Acceptance Based DBT Acceptance Based DBT for Emotion Regulationfor Emotion Regulation

Sandra Georgescu, Psy. D.Sandra Georgescu, Psy. D.

Paul Holmes, Psy.D.Paul Holmes, Psy.D.

IntroductionIntroduction

DBT – one of the 1DBT – one of the 1stst CBTs to integrate CBTs to integrate acceptance/mindfulness and behavior acceptance/mindfulness and behavior change strategieschange strategies

DBT – one foot in the 2DBT – one foot in the 2ndnd & another in the & another in the 33rdrd wave of behaviorism wave of behaviorism

DBT’s leap into the 3DBT’s leap into the 3rdrd wave wave

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DBT as Originally PackagedDBT as Originally Packaged

Intensive Outpatient Treatment involving:Intensive Outpatient Treatment involving: Individual PsychotherapyIndividual Psychotherapy Skills Training GroupSkills Training Group Telephone ConsultationTelephone Consultation Therapists’ Consultation GroupTherapists’ Consultation Group Uncontrolled Ancillary TreatmentUncontrolled Ancillary Treatment

PharmacotherapyPharmacotherapy Acute Inpatient PsychiatricAcute Inpatient Psychiatric

DBT - Stages of TreatmentDBT - Stages of Treatment

Pre-treatment - Pre-treatment - Commitment, Orientation & Agreement Commitment, Orientation & Agreement

on Goals on Goals

Stage I - Stability, Connectedness & SafetyStage I - Stability, Connectedness & Safety

Stage II - Stage II - Exposure & Emotional Processing of the PastExposure & Emotional Processing of the Past

Stage III - Stage III - Ordinary Happiness & UnhappinessOrdinary Happiness & Unhappiness

Stage IVStage IV - Capacity for Sustained Joy - Capacity for Sustained Joy

Stage I TargetsStage I Targets

Severe Behavioral Dyscontrol Severe Behavioral Dyscontrol Behavioral Control Behavioral Control

Decrease control of contrived private experienceDecrease control of contrived private experience1.1. Life threatening behaviorsLife threatening behaviors

2.2. Therapy interfering behaviorsTherapy interfering behaviors

3.3. Quality of life interfering behaviorsQuality of life interfering behaviors

Increase Behavioral SkillsIncrease Behavioral Skills} Core MindfulnessCore Mindfulness} Distress toleranceDistress tolerance} Emotion regulationEmotion regulation} Interpersonal EffectivenessInterpersonal Effectiveness

Become more discriminating in our actions

Relationship Between Knowledge & Relationship Between Knowledge & ActionAction

Knowledge Action

Contact with Consequences results in refined knowledge

Moving ForwardMoving Forward

Meaningless DialecticMeaningless Dialectic Data on emotion and thought suppressionData on emotion and thought suppression Relational Frame Theory (RFT) – provides Relational Frame Theory (RFT) – provides

us with a nominalist model for us with a nominalist model for understanding mind from a behavioral understanding mind from a behavioral perspectiveperspective

Meaningless Dialectic in DBTMeaningless Dialectic in DBT

??????????

MindfulnessMindfulness Cognitive Cognitive RestructuringRestructuring

(content is (content is notnot the the (content (content isis the problem; the problem; problem, just notice) problem, just notice) evaluate & change it) evaluate & change it)

Avoidance of Private ExperienceAvoidance of Private Experience

Escape from events & objectsEscape from events & objects Escape from private experienceEscape from private experience

Thought suppression Thought suppression (Marcks & Woods, 2005; Bower & (Marcks & Woods, 2005; Bower & Woody, 1996, Abramowitz, Tolin & Street, 2001 )Woody, 1996, Abramowitz, Tolin & Street, 2001 )

Emotion suppression Emotion suppression (Gross & Johns, 2003; Gross, 1998; (Gross & Johns, 2003; Gross, 1998; Gross & Levenson, 1997)Gross & Levenson, 1997)

Experiential Avoidance Experiential Avoidance (Feldner, Zvolensky, Eifert & (Feldner, Zvolensky, Eifert & Spira, 2003; Hayes, Strosahl, Wilson, et al. 2004; Chawla & Spira, 2003; Hayes, Strosahl, Wilson, et al. 2004; Chawla &

Ostafin, 2007)Ostafin, 2007)

Relational Frame Theory (RFT)Relational Frame Theory (RFT)

Language about mind was avoided in the 1Language about mind was avoided in the 1stst wave & mentallistic in the 2wave & mentallistic in the 2ndnd wave wave

Rorty (1997) – when we’ve explained the Rorty (1997) – when we’ve explained the use of language in society, we’ve made use of language in society, we’ve made sense of the term “mind”sense of the term “mind”

RFT may have provided us us with a RFT may have provided us us with a functional conceptualization of mind functional conceptualization of mind Mind is unidirectional – once you have it, you Mind is unidirectional – once you have it, you

got it got it

Acceptance Based DBT for Acceptance Based DBT for Emotional RegulationEmotional Regulation

ACCEPTANCEPRIVATE EXPERIENCE

BEHAV. CHANGE

“LIVING MEANINGFULLY”

VALUES

Implications Individual SessionImplications Individual SessionCognitive restructuring strategies are replaced by:Cognitive restructuring strategies are replaced by:

Mindfulness of thoughts, rules and stories – is this the 1Mindfulness of thoughts, rules and stories – is this the 1stst

time you’ve ever had that thoughttime you’ve ever had that thought

Willingness to experience this thought as just that, a thought Willingness to experience this thought as just that, a thought

rather than whatever it may say it is (acceptance) – is it ok rather than whatever it may say it is (acceptance) – is it ok

to have that thought given that it’s here?to have that thought given that it’s here?

Functional assessment of thoughts and stories is carried out Functional assessment of thoughts and stories is carried out

in the context of their commitment to ain the context of their commitment to a valued direction in valued direction in

lifelife

Workability of buying thoughts (short & long-term) is the Workability of buying thoughts (short & long-term) is the

measuring stick that helps inform choicesmeasuring stick that helps inform choices

Private ExperiencePrivate Experience

Lots of questions about it…Lots of questions about it…exposureexposure

Is it ok to have that thought…. As a thought Is it ok to have that thought…. As a thought not as what it says it is? not as what it says it is?

If not, more questions…. About workability, If not, more questions…. About workability, about the thought(s) in a different about the thought(s) in a different context….but its always the context….but its always the SAMESAME thought! thought!

DBT & ValuesDBT & Values

In it’s original DBT proposes “life worth In it’s original DBT proposes “life worth living” as a direction for movement…in living” as a direction for movement…in treatment and in life…treatment and in life…

ANDAND

No definition or process is identified for No definition or process is identified for defining what “life worth living” means…defining what “life worth living” means…

Values on an individual basisValues on an individual basis

Utilizing the Values Living Questionnaire, Utilizing the Values Living Questionnaire, Values compass or Bulls eye to assess the Values compass or Bulls eye to assess the direction that people want to give to their direction that people want to give to their liveslives

An anchor for commitment: conversation to An anchor for commitment: conversation to be had as part of pre-treatment; beginning be had as part of pre-treatment; beginning to define the areas that are meaningful and to define the areas that are meaningful and the directions that people would like their the directions that people would like their lives to takelives to take

ACBS Values assessment toolsACBS Values assessment tools

Far from

In the vicinity

Close

Bullseye

Very close

Developed by T. Lundgren &J.A. Dahl

…….and Skills Training.and Skills Training Skill training modules renamed to reflect an Skill training modules renamed to reflect an

acceptance/ongoing life process instead of a acceptance/ongoing life process instead of a if/then contingencyif/then contingency

Cognitive restructuring strategies have been Cognitive restructuring strategies have been removedremoved from all handouts & from all handouts & replacedreplaced with with acceptance/mindfulness consistent interventions…acceptance/mindfulness consistent interventions… extended mindfulness practiceextended mindfulness practice

Valued Living has been Valued Living has been addedadded to Emotion to Emotion Regulation Skill Area to help extend existing Regulation Skill Area to help extend existing behavioral activation exercises and provide an behavioral activation exercises and provide an anchor/purpose to skill useanchor/purpose to skill use

Skills TrainingSkills Training

MindfulnessDistress Tolerance

Emotion RegulationInterpersonal Effectiveness

AcceptanceSkills

ChangeSkills

Skills TrainingSkills Training Living in the Present (Mindfulness)Living in the Present (Mindfulness)

Goal - to develop an unattached awareness of Goal - to develop an unattached awareness of experience. It is training in perspective-taking.experience. It is training in perspective-taking.

Participants are taught that one cannot control Participants are taught that one cannot control thoughts and feelings. They can only control what thoughts and feelings. They can only control what they attend to. they attend to.

Learn to be open to all things and focus only on one Learn to be open to all things and focus only on one thing.thing.

Learn to differentiate between being lost in Learn to differentiate between being lost in experience and being present in an experience.experience and being present in an experience.

Learn to recognize and practice choosing in the gap Learn to recognize and practice choosing in the gap between an urge and the action typically associated between an urge and the action typically associated with it.with it.

Skills TrainingSkills Training

Living with Distress Living with Distress (Distress Tolerance)(Distress Tolerance)

Considered more active forms of mindfulness.Considered more active forms of mindfulness. The DT activity becomes the focus of attention.The DT activity becomes the focus of attention. Participants are taught to take their distressing Participants are taught to take their distressing

thoughts and feelings with them as they engage thoughts and feelings with them as they engage in a DT skill.in a DT skill.

Learn to re-contextualizing experience.Learn to re-contextualizing experience. Learn to attend to the process of experiencing Learn to attend to the process of experiencing

rather than continuously evaluating the rather than continuously evaluating the experience.experience.

Skills TrainingSkills Training

Living with Emotions Living with Emotions (Emotion Regulation)(Emotion Regulation)

Emotions are adaptiveEmotions are adaptive Emotion is an early brain form of communicationEmotion is an early brain form of communication Emotion is where your language and body meetEmotion is where your language and body meet An emotion is an indicator of a specific way in which you An emotion is an indicator of a specific way in which you

need to take care of yourselfneed to take care of yourself Skills emphasize practice identifying emotion and lesson Skills emphasize practice identifying emotion and lesson

it is attempting to conveyit is attempting to convey Identifying language that would help direct you towards Identifying language that would help direct you towards

actions that would make certain emotions more present actions that would make certain emotions more present e.g. meaning driven behavioral activation/exposuree.g. meaning driven behavioral activation/exposure

Skills TrainingSkills Training

Living with OthersLiving with Others To live meaningfully will involve other peopleTo live meaningfully will involve other people Practice observing your limits while honoring Practice observing your limits while honoring

the limits of othersthe limits of others Being fully present non-judgmentally, validating Being fully present non-judgmentally, validating

one’s emotions and perceptions and one’s emotions and perceptions and communicating honestlycommunicating honestly

Practice making requests and saying “no”Practice making requests and saying “no”