Behavioral Principles in DBT

Transcription

1 Behavioral Principles in DBT Michele Galietta, Ph.D. Associate Professor John Jay College of Criminal Justice DBT is Compassionate Behaviorism VALIDATION-Review

2 Validation Conveying to person that they/their problems are worthy of their attention Communicating that which makes sense/is accurate or is true about their perspective, behavior What Can Validation Do? Regulates client emotions Keeps clients from shutting down or attacking Shows the client that you are attentive, caring and non-judgmental Improves clients willingness to engage in problem solving possible Builds/maintains the relationship Builds credibility/relationship to be directive when you need to Models effective communication Validation Is not always warm and fuzzy Is not the same thing as praise Is not the same thing as reinforcement (although it can be reinforcing to be validated) Does not require that you agree with the other person Is in the eye of the beholder

3 Levels of Validation V1: V2: V3: V4: Being awake to the communication of the client (listening, communicating that you hear and understand) Accurately reflecting what you have been told. Restating without parroting. Stating the unarticulated. Mind reading what the client is not saying. State as a question and be willing to be wrong. Validating through the client s personal history or biology. Behavior is understandable given what the client has experienced in his/her life and/or because of his/her physiology. Levels of Validation V5: Normalizing the client s behavior. The client s responses are what anyone would experience. V6: Radical Genuineness. Use a manner and tone that is not condescending, fragilizing or rule bound. Respond to the client as you would anyone else. Behaviorism The only way to make the tea is to make the tea (not just talk about it)

4 Chain Vulnerabilities Proximal or Distal Prompting Event Links PROBLEM BEHAVIOR Consequences Negative and Positive Immediate and Delayed Context Consequence Respondent Operant Types of Behavioral Strategies Part of Standard CBT Toolkit Psychoeducation & Didactic Strategies Teaching Skills Contingency Management Cognitive Strategies (changing thinking patterns) Exposure & Behavioral Activation Excellent resource is Farmer & Chapman s Behavioral Interventions in Cognitive Behavior Therapy Didactic Strategies DBT is a transparent treatment We educate about biology/diagnosis, behavioral behavioral principles, current literature, whatever might be helpful Sharing information increases knowledge of normative behavior Share what you know and also how to solve problems when you do not know Actively teach problem solving steps

5 Understanding Behavior: The Definitions Reinforcement: anything that increases the probability of a behavior occurring Positive: addition of something after the behavior (praise) Negative: taking away of something unwanted (get out of going to school) Punishment: anything that decreases the probability of a behavior occurring Positive: Adding an aversive (having to do chores) Negative: Taking away something positive (Play Station) Extinction: reducing behavior by stopping what is maintaining the behavior (attention to it) Shaping: reinforcing gradual approximations of the behavior Contingency Management REINFORCEMENT-something that occurs after the behavior and increases its frequency. Positive Reinforcement-Giving a child something pleasurable for that child. ex. Praise, Pokemon Card Negative Reinforcement-You remove something unpleasant. Ex. take away sibling interfering with their play Reinforcement a few important ideas WHAT is reinforcing? Reinforcers are unique to person (though some common) Change with developmental stage of child and child s preferences Natural vs. arbitrary-natural preferable Watch for satiation (too much of a reinforcer- ceases to have value)

6 Timing is EVERYTHING! Immediate vs. Delayed-Timing is KEY Immediate most powerful Continuous vs. Intermittent Reinforce every time when teaching, then move to intermittent Random intermittent reinforcement this is your enemy if you give in to whining or crying b/c it rewards whining and increases the intensity Punishment Punishment is providing an unpleasant consequence following the behavior (shoot unpleasant look, take away TV) Last resort Only effective at reducing behavior when punisher present Does not teach new skills Can set off negative emotions Can weaken relationship, especially if punitive Guidelines for Effective PUNISHMENT Apply immediately after behavior. Be firm enough to work but not more than necessary. Be consistent. Best to use without punitive attitude. Right Heart

7 SHAPING-rewarding small approximations of a behavior, used for teaching new behavior EXTINCTION-removing reinforcers of a behavior makes it go away, note that there will be increase before goes down-be prepared to tolerate it Practice: Shaping Game. Excellent Resource: Malott s Principles of Behavior Cognitive Strategies: Restructuring Train clients to observe their thoughts Identify and change dysfunctional thoughts (not valid, lead to ineffective behaviors) Teaching clients to generate effective thoughts Helping client to develop strategies for using observational information Contingency Clarification Teaching clients to anticipate and weigh consequences (If you do this, then ) Self-involving self-disclosure When you do this, it makes me want to

8 Self-disclosure Orienting Patient Self-Involving Self-disclosure Personal Self-Disclosure as Modeling Seek Supervision; must be in client s best interest Observing Limits Monitor limits. Be honest about limits. Extend limits... Temporarily. Be consistent and firm. Soothe, validate and problem solve around unwelcome limits. Exposure Used in DBT informally in stage 1 To treat emotional avoidance that negatively impacts treatment (e.g. shame) or causes problems in their life To treat avoidance of chains To decrease avoidance in group Formal protocols for social anxiety, phobia (e.g. needle phobia) may be used in stage 1 when appropriate to target Formal Exposure used in stage 2 DBT-PE (Harned) Formal Exposure requires training and supervision Used to treat PTSD responses

9 Informal Exposure Orient the client to what exposure is and how it is effective Do not withdraw cue when it appears, if necessary present cue again (rewind in session) Keep the cue present while blocking action to avoid/end the cue Keep the cue present until SUD s come down significantly, or an agreed upon time has passed Once SUD s decrease or the agreed time has passed, allow the client to end or teach him/her how to stop the experiencing (soothe) Exposure examples 1. While doing a chain, you notice client avert gaze and look to floor (you suspect shame). Ask client to say previous statement while looking at you 2. While client is retelling you part of chain, they begin to hyperventilate and experience panic. Explain purpose of retelling, say you will spend three minutes on this statement or image. Have them rate fear, and continue to repeat statement while looking at you (block avoidance) for 3 min. Remember to Balance Communication Strategies Collaborative (when all is going well) Frank, Direct and Irreverent (when necessary) Switching provides balance

10 Stylistic Strategies: Communication Irreverence A style characterized by calling a spade a spade, as well as using humor, sarcasm, or confrontation Functions to get attention Reframing the client s communication in an unorthodox, offbeat manner Plunging in where angels fear to tread Using a confrontational tone Calling the client s bluff Oscillating intensity Expressing omnipotence and impotence Protocol for TIB (Treatment-Interfering Behaviors) Identify behavior as problem that is getting in the way of progress Do BA on behaviors Problem solve Connect to initial commitment Connect to their goals Validate difficulty (pain, annoyance), but not behavior Applying Contingencies (Consequences) to Change Behavior Reinforce adaptive behaviors. Add positive consequences. Remove negative consequences. Extinguish maladaptive behaviors. Remove or fade reinforcers of problem behaviors. Punish maladaptive behaviors. Add negative consequences sufficient to lead to suppression of problem behaviors.

11 Use Aversive Contingencies when Nothing Else Works or the Behavior is Destroying (the milieu, other patients, staff, etc.). Using Aversive Consequences - Carefully When to use Aversive Consequences: There is no desired/adaptive behavior to reinforce The problem-behavior is significant enough to be worth it Order of Aversive Consequences in DBT Withdrawal of warmth/disapproval Response consequences Repair/Correction-Over-correction Therapy Vacation (very rare) Therapy Termination (almost never) To effectively apply contingencies, staff must regulate their own emotions

12 The What Skills 1. Pause, stop or slow down 2. Observe: notice without words 3. Describe: put labels on the experience without adding 4. Participate: fully engage without self-consciousness These skills are linear with Participation as the goal. The How Skills 1. Non-judgmentally: let go of evaluating 2. One-Mindfully: focus attention on the present moment, doing one thing at a time 3. Effectively: focus on doing what needs to be done, despite the principle or what you think is fair or unfair These skills are designed to be used with all of the mindfulness skills. Behaviorism in The Milieu-REVIEW Purpose is Structuring Environment Teaching Takes place in context of VALIDATION

13 Targets for Line Staff 1. Stop or reduce imminent life-threatening behaviors 2. Stop or reduce program-destroying behaviors 3. Increase generalization of skills to the natural environment (Coach) 4. Improve motivation of clients 5. Improve relationships with staff The role of Lead and Line Staff on DBT Units Lead manages the milieu This means managing front line staff Setting validating tone Making sure schedule RUNS Making sure behavioral principles functioning Making Sure Egregious Behavior Protocol is being done Essential Parts of DBT Milieu Level system is responsive to behavior Incentives present and responsive to behavior Structure (morning meetings, skills practice, mindfulness) Coaching (de-escalating using SPECIFIC language) Coaching to increase skills Non-reinforcement of crisis behaviors/maladaptive behaviors Validation

14 The Purpose of Egregious Behavior Protocol Decrease therapy destroying behaviors Decrease reinforcement of extreme problematic behaviors Decrease contagion of problem behaviors Decrease burn-out of staff (and other Clients) Treatment: Insight Mildly aversive consequence, paired with new learning Egregious Behavior Protocol Client is removed from all activities on the unit, e.g. removal from group, room restriction, removal from structured program in milieu, pass restriction. Client completes a chain analysis of the problem behavior. This can be completed via form or in person, depending upon the skill level of the client. If it is completed with a person, the staff member who is completing the chain should be a person who is NOT reinforcing to the client. Client determines what harm was done to the unit, the staff, other clients, him/herself. Egregious Behavior Protocol (continued) Client decides how to correct/repair for the harm done. This should be directly related to the harm done. Client decides how he/she will overcorrect/over-repair for the harm. This should also be specifically related to the harm. Client reviews plan of correction/overcorrection with unit, team and/or community. Client begins plan of correction/overcorrection. Client returns to unit activities/group.