1. Prof. Amany Haroun El Rasheed
Ain Shams Univ., Cairo, Egypt
M.N.P., D.P.P., M.D.
Master in Mental Hygiene (Johns Hopkins Univ.)
Fellowship in Substance Abuse Treatment & Prevention (Johns
Hopkins Univ.)
APA Membership
FRC Psych
WPA Fellowship
ISAM Membership

2. BPD Can Be Fatal
 Among SUICIDES
40-65% have PD
 Among PD’s
BPD is most associated with suicidal
behavior
 Among BPD
8-10% commit suicide
Up to 75% attempt suicide
60-80% self-mutilate

3. Before You Start
~~~
Decide What
Treatment Your Patients
Will Need

4. Treatments for BPD
- DBT
- Transference-focused Therapy
- Mentalization-based Therapy (MBT)
- Good Psychiatric Management (GPM)
- Pharmacotherapy

5. One Year Health Care Costs Per Patient
DBT TAU
Individual Psychotherapy $3,885 $2,915
Group Psychotherapy $1,514 $ 147
Day Treatment $ 10 $ 876
Emergency Room Visits $ 226 $ 569
Psychiatric Inpatient Day $2,612 $12,079
Medical Inpatient Days $ 360 $1,096
Total $8,607 $17,682

6. Theory of
Borderline
Personality Disorder
in DBT

7. Biosocial Theory of BPD
Biological Dysfunction in the
Emotion Regulation System
Invalidating Environment
Pervasive Emotion Dysregulation

8. Biosocial Therapy of BPD
A. Biological Vulnerability
Patients born with greater emotional
sensitivity.
B. Environmental Vulnerability
Patients grow up in families that fail to
validate private experience.

9. Biosocial Therapy of BPD
C. Biology interacts with Environment and
produces dysfunction
Emotional dysregulation
Cognitive dysregulation
Behavioral dysregulation
Interpersonal dysregulation
Identity dysregulation

10. Development of BPD
Linehan’s Biosocial Theory
BPD individuals grow up in invalidating environments
 their emotions and struggles get
trivialized, disregarded, ignored, or punished (even when
normal)
 non-extreme efforts to get help get ignored
 only extreme communications/behaviors taken seriously
 sexual abuse
Why?
 parents are cruel (invalidated or abused as children)
 low empathy and skill: don’t understand child’s struggle

11. Development of BPD
Linehan’s Biosocial Theory
 BPD individuals learn to invalidate themselves
 intolerant of their own emotions and struggles
(punish, suppress, and judge their emotions, even
when normal)
 They easily “feel invalidated” by others
 They still influence others via extreme behaviors
 self-injury/suicidality to get help
 aggression, self-injury, and suicidality to get others
to back off

12. Theory of BPD
Core Problem: Emotion Dysregulation
• pervasive problem with emotions
• high sensitivity/reactivity (i.e., easily
triggered)
• high emotional intensity
• slow recovery (return to baseline)
• inability to change emotions

13. Theory of BPD
Core Problem: Emotion Dysregulation
• inability to tolerate emotions (emotion phobia)
– vicious circle (upward spiral)
– desperate attempts to escape emotions
– inhibited grieving
– history of invalidation for emotions
– self-invalidation and shame
• inability to control behaviors (when emotional)

14. Theory of BPD
Core Problem: Avoidance
 Denial of problems (avoiding feedback)
 Non-assertiveness and social avoidance
 Drug and alcohol abuse
 Self-injury, suicide attempts , and suicide
 Self-punishment, self-criticism (block emotions)
 Dissociation and emotional numbing
 Anger to block other (more painful) emotions
 Anger to divert away from sensitive interactions
 Hospitalization to escape stressful circumstances

15. A little about DBT . . .
 DBT is a combination of Cognitive Behavior
Therapy and Eastern meditative practices.
 Seven well-controlled randomized clinical
trials with varying research teams have
established DBT as a valid and effective
treatment for Borderline Personality Disorder.

16. A little about DBT . . .
 Several studies have been launched to
substantiate this use of DBT in non-borderline
groups. For instance, DBT has had several
controlled studies and been found effective in
treating eating disorders, and substance abuse
disorders.
 The concept of mindfulness is one of the
primary Eastern meditative aspects of DBT
and has become quite popular in many
realms, not just as a psychotherapy treatment
modality.

17. A Definition of Dialectics
“…debate intended to resolve a conflict between
two contradictory or apparently contradictory
ideas or elements logically, establishing truths
on both sides rather than disproving one
argument.”
Encarta World Dictionary, 1993-2003

18. “Dialect”
 Many meanings
 Accept patient
where they are while
also accepting the
need for change
 Help patients move
from rigid to more
flexible thinking

19. Dialectics as Persuasion
A method of logic or argumentation
by disclosing the contradictions
(antithesis) in an opponent’s
argument (thesis) and overcoming
them (synthesis).

20. The Central Dialectic
Acceptance and Change
 BPD clients often feel invalidated when:
 others focus on change (they feel blamed), but also
insist that their pain ends NOW
 others try to get them to tolerate and accept
 BPD clients need to
 build a better life and accept life as it is
 feel better and tolerate emotions better
 Only striving for change is doomed to fail
 blocking emotions perpetuates suffering
 disappointed when change is too slow

21. DBT Balances:
Standard behavior therapy techniques to induce change
vs.
Acceptance strategies to promote the therapeutic
alliance and keep patients in treatment

22. DBT Balances:
Skills Acquisition: teaching new behaviors
vs.
Validating and Reinforcing existing adaptive
behaviors

23. Radical Acceptance
 Acceptance of reality as is.
 Acceptance is complete and comes from deep
within
 Emotional/physical pain + nonacceptance =
suffering
 Let go and stop fighting reality
 Letting go transforms unbearable suffering into
more ordinary pain, which is part of life
 Turning the Mind implies that acceptance is an
active choice and requires an inner commitment

24. Balance Core Strategies
VALIDATION
Dialectics

25. Dialectical Behavior Therapy
An Overview

26. How is DBT different than Cognitive
Behavioral Therapy?
 Focus on the dialectical processes
 Focus on acceptance and validation
 Emphasis on treating therapy interfering
behaviors
 Emphasis on the therapeutic relationship as
essential to treatment

27. DBT Philosophy
 Individuals with BPD are so sensitive to
negative feedback that their ability to change is
drastically reduced.
 Balance acceptance strategies with change
strategies:
 “You’re great the way you are” and
 “You can do better”

28. DBT Assumptions
1. Difficult behaviors represent maladaptive
solutions, not the problem.
2. Engaging reluctant patients is a therapeutic
task, not a pre-requisite for enrollment.
3. Patients are doing the best they can.
4. Patients need to do better and try harder to
change.
5. Patients want to have lives worth living

29. DBT Assumptions
6. When patients say their lives are
unbearable, this is a valid statement.
7. Patients may not have caused their
problems, but they need to solve them.
8. Patients need to demonstrate adaptive
behaviors in all relevant contexts.

30. DBT Assumptions
9. Safety and security in therapy is not
necessarily valued, in so far as it does not
reflect the real world.
10. Patients cannot fail in treatment.
11. Therapists who conduct DBT need
consultation.

31. Targets for DBT Treatment
1. Stop suicidal and parasuicidal behaviors
2. Address therapy-interfering behaviors
3. Address quality-of-life interfering
behaviors: stop drug use

32. Treatment Program
 DBT Skills Training Group
 Individual therapy
 Phone coaching/consultation
 Emphasis on ongoing assessment and data
collection- Diary Cards
 Clear and precise treatment goals
 Collaborative working relationship between
therapist and patient.

33. Structure of DBT Treatment: Modes
1. Group Skills Training: typically 2 hr. group
per week
2. Individual Therapy: typically 1-2 sessions
per week
3. Phone consultation for crisis
management, skills coaching
4. Team consultation for therapists, typically 2
hrs/week

34. DBT Skills Training Group
 Group meets weekly
 Structured like taking a class:
one hour devoted to reviewing homework
one hour focused on learning a new skill
 Groups are no larger than 10 people

35. DBT: Modes of Therapy
Group skills training
 Acceptance skills
 Mindfulness
 Distress tolerance
 Change skills
 Interpersonal effectiveness
 Emotion regulation

36. DBT: Modes of Therapy
Individual psychotherapy
 Orient to therapy
 Agree on treatment goals
 Target life threatening behaviors
 Attend to therapy interfering behaviors
 Address problems that affect quality of life
 Generalize skills to daily life

37. DBT: Modes of Therapy
Telephone consultation
 In between individual sessions
 Coaching
 Difficulty asking for help
 Relationship enhancement and problem solving
 Reduces crises and increases skill generalization
 Equalize power in relationship

38. DBT: Modes of Therapy
Consultation for Therapists
 Patient reinforces therapist for doing ineffective
treatment and punishes therapist for doing
effective things
 Need peer consultation
 Prevent burnout
 Support use of DBT skills and techniques
 From 2-6 therapists
 Apply validation and change strategies to
therapist

39. Getting Started in DBT Treatment
1. Identify patient goals
2. Identify problems that currently interfere
with goals
3. Define problems behaviorally
4. Patient and therapist make a list of target
behaviors
5. Patient and therapist agree to work on targets
for limited time (one year)

40. Patient-Therapist Agreements
1. Time-limited renewable contract for
therapy
2. Miss 4 sessions in a row = termination
3. Agree to attend therapy, skills
groups, and complete homework
4. Agree to work on self-destructive
behaviors and therapy-interfering
behaviors

41. Patient-Therapist Agreements
5. Take meds as prescribed
6. Therapist will strive to be
competent, ethical, respectful and
accessible
7. Therapist will maintain
confidentiality
8. Therapist will seek consultation
when needed

42. Four Skills Modules
 Mindfulness
 Distress Tolerance
 surviving crises
 accepting reality
 Emotion Regulation
 reduce vulnerability
 reduce emotion episodes
 Interpersonal Effectiveness
 assertiveness

44. Taking Hold of Your Mind
 In DBT there are three states of mind:
- Wise Mind
- Emotional Mind
- Reasonable Mind

45. States of Mind Diagram
Reasonable Mind
Wise Mind
Emotional Mind

46. Reasonable Mind
 This is the
logical part of you brain. The part that
thinks, plans and evaluates what is happening
around you.
 Sometimes
our emotions can get in the way of how
well we do things. Whether we are in physical pain or
emotional pain or any other kind of pain, it makes it harder to
plan and think and organize every day activities we take for
granted.
 Getting ready in the morning: drinking a cup of
coffee, morning routine, taking kids to school etc.
 Building a house
 Following instructions
 Planning a vacation
 Doing math

47. Emotional Mind
 This is
when your present emotional state controls
most of your thinking and behavior.
 Anger-can spur an argument
 Love- you might sacrifice yourself for your children
 Anxiety-you might rush or be unable to concentrate
 When we as people are ina state of emotional reactivity
our minds are often spinning with so many
thoughts it is hard to find the off switch.
 Whether we are reacting to emotional pain, physical
pain, physical or mental over load or any other emotionally
heightened situation we are more prone to stress.

48. Wise Mind
 This part of our mind is a little more difficult
to grasp.
 It is the integration of the reasonable
mind and the emotional mind-this does
not mean the ability to flip back and forth
between the two or see both sides of coin.
 Additionally, you usually cannot evoke
emotions through reason, and you usually
cannot overcome emotions with reason.

49. Wise Mind
 It is the part of the mind that gives you
peace, and knows and experiences truth.
 Some people consider this to be the intuitive
part of the brain.
 It integrates all ways of knowing including all of
the senses-hearing, seeing, smelling etc.
 You will not always be in the wise mind, this
doesn’t mean it is not there!
 Consider: when you have a hard decision to
make, and after your choice your whole body
feels confident, sure and relaxed, that you took
the right course of action. (even if there might
be consequences.)

50. Mindfulness
 Mindfulness is developed through meditative
practice.
 Meditation can be achieved in many ways, it is not just
part of Eastern religious practices.
 Mindfulness happens any time you are
completely focused on one thing, in that
moment, without judgment.
 It is the repetitive act of directing your attention to one
thing at one moment.

51. Examples
 Driving a manual car for the first time you are
aware of each movement, later you can drive on
automatic pilot, but at first you must be mindful.
 Eating dessert and noticing every flavor
instead of attending to the conversation, or looking
around, or eating too fast.
 Walking in the park and being present.
Notice the trees, the children; what it feels like as your
feet hit the ground etc, not being distracted by your
thoughts and thus not noticing anything.

52. Mindful?
 It is rare in our society for a person to be
mindful. We are a society of multi-taskers.
 Typing and talking
 Eating and working
 Plotting out your day as you drive to work
 We are also often preoccupied with the future
or the past
 Worried about what’s for dinner or what to
wear, what our boss thinks, or how much money is
in the bank
 Did I say the right thing, I should have …, I can’t
believe I . . . , If only . . . Etc.

53. Why Mindfulness?
 Whatever your attention is on, that’s
what life is for you at any given
moment. (C. Sanderson)
 If you take a coffee break, or go exercise to
unwind, but all the while you are thinking and
worrying about something- Are you really taking a
break?

54. Why Mindfulness?
 Mindfulness allows you
to pay attention to
what you choose instead of letting your
mind take you captive.
 We allow our minds to keep us prisoner and we are
unable to fully experience each moment because we
are lost in some other moment.
 Mindlessness:
 hinders how we relate to our clients, our co-
workers, our families, our friends etc.
 hinders us enjoying hobbies, vacations, leisure
time, etc.
 affects how we feel about ourselves, what we have
confidence to do and how we treat others.

55. Mindfulness
 Of course it is not always feasible or possible
to be mindful at every moment in the day.
However, without practice it is
difficult to choose to be mindful
because our inner dialogue has a
way of taking us over.

56. Practicing Mindfully
The skills include:
 Observing
 Describing
 Participating
 Being non-judgmental
 Being one mindful
 Being effective

57. Mindfulness:
Taking hold of your mind
“What” Skills “How” Skills
Observe Non-judgmentally
Describe One mindfully
Participate Effectively

58. Observe
 The goal of observingto watch
is
events, emotions, etc without trying to
rid yourself of pain or prolonging a
certain feeling. When you observe you
simply notice what is-without judging it as
good or bad.
 This skill focuses on being aware in the
present moment.

59. Observe
 Observing and doing are different.
(Just because you do something does not mean you are
being aware.)
 Walking doing
 Noticing how fast you walk, how your feet feel hitting
the ground, the sound your shoes make, how your
muscles feel  observing
 Breathing Doing
 Feeling your chest rise & fall, how deep you
breath, the sound of an exhale, the muscles
moving, the feel of your breath on your skin
observing

60. Describe
 Describing is just the facts.
 NO judgments.
 Describing is more interested in the process
than the conclusion or end result.

61. Describe
 Sometimes people make an assumption-
“They don’t like me.” The description of this
might look like- they don’t invite me to
lunch, they don’t make a response when I try to
join their conversation, they avoid me, they
always have little secret jokes etc.
 The description does not warrant the
conclusion there could be many different
reasons people at work have cliques that have
less to do with someone outside the clique than
with some other factor.

62. Describe
 Automatically,judging why a
behavior is occurring can prolong
the behavior or create conflict or
tension. When we allow this to happen
we allow our feelings to determine the
reality, and we may not even be aware of
the descriptors- we automatically see the
conclusion.

63. Participate
 This means entering fully into an activity-
staying in each moment without separating
yourself from the events.
 True participation means getting rid of
self-consciousness and letting go of your
worries or fears. (not planning what you are
going to say or worrying someone is judging
what you are saying etc.)
 Full participation is the ultimate goal in
mindfulness.

64. Participation
 Have you ever had a conversation and found yourself nodding
and giving facial cues?- your body is on automatic
pilot while your mind is somewhere else.
 How often do you drive home without noticing and then
suddenly you are home.
 Participation requires letting your mind and your
body participate together in whatever you are doing.
Every part of you is involved in what you are doing.
 No compartmentalizing.

65. Non-Judgmentally
 This is means you do things without
evaluating them.
 Avoid judging something as good or bad;
valuable or worthless etc.-It just is.
 It does not mean going from a negative
judgment to a positive judgment. (it is not
optimism.)

66. Non-Judgmentally
 In DBT, there an emphasis on
is
consequences of behavior and events, but
that does not necessarily label it as good or bad.
 Change is initiated to create more
desirable outcomes. (this reduces shame
based feelings that can perpetuate behavior with
negative outcomes)
.

67. Non-Judgmentally
An extreme scenario
 You get drunk, attempt to drive home and hit a tree-
Instead of focusing on how bad a person you are and
how you are so dumb and why can’t you do anything
right, what were you thinking, you know better etc.
(probably driving yourself back to drinking or
something else to avoid the bad feelings you now have
about yourself)
 Non-judgmentally you can say- I need my car, I
don’t like how I feel about myself when I get too
drunk and loose control of my thinking, What could I
do to get a better end result.

68. One-Mindfully
 This means
learning to focus the mind and
awareness on the current moment.
 Focusing completely on one activity at a
time.
 Avoid reactions based on mood, negative
thoughts, assumptions, expectations, worries etc.
 One- mindfully is how you participate.

69. One-Mindfully
So back to your conversation with the
friend, so you are no longer worrying
about the future stuck in auto
pilot, you are listening, but as she
is talking you are preparing you
response- oops this is not
keeping your awareness on the
present moment.

70. One-Mindfully
This skill relies on being aware of
your thoughts, feelings etc and
observing them so you can be
careful not to react based on an
assumption or a mood. When you
observe your thoughts before you
speak, you can react without creating
conflict. You can enter your wise
mind.

71. One-Mindfully
 This skill could be practiced when you are baking a
cake, you put all your effort into that activity. You keep
your mind all your thoughts fully on what you are doing
with the cake. You focus on the measuring the textures
the sounds, the smells, etc.
 When you are at home, you focus on home and stop
thinking about that family at work that you are worried
about, frustrated with etc.
 Do give yourself time to One-Mindfully process your
feelings regarding that family. A time to fully
participate with yourself (sit with an emotion) and
acknowledge the whole of what you are feeling and
what you want to do. THEN LET IT GO.

72. Effectively
 This means do what works.
 The goal of this skill is to reduce a person’s
tendency to be more concerned with
being right, feeling good, or being justified
instead of doing what is needed or asked in a
particular situation.
 This skills means learning to give in and
compromise when it leads to an effective
or productive end result.

73. Effectively
 Examples:
 You really want your significant other
to do something special or ordinary for
you and you think, he/she should know
me well enough to do this. You are
hoping it will happen. (this is not
effective. If you want something
you may need to ask for it or
resolve not to be disappointed
when your significant other
doesn’t read your mind.)

75. Distress Tolerance
The emphasis is on skills for
tolerating painful events and
emotions when you cannot make
things better right away.

76. Distress Tolerance Skills Goals
 Crisis survival strategies
 Guidelines for accepting reality
 So as to reduce:
Impulsive behaviors
Suicide threats
Self harm

77. Distress Tolerance
Getting through the moment
without making it worse by using:
1. Distraction
2. Self-soothing
3. Improve the moment
4. Weigh the Pros and cons

78. Distress Tolerance: Distraction
Vision
Scent
Hearing
Taste
Sight

80. Emotion Vulnerability
 High sensitivity
- Immediate reactions
- Low threshold for emotional reaction
 High reactivity
- Extreme reactions
- High arousal dysregulates cognitive processing
 Slow return to baseline
- Long lasting reactions
- Contributes to high sensitivity to next emotional
stimulus

81. Emotion Regulation Skills Goals
 Understand emotions you experience
 Reduce emotional vulnerability
 Decrease emotional suffering

82. Emotion Regulation
 What good are emotions ?
 Reduce vulnerabilities' to negative
emotions (proper sleep habits, proper
management of physical illness, avoid mood
altering drugs, physical exercise)
 Build positive emotions. Pleasant things

83. THE PROBLEM
e.g., AVOIDANCE OR ESCAPE
interpersonal
conflict
(abandon, PROBLEM BEHAVIOR
invalidation)
EMOTION Alcohol & Drugs
DYSREGULATION Self-injury
CUE Aggression
TEMPORARY RELIEF
e.g., others back off
Reinforcement strengthens
this whole process

84. DBT INTERVENES
Teach how
to prevent AVOIDANCE OR ESCAPE
triggers X
PROBLEM BEHAVIOR
EMOTION
Teach
DYSREGULATION alternative
CUE X ways to
avoid or
Teach how to stop this
Regulate or
behavior
distract
tolerate distress X
Reduce power
TEMPORARY RELIEF
of triggers and
emotion
X
vulnerabillity
Stop problem
Without escape,
behavior or
emotion dysregulation
reinforcement
should improve

85. Focus on Emotion Regulation
 Reduce emotional reactivity/sensitivity
 exercise, and balanced eating and sleep
 exposure therapy
 Reduce intensity of emotion episodes
 heavy focus on distraction early on, which
is a less destructive form of avoidance

86. Focus on Emotion Regulation
 Increase emotional tolerance
 Mindfulness
 Observe your emotion
 Experience your emotions as a wave coming and
going
 block avoidance
 Act effectively despite emotional arousal
 Remember you are not your emotion: DO not
necessarily ACT on emotion.
 Opposite action

87. Skills for Reducing Emotions
 Distraction
 activities with focused attention
 self-soothing
 Intense exercise
 Relaxation
 progressive muscle relaxation
 slow diaphragmatic breathing
 Biofeedback
 Temperature
 ice cubes in hands
 face in ice water (whole body dunk)

88. Relaxation Training
 Progressive Muscle Relaxation
 Slow breathing
 breathe from the diaphragm
 5-6 breaths per minute (4 sec in, 6 sec
out)
 exhale longer than inhale

89. Skills Training for Anger
 Work on anger collaboratively
 motivational interviewing style (no labels)
 frame the choice as “right versus effective”
 validate what is valid
 Problem solving
 act on anger when it helps reduce a threat
 Skills training
 Cognitive restructuring (be careful!)
 Exposure

90. Skills Training for Anger
 Gently avoid (time out)
 postpone for a specified amount of time
 distraction
 pros and cons
 Relaxation
 Assertive communication.
 Empathy and explicit validation (no “should”)
 Get help for a “reality check”
 Ask a friend: “Am I over-reacting?”
 What am I failing to understand about other person?
 Is it worth the battle/loss (even if I am right)?

91. Cognitive Restructuring for Anger
 Empathic interpretations of others
 notice “shoulds”
 external attributions (current causes)
 benefit of the doubt
 times client’s intent has been misunderstood
 historical causes
 Ask rather than assume
 Humor
 Acceptance and forgiveness

92. Exposure for Anger
 Thoroughly assess triggers
 In vivo exposure
 role-play
 verbal barbs
 homework
 Imaginal exposure
 client can write a script in advance

93. Responding to Anger in Session
 Discourage simple venting/catharsis
 Link behavior to clients goals
 Refuse to talk about anger-inducing situations
when not productive
 Validate/apologize/repair to the extent that
therapist made a mistake.
 Do not avoid the issues that prompt the anger
if they are reasonable to deal with

94. Acknowledging what is sane, true and
valid about a patient’s point of view.
Validation must be authentic and
genuine. Validation is not synonymous
with approval, agreement, or sympathy.

95. Invalidating Environment
Pervasively negates or
dismisses behavior
independent of
the actual validity
of the behavior

96. DBT says watch out for
Invalidating Environment
Communication that penetrates or reflects to the
individual, that his or her emotional displays
and communication of private
experience, are incorrect, inaccurate, faulty
inappropriate or otherwise invalid.
This experience alone is painful and dismisses the
person’s individual interpretations….teaches the person
that others know better NOT you.
November 2010

97. The attitude communicated:
“You can pull yourself up by your bootstraps”
Belief:
Any individual who tries hard enough can make it!
“Talking about problems just makes problems worse.”
“A child cries on the playground . . . Adult says, “I’ll give you a real reason to
19
cry” 02/2003
.
November 2010

98. The DBT Model suggests to focus on skills
training and behavior change, as well as on
the validation of the individual’s current
capabilities and behaviors.
02 /20 03 19
November 2010

99. Validation
 Validation is:
 Finding the kernel of truth or wisdom in the
client’s behavior (no matter how bad it is)
 Seeing the world from the client’s point of
view, and saying so! (Without knowing
where our clients are coming from we fail to
understand them and therefore fail in
providing the best treatment possible.)

100. Validation
 Validation does not mean you have to:
 Agree with the client
 Approve of the client’s behavior, or
 Convey warmth

101. Levels of Validation
 Listen and pay attention
 Show you understand
 paraphrase what the client said
 articulate the non-obvious (mind-reading)
 Describe how their behaviors/emotions…
 make sense given their past experiences
 make sense given their thoughts/beliefs/biology
 are normal or make sense now
 Communicate that the client is capable/valid
 actively “cheerlead”
 don’t treat them like they’re “fragile” or a mental patient

102. Validation
What (“yes, that’s true” “of course”)
 Emotional pain “makes sense”
 Task difficulty “It IS hard”
 Ultimate goals of the client
 Sense of out-of-control (not choice)
How
 Verbal (explicit) validation
 Implicit validation
 acting as if the client makes sense
 responsiveness (taking the client seriously)

103. Validation
 Staying Awake: Unbiased listening and
observing-Just be quiet and stay focused on the
client.
 Accurate Reflection-saying back to them
what they told you, but in different words and
without judgment.
 Verbalizing the unspoken
emotions, thoughts or behavior
patterns- before you do this you must have a
solid relationship with the client.

104. Validation
 Validation in terms of past learning or
biological dysfunction-what the client has been
previously taught or in the context of their mental
illness, learning disorders, etc
 Validation in terms of present context or
normative functioning-Understand where they
are coming from in terms of what they are going
through right now or their stage in life and
development
 Radical Genuineness-Being kind and real at the
same time

105. Functions of Validation
 Increases client willingness to change
 Strengthens therapeutic relationship
 Reinforces staying in therapy
 Reinforces clinical progress
 Provides feedback to shape behavior
 Increases self-validation by modeling validation
 Increases positive expectancies (believing in
client)

106. Self-Validation
Get the patient to say:
“It makes perfect sense that I … because…”
 it is normal or make sense now
 of my past experiences
 of the brain I was born with
 of my thoughts/beliefs
Get the patient to act as if she makes sense:
 non-ashamed, non-angry nonverbal behavior
 confident tone of voice

107. Problem Solving
 Functional analysis (chain analysis)
 Solution analysis
 accept, tolerate, mindfulness
 change, regulate
 self vs. environment
 Anticipate and solve obstacles
 Skills acquisition (model)
 Rehearse – “dragging out new behavior”
 Commitment

108. Problem Solving
Figuring out what to focus on:
 Self-injury
 Therapy-interfering behavior
 Emotion regulation and skillful behavior
 shame and self-invalidation (judgment)
 anger and hostility (judgment)
 dissociation and avoidance
 In-session behavior

109. Understand the Problem
Do detailed behavioral analyses to discover:
 environmental trigger
 key problem emotions (and thoughts)
 what happened right before the start of the
urge?
 what problem did the behavior solve?
and conceptualize the problem (i.e., identify factors
that interfere with solving the problem)

110. Chain Analysis
Vulnerability Problem behavior
Prompting event
Links
Consequences

111. Chain Analysis
 Analysis is of chain of events moment to
moment over time
 Examine vulnerabilities, antecedents and
consequences of problem behavior
 Allow for determination of patterns of
behaviors
 Examine options for getting on a different
path away from problems behaviors

112. Chain Analysis
1. Pre-existing vulnerabilities: what
conditions make client more likely to engage
in problem behavior?
2. Precipitating event: what external event
triggered the problem behavior? Where was
the point of no return?
3. Links in the chain leading to problem
behavior: include bodily
sensations, thoughts, feelings, behaviors, eve
nts in the environment

113. Chain Analysis
4. Problem behavior occurs: be sure problem
is defined in specific behavioral terms
5. Consequences: what happened next?
Helps to identify reinforcers for problem
behavior.

114. Diary Cards
 Daily monitor of target symptoms and skills usage
 Target symptoms include:
- self harm urge and action
- substance use
- suicidal ideation
- level of misery
 Allows individual therapist to target most urgent
target symptoms for a session

115. Understand the Problem
Identify factors that Interfere with solving
the problem
 Lack of ability for effective behavior
 Effective behavior is not strong enough
 Thoughts, emotions, or other stronger
behaviors interfere with effective behavior

116. Behavioral Formulation
1. Summarize the story
2. Add any insights you have
3. Identify which links in the chain are
dysfunctional
4. Identify reinforcers: what keeps this problem
behavior going?
5. Identify function: how does this target
behavior serve the patient?

117. Skills for Reducing Behavior
 Pros/Cons of new behavior
 Mindfulness of current emotion/urge
 Postpone behavior for a specific small amount
of time (fully commit)
 Distract, relax, or self-soothe
 Postpone behavior again
 Do the behavior in slow motion
 Do the behavior in a very different way
 Add a negative consequence for behavior

118. Skills for Increasing Behavior
To get opposite action:
 Pros/Cons of new behavior
 Mindfulness of current emotion/urge
 Break overwhelming tasks into small pieces
and do first step
 something always better than nothing
 Problem solve; Build mastery

119. Skills Training Procedures
 Skills acquisition
 Skills strengthening
 Skills generalization

120. Solution Analysis: new alternative
behaviors to replace dysfunctional links
1. Brainstorm all possible solutions:
2. Remember 4 Solutions to Any Problem:
1. Solve the problem
2. Feel better about the problem
3. Tolerate the problem
4. Be miserable
3. Pick a solution to work on

121. Solution Analysis: new alternative
behaviors to replace dysfunctional links
4. Make a commitment to try the solution
5. Strengthen the commitment using
commitment strategies
6. Troubleshoot the solution
7. Rehearse the solution

122. Contingency Management: Requires
no co-operation from the patient
1. Reinforce desired behaviors
(surprising how we forget this)
2. Fail to reinforce maladaptive
behaviors: extinction
3. Punish maladaptive behaviors: will
only suppress behavior

123. Response to Unacceptable Behaviors
1. Describe the problem behavior to the
patient
2. Patient performs chain analysis on the
problem behavior
3. Patient reviews chain analysis with
therapist for behavioral formulation
4. Patient presents chain analysis to
community, gets feedback

124. Response to Unacceptable Behaviors
5. Patient and therapist identify damage done by
problem behavior
6. Correction: make amends for damage done by
returning the situation back to baseline
7. Overcorrection: the amend actually improves
the situation (“makes is better than it was to
start with”)
8. Correction-overcorrection procedure is
strengthened by therapist withholding some
goody (warmth) until patient successfully
completes the overcorrection (then warmth is
restored)

125. Extinction Procedures
1. Orient the patient: explain the procedure and
the rationale
2. Withdraw reinforcement for the maladaptive
behavior
3. Validate, soothe, cheerlead

126. Extinction Procedures
4. Remind patient of rationale and his/her
prior commitments.
5. Find an alternative behavior to reinforce
6. DO NOT give in halfway through the
extinction procedure: intermittent
reinforcement will make the problem
behavior very durable

127. Ultimate Aversive Sanction:
Vacation from Therapy
1. Describe the problem behavior to the patient
2. State that failure to stop this behavior is
leading to vacation
3. Give patient a chance to escape the vacation
(by solving the problem)

128. Ultimate Aversive Sanction:
Vacation from Therapy
4. Place patient on vacation.Patient
may resume therapy when problem is
solved.
5. Give appropriate referrals for
continuity of care
6. Maintain non-demand contact with
patient (“pining for his/her return”)

130. Interpersonal Effectiveness
 The emphasis is on learning and
practicing skills that make relationships
with others work better.

131. Interpersonal Effectiveness Strategies
 Including the following:
 Assertiveness skills
 Communication skills
 Refusal skills
 Conflict resolution skills

132. Interpersonal Effectiveness
“DEAR MAN”
 Describe: Describe the situation - Stick to the
facts
 Express: Express your feelings about the
situation
 Assert: Assert yourself by asking clearly
 Reinforce: Reinforce or reward the person
ahead of time by explaining consequences

133. DEAR MAN
 Mindful: Maintain your focus on your
objectives, ignore if other person
attacks, threatens or tires to change subject.
 Appear Confident: Be effective and
competent, good eye contact, confident
voice
 Negotiate: Be willing to give to get, offer and
ask alternative solutions. Turn the table to
other person. “What do you think we should
do ?”

134. Therapy Interfering Behaviors (TIB)
 arrives late
 leaves early
 passive or helpless
 not do diary card
 excessively talks (hard for therapist to talk)
 complains but does not work in session
 excessively angry
 excessively judgmental/critical of therapist

135. DBT Treatment Outcomes
DBT has better outcomes than TAU on:
• suicidal behavior (self-injury)
• psychiatric admissions and ER
• treatment retention
• angry behavior
• global functioning
All treatments show improvement on:
• suicide ideation
• depressed mood
• trait anger

136. DBT: Outcome Data
 Controlled clinical trial
 Levels of self-injury were half that of control
group
 Levels of re-hospitalizations were half that of
control group
 Makes DBT very appealing to medical
community and financial supporters

137. Final Wisdom
The world is full of suffering,
it is also full of overcoming it.
Helen Keller

138. THANK YOU