Dialectical Behavior Therapy Cutting, Substance Abuse, and Suicidal Ideation Ontario Psychological Association Annual Conference October 22, 2016

Transcription

1 Dialectical Behavior Therapy Cutting, Substance Abuse, and Suicidal Ideation Ontario Psychological Association Annual Conference October 22, 2016 Amanda A. Uliaszek, Ph.D., C.Psych Departments of Psychology and Psychological Clinical Science University of Toronto Scarborough

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3 Workshop Objectives What are your objectives for the next two hours? Examine common triggers and maintenance factors of non-suicidal self-injury (NSSI), substance abuse (SA), and suicidal ideation (SI) Review the basic tenets and components of dialectical behavior therapy (DBT) Learn and practice techniques to use with clients experiencing these symptoms.

4 Workshop Agenda 1. Review of the fundamentals of NSSI, SA, and SI as treatment targets. 1. Experiential exercises 2. Explore how DBT is an ideal treatment to address these targets 1. Practice therapeutic tools 3. Review the Distress Tolerance skills

5 Case of Mark Mark is a 23-year old male client who comes to your facility complaining of feelings of depression and amotivation. He describes feeling down and restless most of the time, having a short temper with friends and family, and being unable to perform at work. He describes difficulty sleeping and low appetite, as well as problems concentrating. He uses marijuana and alcohol to help him sleep and describes burning himself with cigarettes just to feel something. He knows that if things don t get better he can always kill himself to end the pain. He is desperate to feel happier and get along better with his family. He is also worried about losing his job. He says that the marijuana and alcohol use are a huge help to him and that the burning is no big deal just a stupid thing he does sometimes when he can t sleep and his thoughts are racing.

6 Case of Mark Mark is a 23-year old male client who comes to your facility complaining of feelings of depression and amotivation. He describes feeling down and restless most of the time, having a short temper with friends and family, and being unable to perform at work. He describes difficulty sleeping and low appetite, as well as problems concentrating. He uses marijuana and alcohol to help him sleep and describes burning himself with cigarettes just to feel something. He knows that if things don t get better he can always kill himself to end the pain. He is desperate to feel happier and get along better with his family. He is also worried about losing his job. He says that the marijuana and alcohol use are a huge help to him and that the burning is no big deal just a stupid thing he does sometimes when he can t sleep and his thoughts are racing.

7 Brief Descriptions NSSI (aka self-harm) Cutting Burning Hitting Head banging Scratching Hair pulling Substance Abuse Alcohol Illicit drugs Prescriptive drugs OTC drugs Other substances (i.e., huffing) Suicidal Ideation Suicidal thoughts Suicidal threats Suicidal planning Suicide attempts

8 NSSI-SA-SI Clients often do not want to work on these issues Positive consequences Shame Biological effects Hopelessness Clinicians may avoid these topics Hopeless Want to avoid conflict Fear Stuck

9 Stuck? Think about a client with whom you feel particularly stuck. Imagine your last interaction with that client. What feelings are you feeling? What thoughts are you having? What are your urges? What do you do?

10 Stuck? Month 1: You attempt to target the NSSI/SA/SI in session. Mark continues to insist they aren t a big deal and there are more important things to talk about. He gets angry. Month 3: Mark has started to show improvement in his mood and his work performance. You ask about the marijuana/alcohol use and find it has worsened. Mark insists he needs it to sleep and to function and refuses to commit to change this behavior. Month 6: Mark has a major fight with his girlfriend and gets drunk and burns himself at night. He tells her he ll kill himself if she leaves. He tells you about this, but insists it s a one time thing.

11 Misconceptions Common misconceptions about NSSI It s for attention Most commonly done in secret and associated with a high degree of shame It doesn t make any sense We can directly map the antecedent and consequences It s for self punishment Neurological evidence suggests it is for emotion regulation

12 Misconceptions Common misconceptions about SA Ingesting any substance is bad There may be healthy and adaptive ways to utilize substances Abstinence may not always be possible 100% of the time SA is just evidence of a deep-rooted problem Reducing SA can actually help more pervasive emotion dysregulation difficulties

13 Misconceptions Common misconception about SI Suicidal people want to die Suicide is a problem with living, not a problem with dying

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15 Emotion Dysregulation Difficulty using adaptive emotion regulation strategies Problem-solve Reappraisal Physiological interventions Frequently uses maladaptive emotion regulation strategies Rumination/Worry Suppression/Avoidance Impulsive behavior Physiological interventions

16 Tying it All Together: Emotion Dysregulation Emotion Dysregulation Entrenched Impulsive Behavior Patterns

17 Negative Reinforcement Schedule SELF-HARM SUBSTANCE ABUSE SUICIDAL IDEATION EMOTION EMOTION

18 Remember Mark? Anxiety worrying he will be tired for work Smokes marijuana Relaxes and falls asleep Angry and upset that his girlfriend broke up with him Burns himself with a cigarette Feels more calm Feels sad and hopeless about his current situation Fantasizes about committing suicide Feels relief that there is a way out

19 Emotion dysregulation as the common vulnerability across behavioral/cognitive dysregulation So what do we do now?

20 So far So far we ve learned 1. A challenge to treating NSSI/SA/SI is getting clients on board to target these issues (getting unstuck) 2. We must identify the components in the emotion dysregulation-entrenched impulsive behavior cycle to target these issues 3. We need to replace these behaviors with more adaptive behaviors DBT MAY BE THE ANSWER

21 Dialectical Behavior Therapy (DBT) Originally developed to by Marsha Linehan to treat suicidality (Linehan, 1993) Now considered a treatment for Emotion Dysregulation (Linehan, 2015)

22 A CBT Adaptation Mindfulness Dialectical philosophy Radical behaviorism Skills training

23 Mindfulness Mindfulness is an intentional focus and non-judgmental observation of the present moment Increases focus and awareness Calming/soothing effect Better control over actions and decision-making Helps identify thoughts and emotions Present moment focus

24 Dialectical Philosophy Two things that seem like (or are) opposites can both be true. Emphasis on holism and synthesis Acceptance and Change

25 Dialectics Emphasis on synthesis Movement, speed, and flow Remember both sides contain and kernel of truth Clients and therapists can get stuck and one side of a dialectical dilemma

26 Evidence that you are stuck Frustration Feeling stuck Hopeless Impatient Wanting to quit Rigidity Having judgments

27 Dialectical Strategies Both, and approach Try asking, what is being left out? Examples Entering the Paradox: highlight the paradoxical contradictions of life Devil s Advocate: Argue in favor of the irrational belief or behavior Extending: Take the client more seriously than s/he takes her/himself Making Lemonade out of Lemons: Use dysfunctional behavior as a learning opportunity

28 Remember Mark? Anxiety worrying he will be tired for work Smokes marijuana Relaxes and falls asleep

29 The typical situation in which I feel stuck is My client continues to drink/use marijuana daily and refuses to recognize it as a problem. He says he needs it to sleep, but I believe it is a maladaptive coping mechanisms that is causing health and financial problems. When I bring it up he gets angry and will often shut down for the rest of the session.

30 When this happens, my client will typically say I don t understand why you can t leave me alone about it. I m not dependent on it and it is actually good for me in that I can get to sleep easier and don t find myself worrying all through the night. It s basically the same as taking Prozac so what s the difference. What are you my mother now telling me to just say no

31 Entering the paradox Your life is hard and drinking/drug use helps, and I m asking you to stop. It s one of those times in life you re asked to do something difficult. I care about you and I m asking you to do something that will be extremely difficult.

32 Devil s advocate Maybe you re right it does seem to be helping you sleep and to not worry. It s probably not worth the extra effort of learning how to relax and dispel worries just using your own mind and skills. That would probably be too hard anyway. You definitely need drugs and alcohol in order to function.

33 Extending Maybe alcohol/marijuana should be treated like a prescription. I can start recommending it to more of my clients. I have several teens and single moms that have trouble falling asleep. Drinking/drugs would be good for them as well why not?

34 Making lemonade out of lemons Frankly I m glad that you feel you need drugs and alcohol in order to function. It is a great opportunity for us to practice some of the skills and see if they can work even better than drugs or alcohol. And if not, at least you know something that works for you and you can go right back. What do you say trying a mindfulness exercise before sleep tonight to see if that works?

35 Radical Behaviorism Learning/behaviorism takes place continuously and should be capitalized on during session. You should identify the problem behavior, antecedents and consequences

36 Radical Behaviorism Dialectic between individualistic and common antecedents and consequences Necessary to probe for most problem behaviors

37 Examining Triggers and Consequences of NSSI, SA, and SI Chain analysis (Linehan, 2015) Way to understand behavior Way to change behavior Links in the Chain Vulnerability factors Prompting event Links Problem behavior Consequences

38 Chain analysis: Setting the stage Rationale for examining antecedents and consequences Draw link between maintained behaviors and antecedents/consequences Can be extra helpful to impulsive and/or emotionally labile clients You said that sometimes you act/feel really impulsively/badly/strongly and you don t even know why Rationale for drawing the chain analysis Easier to see all of the parts Easier to remember the details Something to take home or refer back to Do an easy example Builds confidence in process Pull an example from your own life or from something they ve told you

39 Steps to a Chain Analysis 1. Identify problem behavior: 2. Describe the prompting event 3. Identify vulnerability factors 4. All links in the chain (thoughts, emotions, behaviors, physiology, events) 5. Describe consequences

40 Remember Mark? Angry and upset that his girlfriend broke up with him Burns himself with a cigarette Feels more calm

41 Links in the Chain Vulnerability Factors Consequences Prompting event Links Problem Behavior Has not slept well in days; Was suicidal after last breakup Feels sad; Calls exgirlfriend She tells him to never call her again Anger Does three shots of whiskey Racing negative thoughts Burns self Thoughts quiet Feels calm Watches tv/falls asleep

42 Pros and cons of calling Solution Analysis Go for a run Mindfulness exercise 24 calling ban Has not slept well in days; Was suicidal after last breakup Feels sad; Calls exgirlfriend She tells him to never call her again Anger Does three shots of whiskey Racing negative thoughts Burns self Thoughts quiet Feels calm Watches tv/falls asleep Call therapist Ice bath

43 Chain/Solution Analysis: Mark Feels sad and hopeless about his current situation Fantasizes about committing suicide Feels relief that there is a way out 1. Problem behavior: Fantasizes about jumping in front of GO train and how his friends and ex-girlfriend will react when they hear the news 2. Prompting event: Sees on Facebook that his girlfriend is having fun with friends 3. Vulnerability: Recent break up with girlfriend; alcohol use throughout the day

44 Links and Consequences Links She s moved on I m worthless Sadness and anger Starts to look up all his ex-girlfriends and friends Everyone s life is better than mine; no one even cares if I live or die *Suicidal fantasies* Consequences At least all this pain would be over and people would actually care about me Feels satisfied and more calm

45 Links and Consequences Links She s moved on I m worthless Sadness and anger Starts to look up all his ex-girlfriends and friends Everyone s life is better than mine; no one even cares if I live or die *Suicidal fantasies* Consequences At least all this pain would be over and people would actually care about me Solutions Opposite action/behavioral activiation Seek out a friend or therapist for support Check the facts Improve the moment with positive imagery Contribute Feels satisfied and more calm

46 Chain Analysis: Troubleshooting I don t feel like doing this Validate Remind client of agreed upon targets and explain that this is an effective way for many people to address problem Ask if there is another way to do this that would be helpful I can t remember anything Validate Ask if this is consistently a problem, then talk about increasing mindfulness Troubleshoot a way for the client to write down important events in the moment (like on a diary card) Don t back off right away (this is reinforcing) do the chain anyway.

47 Troubleshooting cont None of these solutions will work Validate Reassess commitment and motivation Make a deal for the client to try something out and then agree to change course when it doesn t work Agree that not all strategies work all of the time, but practicing skills will usually help in the long term

48 Solutions: DBT Skills Provides a protocol for teaching skills Mindfulness Interpersonal Effectiveness Emotion Regulation Distress Tolerance Homework provides a format for practicing skills A focus on validation increases reinforcement Motivation is increased through examination of long term consequences

49 DBT Skills Mindfulness What skills How skills Wise Mind Skillful Means Emotion Regulation Labeling emotions Check the facts Opposite action Problem solving Accumulate positive emotions Build mastery Cope ahead PLEASE Mindfulness of current emotions Skills breakdown point Distress Tolerance STOP Pros and Cons TIP ACCEPTS Self-soothing IMPROVE Radical acceptance Turning the mind Willingness Half smile Willing hands Mindfulness of thoughts Interpersonal Effectiveness Clarifying priorities DEAR MAN GIVE FAST Asking for something/saying no Mindfulness of others How to end relationships Dialectics Validation Behavior change strategies

50 Distress Tolerance Notion that one cannot stand or accept the presence of extreme emotions Used when clients are in a crisis (i.e., a problem they cannot solve) and have the urge to use maladaptive coping They should not be overused as they typically represent temporary solutions Distress tolerance skills allow time to reduce emotional intensity without making the problem worse Once emotions are down-regulated, emotion regulation or interpersonal effectiveness strategies can be employed if necessary

51 STOP! Stop Take a step back Observe Proceed mindfully

52 TIP These skills TIP your body chemistry Cons Similar physiological effects at reducing emotional arousal as medications, selfharm, and drugs Increase activity in the parasympathetic nervous system Effect is immediate and requires little thinking Experiential avoidance Temperature Intense exercise Paced breathing Paired muscle relaxation

53 Temperature Tipping the temperature of your face or body with cold water or ice Ice packs or an water/ice bowl on the face while holding breath will activate dive reflex Squeezing ice will simulate self-harm without the problem of tissue damage, scarring, and shame Dive reflex: Mammalian response for the heart rate to slow down when immersed in cold water without oxygen. This increases activation of the parasympathetic nervous system.

54 Intense exercise Intense aerobic exercise for 20 minutes Addresses fight-or-flight using appropriate coping Significant research demonstrating a reduction in rumination and an increase in positive affect during and after exercise 70% of target heart rate = reduction in anxiety 55-70% of target hear rate = increase in positive affect Have participants look up their target heart rate and download a heart rate app on their phone (if possible)

55 Paced Breathing/PMR Paced breathing Slowing to 5-6 breath cycles per minute, with exhale longer (i.e., 4 second inhale, 8 second exhale) Paired muscle relaxation Progressive muscle relaxation with paired breathing

56 Distracting Skills Activities Contribute Comparisons Emotions Pushing away Thoughts Sensations

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59 Improve the moment Imagery Meaning Prayer Relaxation One mindfully Vacation Encouragement

60 Inspirational Quotes You cannot protect yourself from sadness without protecting yourself from happiness The one thing you can t take away from me is the way I choose to respond to what you do to me. The last of one s freedoms is to choose one s attitude in any given circumstance. If there is meaning in life at all, then there must be meaning in suffering

61 Radical Acceptance Complete and total openness and awareness to facts as they are in this moment Use this when life has dealt you a major trauma or difficulty Acceptance is not agreement Just this one moment

62 Radical Acceptance What do we have to accept? Reality is what it is Everyone has limitations Everything has a cause and effect Life can be worth living even if it causes pain

63 Radical Acceptance Why do it? Rejecting or denying reality doesn t change reality Changing first requires acceptance Pain cannot be avoided Rejecting reality turns pain into suffering Suffering Pain

64 Mindfulness of Current Emotion Observing and describing emotions without trying to inhibit them, block them, or distract from them Why do it? Emotions cannot hurt you Emotions cannot last forever Freedom from controlling Reduce their intensity and the likelihood of return When we experientially avoid through self-harm, the same emotions are likely to return again and again

65 Exercises Experience emotion as a wave Opening your heart Pay attention to body sensations This too shall pass

66 Important Tips Regarding Skill Use Learning Practice Reinforcement Motivation

67 Thank you for your attention and focus I m happy to answer questions now and through future correspondence: Amanda A. Uliaszek, Ph.D., C.Psych Assistant Professor: University of Toronto Scarborough auliaszek@utsc.utoronto.ca Clinical Psychologist: Evidence Based Therapy Training and Testing (EBT 3 ) Dr.uliaszek@ebt3.com