational Mind Emotion Mind Intuitive Mind Trauma Mind Wise Mind Dominated by reason, logic Dominated by emotional reactivity Perceptions in the absence of perceptible cues, non-verbal encoding and decoding. Extreme distress, high emotional reactivity, vacillating between hyper-arousal and numbness, negative self view, fight, flight and freeze Dominated by intrapersonal coherence and internal attunement of body, brain, mind and relationship. Safety, coherence and effectiveness. 62 STATES OF MIND PARADIGM THOUGHTS Sense Of Self URGES Emotion INTERNAL MODEL OF OTHERS AND THE WORLD BEHAVIORS Somatic Experiences 21

22 INTUITIVE MIND PARADIGM Observer Evaluator Ambiguous To Unsafe I have a gut feeling something s not right Anxious Curious On alert Increased Energy Uneasy Assess explicit cues Proceed with caution Effective fight or flight Distance Develop an action plan TRAUMA MIND PARADIGM I m bad Incompetent Dangerous Disconnected Out of Control I M SO STUPID BAD THINGS HAPPEN BECAUSE I M BAD Fear Helplessness Shame NAUSEAUS SHAKY CUT HIDE SEXING Binge Overmedicate Sleep WISE MIND PARADIGM Negotiable Neither self nor others are less than human Integrated Present in the moment Balancing Internal locus of control Anger I need to create a pause and bring the anger down Warm Increased heart rate Focus on safety and effectiveness 66 Self-observing Assessing Needs Enact a goaldriven action plan 22

23 Distress Tolerance Crisis Survival Strategiestolerating short term pain (doing) Guidelines for Accepting Reality -tolerating long term pain(being) 67 Behavioral Tech, LLC Distress Tolerance 68 The Doing Improve the Moment Self-soothing Distractions The Being Turning the Mind Willingness over Willfulness Radical acknowledgement/acceptance Addressing Deficits in Capacity to Regulate Self and Environment Interpersonal effectiveness skills address capacity to interact effectively with environment and increase probability of positive reinforcement. Other skill sets needed to ensure successful application of interpersonal skills. Interpersonal skills to be advanced only as quickly as the other skills improve Emotion regulation skills are taught as a means of regulating emotional responses through identifying and labeling emotions, decreasing emotional vulnerability through self-care, increasing pleasure, and regulation of emotional responses through opposite action. 23

24 Situations for Interpersonal Effectiveness Attending to Relationships Balancing Priorities vs. Demands Balancing the Wants-to-Shoulds Building Mastery and Self-Respect Behavioral Tech, LLC 70 Emotion Regulation Goals of Emotion Regulation Module Understand emotions Reduce emotional vulnerability Decrease emotional suffering Change by acting opposite to painful emotions Behavioral Tech, LLC 71 The DBT Model of Emotion Teaching clients about emotions and emotion regulation is a necessity and requires some definition of emotion. Emotions are complex, brief, involuntary, patterned, fullsystem responses to internal and external stimuli. Patterned actions associated with emotional responses are part of the emotional response rather than consequences of the emotion. Viewed as a sequence interrelated, synchronized changes in the states of all organismic subsystems Modifying any component of the emotional system is likely to change the functioning of the entire system 24

25 Five Subsystems of Emotions Emotional Vulnerability to Cues Internal and external events that serve as emotional cues, including attention to and appraisals of the cues Emotional responses: physiological, cognitive, experiential, and action urges Nonverbal and verbal expressive responses and actions Aftereffects of the initial emotional firing including secondary emotions DIARY CARD DATES NAME DAY DESRIBE THE TRIGGER SITUATION FEELING & INTENSITY URGE DBT SKILL NAME: RATE (SEE BELOW) WHAT YOU DID? AFTERMATH: DISTRESS LEVEL 0-10 IMMEDIATE 1 HOUR RATING SCALE 0 - DIDN T THINK ABOUT OR USE 1 - THOUGHT ABOUT; DIDN T USE BECAUSE DIDN T WANT TO 2 - THOUGHT ABOUT; DIDN T USE BUT WANTED TO 3 - TRIED; BUT COULDN T USE 4 - TRIED; COULD USE BUT DIDN T HELP 5 - TRIED; COULD USE; HELPFUL 74 Behavioral Analysis Checklist 1. T helps C define the problem Choose a focus Formulate the problem in terms of behavior Describe the problem behavior specifically, i.e., frequency, duration, intensity, topography T weaves validation throughout 2. T (and C) conduct a Chain Analysis T and P select one instance of problem to analyze T attends to small units of behavior with attention to defining the behaviors beginning, middle and end, in terms of emotion, bodily sensations, thoughts, images, overt behaviors, and environmental stressors, overt behaviors and environmental stressors Conduct in session analysis T maintains C s. and owns, cooperation T helps C monitor her behavior between sessions, diary cards are essential 3. T generates hypotheses with C about variables influencing or controlling behaviors in question T and C use the results of previous analyses to guide the current one T is guided by DBT theory Anti-DBT Tactics T colludes with C in avoiding behavioral analysis or targeted behaviors T unduly biases information gathering to prove T s own theory of C s behavior 25

26 Behavior Analysis 76 Basic Treatment Strategies Strategies - Both a plan of action and finesse in carrying out the plan Dialectical Strategies- pervasive, inform the entire treatment Core Strategies-problem solving and validation Stylistic Strategies- compatible interpersonal and communication styles Case Management Strategies-how the therapist interacts with and responds to the client s social network Treatment Strategies Keeping the client off balance Entering the paradox Using metaphors Making lemonade out of lemons Allowing for natural change Extending Activating Wise Mind 26

27 Summary Points Understanding and application of dialectics to treatment process continues to evolve in DBT Dialectics guides the therapist s actions and inquiry Dialectics furthers the process of behavioral change No therapist without a client, no beginning of treatment without end goals, no theory devoid of practice Therapists are consistently engaged in some dialectical process, operating out of some theory of behavior change, responding to client responses generated by past interventions in determining the next move A focus on dialectics shifts attention to the process occurring rather than to the endpoint toward which one is moving Behavioral Tech, LLC 80 27