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Expanded Techniques inCognitive Behavioral TherapyLEANNE CARLSON, PH.D, HSPP 8395 KEYSTONE CROSSING, SUITE 104 INDIANAPOLIS, INDIANA 46038 WWW.LEANNECARLSONPHD.COM EMAIL: [email protected]
Dialectical Behavior Therapy (DBT)
Developed by Marsha Linehan, Ph.D., ABPP, DBT is the gold standard for the treatment of Borderline Personality Disorder. Use of DBT techniques has expanded significantly for use with people with all types of issues in emotional regulation. As nearly all clients present with some sort of dysregulated emotions, DBT can be useful in a wealth of clinical settings.
Please see DBT Skills Training Handouts and Worksheets, Second Edition by Marsha M. Linehan for resources.
Emotional Regulation
The ability to IDENTIFY, PROPERLY LABEL, and APPROPRIATELY EXPRESS AND/OR COPE WITH emotional information
Vulnerabilities to Acquiring Regulation Skills
▶ Biology ▶ Lack of Skills due environmental/parenting issues ▶ Mood Disorders ▶ Flooding (HR above 100; “brain fog”) ▶ Myths about Emotions: “Emotions are weakness”, “Painful emotions are bad” “Emotions are truth” “Others need to approve of my feelings”; “Having emotions means you’re out of control”
Identifying Emotions
The ability to identify and correctly label feelings is dependent on a person’s ability to identify specific physical and psychological changes related to each emotional state. (DBT Worksheets, pgs. 214-223) ▶ Biological changes ▶ Nervous system reactions ▶ Body sensations/action urges ▶ Facial/Body Language ▶ Language/Actions
DBT Domains of Regulation
▶ Mindfulness
▶ Interpersonal Effectiveness
▶ Emotional Regulation
▶ Distress Tolerance
Mindfulness
▶ Wise Mind – Balance between Emotional and Rational Mind ▶ Observe – 5/4/3/2/1 ▶ Describe -5/4/3/2/1 ▶ Participate- Real or in Imagery ▶ No Judgment – allow feelings ▶ One Mind – one molecule of behavior at a time ▶ Be Effective – set a goal and execute it
Interpersonal Effectiveness
▶ Goal Setting - Objectives/Relationship/Self-Respect ▶ DEAR MAN-
Describe, Express, Ask, Reinforce, Mindfulness, Appear (confident), Negotiate
▶ GIVE - Gentle, Interested, Validating, Easy Manner
▶ FAST- Fair, (no) Apologies, Stick (to values), Truthful
▶ Role Playing – practice new skills ▶ Modulate Intensity- Effectively Intense
Emotional Regulation
▶ Mindful of Emotions ▶ Opposite Action – doing the opposite of what emotion tells you ▶ Accumulate Positives – what to look forward to ▶ Build Mastery ▶ Cope Ahead ▶ Treat Physical Illness ▶ Enough Sleep ▶ Exercise
Distress Tolerance
▶ Distraction ▶ Self-Soothing ▶ Urge Surfing ▶ Pros and Cons ▶ Mindful Activity ▶ Accepting Reality
Schema Therapy
Developed by Jeffrey Young, Ph.D., Schema Therapy was also developed as an advanced technique to treat clients with characterological problems, particularly Borderline Personality Disorder (BPD) and Narcissistic Personality Disorder.
Schema therapy integrates cognitive behavioral theory with Gestalt, object relations, attachment, developmental. and psychoanalytic theories. Schema theory expands cognitive behavioral techniques to a developmental framework, exploring early origins of cognitions and maladaptive coping styles.
Schema
Schema – “in social science, are the mental structures an individual uses to organize knowledge and guide cognitive processes and behavior. Examples include rubrics, social roles, stereotypes, and worldviews.” Source: Encyclopedia Britannica
It is important to understand that schemas DO NOT include behavioral components. Behavior is developed in response to self-defeating emotional and cognitive patterns
Early Maladaptive Schemas
▶ Broad, pervasive themes ▶ Composed of memories, emotions, cognitions, and
bodily sensations ▶ Regard both self and the self’s relationship to others ▶ Developed in childhood and adolescence ▶ Elaborated over time, often through self-fulfilling
prophecy and repeated dysfunctional relationships ▶ Significantly dysfunctional
Origin of Childhood Schemas
Maladaptive schemas are created from unmet needs of childhood ▶ Secure attachment (safety, stability, nurturance, acceptance) ▶ Autonomy, competence, identity ▶ Validation of individual needs and emotions ▶ Spontaneity and play ▶ Realistic limits and self control (boundaries)
What fosters maladaptive schemas?
▶ Toxic frustration of needs – emotional and physical deprivation
▶ Trauma/victimization
▶ Indulgence, overprotection, lack of autonomy and boundaries
▶ Selective internalization and identification of a toxic parent
Temperamental Traits in Personality
Labile ------- Nonreactive Dysthymic------ Optimistic
Anxious ------ Calm Obsessive ------Distractible
Passive ------ Aggressive Irritable ------ Cheerful
Shy ------ Sociable
Schema Domains (1)
Disconnection and Rejection
▶ Abandonment/Instability – people don’t stay ▶ Mistrust/Abuse – others will abuse and exploit, given the chance ▶ Emotional Deprivation – emotional needs won’t be met (nurturance,
empathy, and protection) ▶ Defectiveness/Shame – inherently “bad”, inferior, invalid, unwanted ▶ Social Isolation/Alienation – different and unable to belong
Schema Domains (2)
Impaired Autonomy or Performance
▶ Dependence/Incompetence – cannot competently handle everyday responsibilities
▶ Vulnerability to Harm/Illness – medical, emotional/external catastrophe ▶ Enmeshment/Undeveloped Self- often presents as a lack of personal
direction or “emptiness” ▶ Failure – has failed or ultimately will fail, inadequate in achievement
Schema Domains (3)
Impaired Limits
▶ Entitlement/Grandiosity – belief in personal superiority or entitlement to rights; not bound by rules of reciprocity, insisting one can do or have whatever they want, regardless or effects on others.
▶ Insufficient Self-Control/Self-Discipline – refusal or difficulty restraining emotional responses OR discomfort avoidance – avoiding pain or conflict at the expense of commitment and integrity
Schema Domains (4)
Other Directedness
▶ Subjugation – surrendering control to avoid anger, retaliation, and abandonment ▶ Subjugation of needs (preferences, decisions, desires ▶ Subjugation of emotions (particularly anger)
▶ Self-Sacrifice ▶ Approval/Recognition Seeking – esteem is dependent on the reactions of
others rather than own sense of self and values
Schema Domains (5)
Overvigilance and Inhibition ▶ Negativity/Pessimism – impaired outcome and fear of mistakes
▶ Emotional Inhibition - of anger, positive emotions, vulnerability, or excessive focus on rationality (based on fear of loss of control)
▶ Unrelenting Standards – perfectionism, rigid rules, time and efficiency
▶ Punitiveness – allowing mistakes in self or others, usually showing anger if others do not meet standards or have different feelings
Assessment
▶ Clinical Interview
▶ Explore childhood, particularly parental relationships and traumas
▶ Young Schema Questionnaire
▶ Imagery Exercise
▶ Safe Place ▶ Childhood Memory of upsetting situation ▶ Talk back to the parent/authority figure ▶ Intensify emotion ▶ Transfer to current life – talk to others in image ▶ Return to Safe Place
Intervention
Give Voice to the Healthy Adult
▶ Support and Refute evidence for schemas that are held ▶ Debate between the schema and the Healthy Adult ▶ Advantages/Disadvantages of current coping ▶ Schema flash cards ▶ Schema Diary
DBT and Schema Resources
Farrell, Joan M. Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self- Reflection Workbook for Therapists
Linehan, Marsha M. DBT Skills and Training Handouts and Worksheets, Second Edition Linehan, Marsha M. DBT Skills and Training Manual, Second Edition
VanderKolk, Bessel The Body Keeps Score: Brain, Mind, and Body in the Healing of Trauma
Young, Jeffrey; Klosko, Janet; Weishaar, Marjorie Schema Therapy: A Practitioner’s Guide Young, Jeffrey Reinventing Your Life: The Breakthrough Program to End Negative Behavior and Feel Great Again.
DBT Diary –app for resources and DBT records for clients