Dialectical Behavior Therapy (DBT) has been designed to help man people struggling with psychological, emotional, and behavioral problems.
DBT has been used to treat major depression (major depressive disorder), Borderline Personality Disorder (BPD), eating disorders, like Bulimia Nervosa and Anorexia Nervosa, and drug problems.
Please find the transcript below. At the moment there are some errors in the transcript, which will hopefully be resolved soon.
Transcript:
Thank you all for coming for the fall semester. We are honored to have Dr. Ryan Fuller from New York Behavioral Health and his assistant director Gina Rossini, who is going to introduce Ryan and tell us about NYBH.
I am Gina Rossini assistant director from NYBH I have a lot of information about our agency we have therapy from [substance use disorders] to anxiety and depression eating disorder. Dr. Fuller is the Clinical Director formerly the Director of Research at the Albert Ellis Institute and has presented of all over the world. We are very honored you guys had us here and your partner Beth Israel, and now I will turn it over to Ryan. If you have any questions about us please sign up for a newsletter.
Okay, first thanks for coming, and second, I will make sure to do my best hit these objectives so you can receive and you can lawfully and legitimately receive your CEUS for credit. With that said I’m probably going to hit other things. As much as possible, I want to make the presentation interactive at times and cater it to where you are and what you guys are wanting. So really what I’m going to be looking to do is perhaps have more of emphasis on an philosophical shift towards working with these clients maybe adopting or considering a philosophical shift from where you are or reinforcing where you are philosophically on where you are further understanding based on the theoretical how folks with borderline symptoms have developed.
How many of you have a background in behavioral work or theory? It doesn’t matter to me just engage things and how many have a background with dialectical theory specifically?
How many of you have practiced core skills out of a workbook for DBT?
So, as you see from the title Dialectical Processes and Behavioral Therapy Understanding and Treating Borderline patients I’m going to cover some service stuff on DBT but what I’m really going to be trying to stress is what probably sort of is inherent with DBT that makes it effective. That might be effective in your own practices already that might be effective in other forms of therapy and looking how there are these common elements. And one thing when you are about to study DBT is that Marsha Linehan, who makes very clear, who developed this she makes it very clear in that what she has really done is a remarkable job in being comprehensive on approaching on how to deal with very, very tough clients. And, what I think she is very humble about saying is that she just went on to say that she worked with what went very, very well and took it. From people like Art Nezu, like problem solving from some cognitive modification from some of the cognitive theorists, meditation and mindfulness skills form some Zen practices or Christian contemplative practices. By doing so she did put it together in this really structured comprehensive package found at this point an effective method of delivery which we will talk about in the package which is quite comprehensive and in a way to disseminate and train people which in some ways its very, very flexible but in the same way it provides structure and support it provides plenty of worksheets in the program to utilize it, it is user friendly with that said in her seminal training manual she did a very good job in going back to research all areas bio? Social theory on psychosocial theory? So she went back to research all these areas trying to understand these clients so with the systematic program of research has tested the?. So I’m going to start off by asking – so you get a phone call from a fellow professional probably from someone in this room and they start off by saying hey there is a client I can’t see it turns out you know she has some borderline symptoms you know some borderline symptoms some self-injury and stuff I think you would be great for her. Laughing! What kind of things come to mind from the person receiving that call? Anyone have openings in their practice right now because I get lots of borderline calls. Answer: Probably a difficult person being referred to you. Ryan: Okay. (I couldn’t make out what she said) But you said And they love you or probably just think you are gifted. Laughing What else? I feel like complimented – Ryan: just give me your phone number. Okay you feel complimented because. Audience person said wow I would feel like Inaudible. Anyone else, yes. Some fear and anxiety because prognosis isn’t so good. Okay. I don’t think I have the skills set I think you are so much better a clinician than me. Laughing Yea. Audience: Inaudible. Ryan – This is a client who has really taken to me says the most positive
Things to me at times is fully present in therapy lots of interaction Ryan: yea go ahead Audience: Inaudible. So, who does have a lot of experience with borderline clients? We will talk a little about the prevalence. How many have referred a borderline to a more appropriate clinician? Not every referral of a borderline is a hostile referral. Like I’m really out to get Susan I mean there are more appropriate clinicians and more appropriate settings and my understanding is that it is important. The reason I’m asking the question is because one of the things I hopefully want to get folks to consider is really thinking how we shift and feel about these clients because they are difficult to treat, and I don’t think there are any scientific literature that says otherwise. There are some difficult behaviors and we will look into some specific ones that are quite scary. And that means it makes sense that there is going to be fear in that kind of thing. At the same time what they are going to need is a clinician that are going to with humility enter into their lives and be with them while they are suffering while providing effective treatment and that is not something easy to do when you can imagine the kind of automatic thoughts that come up for us the kinds of attributions we are making about the person referring them about what the client’s behavior is really about in terms of intention and what it may mean about us that they are sent to us. Even the compliment which sounds like its quite positive has two sides to it right because to some extent. By gosh, I mean I’ll send her 15 borderlines next week. One of the things we are going to talk about to some extent one reason of the package of DBT, I think, it is affective and that takes a toll on a clinician and clinicians treating folks like this need a great deal of support which is part of the rationale for the consultation team. So, anyway you cut it you think oh it’s a compliment I can do this I had the training or oh my gosh what have I gotten myself into and in either case I think it requires careful self-awareness, clinical skill and coordinated support with team members. Okay so how likely is it that a clinician is going to be treating someone with borderline personality disorder. So, 11% of all out patient according to some studies qualify for borderline personality disorder and 19% of inpatients, 33% of outpatients with access to and in terms of inpatients to access 63% now one thing I have to quote one of my mentors who said personality disorders are like truffles you can’t have just one look at the scientific data on the DS in practice two not that reliable in terms of discriminating among personality disorders but what we do find is that there are a whole lot of overlap so there isn’t exactly clear and I make no bones about it I am very much rooted in sort of a behavioral perspective so it is useful as the DSM can be in times of terms of communication and sometimes certain clusters of symptoms information in understanding can be helpful even today you will notice what I’m saying borderline a lot even though we are looking at the behavior and it is not going to be as critical to me as much as the diagnosis but rather as understanding what the functions of the behaviors are and so to some extent there is this overlap but even if the client is exhibiting behavior but doesn’t have borderline diagnosis but by my standpoint that really doesn’t matter. Developing the sort of skill set with DBT or other behavioral therapies it’s really about applying those to any individual in your practice and understanding when and how to do that. I will cover DBT points but it’s really about understanding what’s behind it. When Marsha Linehan first started developing this treatment she had no idea borderline personality disorder was even a term in what they were she had an interest in folks that were suffering to a degree that she didn’t want them to die and they were self- injuring a lot and she sort of decided that was what she was going to deal with and more power to her it’s obviously a group that lots of folks don’t want to deal with so she went out at the time to apply the traditional cognitive behavior therapies and found that it didn’t go over so well. So then, she tried to go back to the drawing board to see what could be missing. So, in a very sort of simplistic way the dialectical behavior therapy process is in some ways combing typical or traditional behavior therapy and cognitive therapy as well with more acceptance-based strategies that are very similar to Zen or as religious Christian or contemplative practices or other philosophies. It’s this dialectic of yin and yang that sort of change and acceptance work. Certainly, some behavior therapists say yes there has been acceptance before but she certainly has made it very, very clear that that is what it is about. Even though most of the literature that even that she writes she is going to say borderline she is very much looking at each particular behavior of the individual as the behavior and not so much from this medical model but rather how do we understand this behavior from what happens before but what happens after and understand its function and then we can intervene. Okay so why are these borderline-patients so difficult to treat I’m going to answer that with a question.
Q. What are the components of affective therapy?
A. Relationships boundaries compliance with what I say treatment understanding and empathy trust and hope self-listening like micro skills cultivating self-evidence.
Ryan: I am going to put up somethings that probably aren’t there and may sound rather cold but therapeutic bond which I think incorporates a lot of bond and trust and communication and listening and alliance and clear treatment planning and by the way if you have questions feel free to blurt them out so far it’s not slowing me down, but if I don’t get to something it’s not a big deal.
Clear Treatment planning, ongoing assessment, use of affective treatment what do we know works, client motivation that’s a crucial one probably accounts for a lot more of a variance than we would like to admit it doesn’t matter how good you are if they are not really motivated it’s not going to do too much good. Therapist’s motivation. And I’m not sure that comes into play especially early in folk’s careers as much because it’s really, really exciting at first but after you have had a couple of really, really tough clients and you kind of hit your head against the ceiling and the wall and the floor and the desk sometimes it can _______ that’s why a team or support team is so important. So, if these are the components of affective therapy think about why these folks are so hard to treat because they don’t do their homework. how many of you guys give homework during the session answer: 3 (out of the whole room) yea it’s hard giving homework people don’t like doing homework.
We will talk about that.
What are their symptoms these folks coming in? What are their symptoms intense emotional responses. What if a person comes in with an emotional response like panic.
What’s a sympathetic and empathetic therapist supposed to say. It’s going to be ok. That sounds pretty warm doesn’t it? What’s that? What did you say? ___________________ I can sit there but what it feels like a fairly- human normal response when a person comes in in a panic do I want them to be in a panic? Who wants their client to be in a panic? I’m a behavior therapist I’m going to like sit there is a tarantula on my lap normally if someone comes in really fearful most people when you think about fear don’t like it they do things to get rid of fear and I don’t like your fear usually I don’t like my own fear if it’s near me and I start feeling bad and maybe I’ll start experiencing some vicarious fears. Let me help you it’s going to be all right. But that can be an experience that is invalidating and with a borderline if we look at their issues what about anger when someone comes in angry let’s just say let’s escalate that a little let’s build on that give me another hostile thought you were thinking about your co-worker yea that one the one sitting beside you you know this morning when he or she blah blah how any of you have done that you’re in the 75% anger right now I’m going to try to get you to a 90 or 95 in the next 5 minutes (laughing) what could you really think about what a jerk that person is. Inaudible have you done that with anger (yes, I have) in a treatment study that’s what we have done but for most of us that’s not our natural
Human response so there may be good reason for it but I think typically if we are at home and a friend comes in and say they are angry that’s not what I do even though I think that might actually be a very affective strategy the human response I think in some way might work against us at times sometimes it’s the right one I just want to be careful of being very self-aware. Okay, so what if someone comes in and says I want to kill myself how many have some of their clients come in this week and say I want to kill myself.
How do we respond to that? What? Just do it. Laughter You don’t really want to do it, this is a delicate thing.
How do you respond to this stuff, not easy.
What’s easy to know what invalidating, what’s encouraging,
what’s validating, what’s enforcing suicide, is scary stuff.
It’s also paired with a very active nervous system but it’s paired with an environment that may be invalidating.
And so the typical kind of environment that seems invalidating is one where what happens to feelings. How does one have negative feelings towards family. They are stuck. Yea but how does stuck how does a parent respond I’ll give you something to cry about. You’re showing invalidation and crisis and crying.
Even seemingly the smallest little thing can set them off. So how do we deal with this. I do think it’s important with these folks to maybe its very clear that the smallest brush at times can be experienced as intensely, intensely painful. And a slow return to base line so it could have been there for quite a while. And then an inability to regulate. So in the scheme of therapy TMT (_____________ based therapy)? And again you really pull these apart again and I’m really less familiar with TFT? And, there really are some similar elements it’s helping clients to get create a little distance between their internal existence and their feelings and their thoughts in their behavior. Mood dependent behavior she talks about it’s intermittent there are moments when you know it just seems like these emotional skills are out the window in terms of emotional intelligence. How did this come about? These is some evidence that there is some biological to look at the 5 factor theory on neurosis and to some extent that is going to be true to a lot of people what happens it’s also known to be paired with very active nervous system but it’s paired with an environment that can be very invalidating and so the typical environment that seems invalidating
One where what happens to negative feelings in this family. They are stuck. Yes they are stuck how does a parent respond.
Kids crying what do you say I’ll give you something to cry about your not suppose to be angry with your family members we love you, you don’t express anger to mommy all right what are you angry about my gosh I’ve given you
Everything. So the child doesn’t learn to accept
Their own emotions. So they might see them as invalid they don’t trust their guttural responses they don’t know how
To experience them so they don’t learn how to express them learn some of the vital skills identifying, labeling and regulating them so there is this combination that the stress model lots of literature and DBT goes a step further it’s not just this predisposition that has an actual evolution that cycles
between these kinds of things its predisposing and invalidity that it builds and evolves over time. It goes out the window over a period of time. How does this come about. There is some evidence that there is biological pre disposition. There are genetic links to co_____________? So you will see borderline sometimes having access ? disorders. Certainly there are many of symptoms child and sexual abuse. So the child and sexual abuse in this literature child and sexual abuse usually ranges from 40 to 76 % it’s very, very high which some people typically assume but it doesn’t mean all the cases are that way. But, it certainly does happen a lot. So there is this chaotic storm and you will hear clients say often enough there are so many emotions and worries and thoughts going on I am just overwhelmed I cannot deal with this stuff. It makes sense why so and other extreme and self-injuring behaviors will help and someone mentioned before that we may experience this where an emotional burn victim which seems like the smallest thing can set him off. How do we deal with this. I do think it’s important with these folks to make sure we have some idea of what science has supported and going out and believe me this is a brief introduction of behavior therapy but I believe this is going a brief introduction of getting what you need in terms of training and supervision of what does the literature say DBT has advocacy probably folks say more than that anything else being shown for borderline to be effective. Jeff ? has a lot of trials to TFT and minimalization based treatment is starting to look good too. So scheme therapy TFT therapy so really if you I’m less familiar with TFT and minimalization. There really are some similar elements its creating clients to get a little distance between their internal experiences these feelings and their thoughts in their behavior. So mood dependent behavior. I was just feeling so bad so when you are feeling so bad what do you want to do curl up in a ball and stay in bed or drink your face off or binge the latter thing you want to do is be social or go for a jog or something. And so for some extent even TFT or minimalization TFT is obviously looking at the relation but so is DBT there is a secondary target what’s interfering with regulating them. So there is probably this combination that is a stress model that is incited by lots of DBT goes a step further and says it has a transactional model saying it’s not just this sort of predisposition that mixes with stress but there is this transactional evolution that cycles between these types of things this predisposition this vulnerability and evolution and builds over time putting people at greater, greater risk. Some of us won’t be able to have a phone team or a skill team if you do that’s wonderful. DBT is heavily rooted in behaviorism and it’s probably a good idea I will give you info on the book. In helping do a chain analysis so we are looking at the function. On the behavior. What happening when you cut yourself what first happened what did you hear what happened before what happened afterward. What the behavior and what changes took place so we an understand why. Relaxation exposure skills the DBT specialist will explain. The notions behind a dialect there can be one some of the starts in view the theory and the perspective in order to define any thing I will have to control I can’t have peace without conflict, I can’t really have an unwise defeating behavior without some adaptive aspect. It’s understanding that the within all of this there is a thesis contained yen and yang. And through a process to synchronize these forces and move forward. To see the case not simply a matter _________________ there may be imposing forces so if we make room for them they can interact so we can accept the present and push the client to change. And it’s beginning to understand how we may validate their emotional state currently and give them a behavioral contract to sign to push their behavior forward. But doing it in a way personally that they are experiencing its validating and they are in this to be helpful to them. It’s a way of letting them know that maybe there are extra phone calls at this point that aren’t really appropriate not because we are burnt out or because we want to abandon them because it’s time for us to step back and remove the scaffolding ___________ stepping back far enough to take the few extra steps on their own allowing them to get the sense of independence and that’s a very difficult line to walk and a balance to strike. That’s the case we have to do with all of our clients but particularly with DBT clients. If you guys want any of these I will fill you in. ___________________________. If you think about anyone with dialectical problems what do you see when working with these types of clients. Active passivity and apparent confidence and think about how that manifests let’s think out this we have these clients that are somehow out there hitting balls out of the ballpark they can do amazing things and the smallest task is overwhelming. And think about what attributions you might make at a time like that or I might make. Just last week you were on the floor of the stock exchange and now you’re telling me you can’t call your landlord and you are dropping this on me in the last two min and now you’re calling me at home afterwards. It’s easy for me to think my gosh you’re being manipulative so it’s very important for us to understand these dialectical problems and to help the clients move through them. Intense emotionality at times you’ll hear the folks saying I got so much pain I got so many emotions and the next something is wrong with me this isn’t right no one else responds this way why am I getting so upset you can see how easily that can move into what am I hear for. There is something wrong with me. So we have to understand why these imposing forces are perhaps able to be seem as one thing we can help sympathize with the client. So basically doing individual therapy with these folks or group settings telephone consultation which is usually coaching and case consultation for the therapist where it is you’re really supporting each other you’re trying to understand and if you are doing the kind of analysis of the chains properly and moving through the skills. All what can we take into our practice like what can each of us do now first style perhaps changes in style how many of you are kind of Rogerian in your style and approach. Warmth empathy good stuff. So two primary styles in DBT the 1st is Rogerian in DBT we certainly want to be warm and emphatic and be able to paraphrase and reflect and let the client know that we are there with them and we do believe they have within them the capacity to change and there is another style which gets more play obviously because it’s a little more different style. Second is a philosophy which you hit on we’ll mention names and some of the skills some of which you may have used maybe you used. If you have a high case load with a high percentage of borderline folks a little break between sessions (and I’m the pot calling the kettle black I now realize) a bathroom break maybe a little food a phone call I don’t think I’ve had a personal phone all during the day in years but might really be not you taking care of you but you taking care of your clients. Because 99% of the time we may be incredibly emphatic there are certainly dangers involved in not taking care of ourselves and just getting caught off guard by that one client who manages to throw something out that may have some suicidal content and it may get us anxious not necessarily saying something angry or intentionally rejecting them but if your client is like an emotional burn victim it doesn’t take too much. So I think as much as possible you have to really want to be aware of where our own thermometer is and take care of ourselves not that we are going to take their heads off but we just might impulsively say something that just isn’t interpreted a little wrong. At the same time we have to be gentle with ourselves because we are going to make mistakes. The part that gets a little more play is the irreverent. How many of you can say you are stuck maybe one or two okay laughter I came out of a school not from Linehan but from a school that is fairly irreverent and I will say it can be incredibly incredibly effective it’s really important to be flexible in our styles and you know when I approach a client I vary it depending on who the client is and where they are. But, the irreverent style in a way can help shift their cognitive take and get them to be a little more flexible about something by one putting them off balance a little and by perhaps even allowing them to see the humor in it. It’s not so rigid and inflexible for everything to be taken seriously. There are clinicians working with this population that how many ever infused humor in a discussion about death? Or suicide I’m not encouraging this by the way but what I want is for people to consider what our normal boundaries are I’m not saying push them but irreverence can be used and here’s the caveat but is the easiest thing to misuse. There are people like Marsha Linehan and Albert Ellis that I think that have demonstrated again and again on videos how skillful it can be used, but when people have a tendency to go out and try to mimic them directly they intend to apply it inappropriately so I really think it’s about being self-aware getting proper supervision in that but let’s something we can have in our arsenal to be effective . Here are things to incorporate. Patients are doing the best they can. Everyone every time in that moment with what their experience has been and what their biology is they are doing the best they can. And I think that’s intellectually easy to grasp who thinks that’s not easy to grasp? Certainly, sometimes it’s not. I think intellectually sometimes it can sink in but in practicing it it’s very easy to think no no the person they could have made a better choice they knew better. I mean you had that person go in relapse after they just had a great group session the week before and they went out and drank and you said come on you knew better than that come on. Where were your skills where were your little crisis cards when you went out how did you get in that situation I don’t understand. Patients want to improve I mean sometimes we think there is a secondary game and we are going to assume I’m not sure they want to improve no think about how that’s really balanced with this notion of being ambivalent with this notion of being lots of us all the time with this notion that there is __________________ and they want to improve patients want to do better and try harder and be more motivated to change. So think about that right we accept you as you are and we know you have to work harder. Patients may have not caused all their own problems but they have to solve them. So there is this notion of responsibility yea your life has been tragic you have had so much trauma and but I understand but it’s up to you I’m here with you I’m working with you we have a 12 month contract I’m not going anywhere and it’s yours to do. The life of a borderline suicide is unbearable _____________________ see how philosophically this might come at odds with some of the cognitive therapies I would say that Marsha Linehan’s work is scientifically incredibly supportive my take is at times she is this can be taken as a strength and as a weakness is more pragmatic than philosophical literal which makes sense on the dialectical there is not necessarily the truth but what is functional. But even other therapies which are in the dialectical mode which have some philosophical differences in this way. But you can see how that has a strength to see how you can emphasize and understand how that client is. Patients must understand ___________________ in all general ________________. Is really crucial. Patients can never fail in therapy and that is important to remember so they can never fail. Maybe the therapist can’t either but if both are carrying things out maybe the therapy itself might have been what wasn’t working. Therapists treading borderline patients need support so it’s definitely incredibly important to make sure that if you are treating borderline patients that you are booked into a team or some kind of set of peers that are helping you out.
All right. Sounds like we are winding down so I’ll take any questions you may have. Probably if it’s anything lengthy I will stay afterwards and let the other people get back to their lives. Any Questions. Inaudible. If anyone leaves I will not take offense and I will talk to the ones that are staying. If you actually signed the sign up in the back I will post some trainings. Linehan’s group certainly does training around fairly frequently you certainly do seminars in that kind of thing. I don’t know the particular study group there are times when there are presentations that are given locally the one thing they are careful about is the standard DBT is really considered on working on a consultation team with telephone and that kind of thing right now they are doing a telephone comparison study to see what if we just do the skills groups and not the rest. So you certainly get training in those kinds of things and if you sign up I will e-mail you when I become aware of things like that and I will put a link to the book. The book is very comprehensive it may be a little I think it’s good but it’s not very small there are all kinds of local trainings and times and things like that.
I know that Alan Bergman at ____________ did a lesson on DBT training last year I don’t know about Mt. Sinai they might. Not sure. ______________ She just had one in Connecticut or Maine and in NY 2 yrs. ago she has a new technique that is fun it’s based on the ________ reflex but she will put in her new skills workbook I’ll be interested in the new feedback. She is based out of Washington but she does trainings on the East Coast at least once or twice a year. ___________________ Yea I think there is a sign up outside we will keep things up dated. ______________________ I can I mean the notion behind personality disorder if you take a strong review first there has been a little personality work on folks done with borderline and there is some evidence they have
From a DSM standpoint you want to be very clear how Axis 1 and Axis 2 are interacting you can certainly see how misdiagnosis can occur and when you talk about age cutoffs for the DSM you have to be 18 and with bi-polar when people try to say what’s going on in adolescence and things you know if you look at sime of the extreme maniac behavors like borderline clients are diagnosed with DBT that do not have bi-polar but its easy to confuse them when you look at diary cards with biological aspects that will be good for DBT as well CBT you do cognitive work working on structure etc. helping them regulate their sleep and diet.
___________________ my guess depends on getting a clinician talking not about any data broadly speculating probably a mode of treatment that is low where they come in experience invalidation or intense stuff or don’t come back or come back they are not going away but don’t ever assume that is the case DBT is cultivating that balance that is highly motivated for the client where they are getting acceptance and change to some extent it helps them to believe there is the possibility for structure and help and it makes them feel safe but it’s a tough thing to challenge. Sometimes we don’t do anything wrong but they aren’t ready or some clients are very happy to come back again.
Thank you very much Dr. Fuller applause