MORE ABOUT GATEWAYS USE OF DBT

Most of the work we do is significantly more casual than the one-on-one therapeutic sessions that are primary to the original form of DBT developed by Linehan. Our individual therapeutic encounters are most likely to occur outside the counselor’s office, and in direct response to a present moment experience. Our teaching moment comes in helping a student to overcome an immediate crisis. Still, the same premise applies in that the students, clients and counselors need to acquire the working vocabulary and skills training in advance of the actual work and the counselor must understand the nature of how DBT operates in order to be effective in the moment.

Since we teach our counseling staff to borrow from a number of behavioral and cognitive change therapies in working with the population we serve, the structure of individual dialectic behavioral therapy and some of the strategies used for classic DBT therapy are used in training sessions for introductory purposes only and to assist the counselor in acquiring a full working knowledge of DBT. However, the basic tenents of DBT remain unchanged and the successful counselor must accept a number of working assumptions in order to establish the required attitude for success:

1. The student wants change in her life and a good resolution to the problem and, in spite of appearances, is trying her best at any particular time.
2. The student’s behavior pattern is understandable given her background and present circumstances. Her life may currently be chaotic and stressful or the conditions of her life dire. The solution is not to pretend that life is different or to give into feelings of despair but rather to make life worth living.
3. In spite of this, the student needs to try harder if things are ever to improve. She may not be entirely to blame for the way things are but it is her personal responsibility to make them different.
4. The student can not fail in DBT. If things are not improving it is the method of management that is failing.

DBT involves acquisition of a skill set for managing people and situations that many at-risk teens lack. Although these teens, like clients diagnosed with BPD, are often described as "manipulative" – and this implies that they are skilled at managing other people - it is precisely the opposite that is true. The awkwardness and inability to manage conflicts in ideas, people and situations results in the others feeling manipulated to reach a resolution instead of that knowing their ideas are recognized, valued and understood and that the student is synthesizing them.

Other similarities between DBT and good parenting are that the counselor interacts with the client in a way that is:

1. Accepting of the client as she is but which encourages change.
2. Centered and firm yet flexible when the circumstances require it.
3. Nurturing but benevolently demanding.

DBT depends on its success on having the co-operation of the client from the start; therefore, attention is given to orienting the client to the nature of DBT and obtaining a commitment to undertake the work.

SKILLS TRAINING is usually carried out in a group context, ideally by someone other that the individual counselor. At the Ranch, these skills training groups are mandatory for all teen members of the Ranch, for counseling staff and for volunteers who work consistently with clients. Ongoing counseling consultations continue for staff following the initial skills training.

In the skills training groups, clients are taught skills considered relevant to the particular problems experienced by people with borderline personality disorder. There are four modules focusing in turn on four groups of skills:

1. Core mindfulness skills.
2. Interpersonal effectiveness skills.
3. Emotion modulation skills.
4. Distress tolerance skills.

The 'core mindfulness skills' are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment.

The 'interpersonal effectiveness skills' which are taught focus on effective ways of achieving one's objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people.

'Emotion modulation skills' are ways of changing distressing emotional states and 'distress tolerance skills' include techniques for putting up with these emotional states if they can not be changed for the time being.

Counselors receive DBT from each other at the regular COUNSELOR CONSULTATION GROUPS and, as already mentioned, this is regarded as an essential aspect of therapy. The members of the group are required to keep each other in the DBT mode and (among other things) are required to give a formal undertaking to remain dialectical in their interaction with each other, to avoid any pejorative descriptions of client or counselor behavior, to respect counselors' individual limits and generally are expected to treat each other at least as well as they treat their clients. Part of the session may be used for ongoing training purposes.

In classical treatment modules utilizing DBT, the individual counselor is the primary counselor. The main work of therapy is carried out in the INDIVIDUAL THERAPY sessions. Between sessions in a classic DBT module, the client is offered TELEPHONE CONTACT with the counselor. That contact is not for the purpose of psychotherapy. Rather it is to give the client help and support in applying the skills that she is learning to her real life situation between sessions and to help her find ways of avoiding self-injury. At GATEWAYS, the function of this contact is transferred to the interaction that occurs between the counseling staff and the client on a daily or weekly basis.

Because DBT works best when there is a genuine relationship between counselor and client, the on-going contact is a necessary adjunct to therapy. It provides the client support and also serves the purpose of relationship repair where the client feels that she has damaged her relationship with her counselor and wants to put this right before the next session.

STAGES OF THERAPY AND TREATMENT TARGETS

Clients who present multiple problems can pose problems for the counselor in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organized into a number of stages and structured in terms of hierarchies of targets at each stage. While we do not necessarily provide a treatment assessment for each young person who uses DBT techniques after participating in skills training, when clinical assessment is deemed necessary, the stages of treatment may be referenced as a means of understanding a client’s needs.

The PRE-TREATMENT STAGE focuses on assessment, commitment and orientation to therapy.

STAGE 1 focuses on suicidal behaviors, therapy interfering behaviors and behaviors that interfere with the quality of life, together with developing the necessary skills to resolve these problems.

STAGE 2 deals with post-traumatic stress related problems (PTSD)

STAGE 3 focuses on self-esteem and individual treatment goals.

The targeted behaviors of each stage are brought under control before moving on to the next phase. In particular post-traumatic stress related problems such as those related to childhood sexual abuse and in a DBT module they are not dealt with directly until stage 1 has been successfully completed. Problems of this type (flashbacks for instance) emerging while the client is still in stages 1 or 2 are dealt with using 'distress tolerance' techniques. The treatment of PTSD in stage 2 involves exposure to memories of the past trauma.

Therapy at each stage is focused on the specific targets for that stage which are arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy but it is essential for counselors working in each mode to be clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking.

TREATMENT STRATEGIES

Within this framework of stages, target hierarchies and modes of therapy a wide variety of therapeutic strategies and specific techniques is applied.

The core strategies in DBT are 'validation' and 'problem solving'. Attempts to facilitate change are surrounded by interventions that validate the client's behavior and responses as understandable in relation to her current life situation, and that show an understanding of her difficulties and suffering.

Problem solving focuses on the establishment of necessary skills. If the client is not dealing with her problems effectively then it is to be anticipated either that she does not have the necessary skills to do so, or does have the skills but is prevented from using them. If she does not have the skills then she will need to learn them. This is the purpose of the skills training.

Having the skills, she may be prevented from using them in particular situations either because of environmental factors or because of emotional or cognitive problems getting in the way. To deal with these difficulties the following techniques may be applied in the course of therapy:

1. Contingency management
2. Cognitive therapy
3. Exposure based therapies
4. Pharmacotherapy

The principles of using these techniques are precisely those applying to their use in other contexts and will not be described in any detail. In every form of DBT, even classical patient therapy, they are used in a relatively informal way and interwoven into therapy.

One of the reasons DBT adapts so well for the environment at The Ranch, is that it is inherently flexible. Contingency management is used throughout therapy, using the relationship with the counselor as the main reinforcer.

There are no “hidden agendas” either, the clear expectations of acceptable behaviors are posted, clarified and discussed openly and regularly. Care is taken to systematically reinforce targeted adaptive behaviors and to avoid reinforcing targeted maladaptive behaviors. This process is made quite overt to the client, explaining that behavior which is reinforced can be expected to increase.

A clear distinction is made between the observed effect of reinforcement and the motivation of the behavior, pointing out that such a relationship between cause and effect does not imply that the behavior is being carried out deliberately in order to obtain the reinforcement. Didactic teaching and insight strategies may also be used to help the client achieve an understanding of the factors that may be controlling her behavior.

The same contingency management approach is taken in dealing with behaviors that overstep the counselor's personal limits in which case they are referred to as 'observing limits procedures'.

Problem solving and change strategies are again balanced dialectically by the use of validation strategies. It is important at every stage to convey to the client that her behaviors, including thoughts feelings and actions are understandable, even though they may be maladaptive or unhelpful.

Significant instances of targeted maladaptive behavior occurring since the last session (which should have been recorded on the diary card) are initially dealt with by carrying out a detailed 'behavioral analysis'. In particular every single instance of suicidal or parasuicidal behavior is dealt with in this way. Such behavioral analysis is an important aspect of DBT and may take up a large proportion of therapy time.

In the course of a typical behavioral analysis a particular instance of behavior is first clearly defined in specific terms and then a 'chain analysis' is conducted, looking in detail at the sequence of events and attempting to link these events one to another. In the course of this process hypotheses are generated about the factors that may be controlling the behavior. This is followed by, or interwoven with, a 'solution analysis' in which alternative ways of dealing with the situation at each stage are considered and evaluated. Finally one solution should be chosen for future implementation. Difficulties that may be experienced in carrying out this solution are considered and strategies of dealing with these can be worked out.

Behavioral analysis can be seen as a way of responding to maladaptive behavior, and in particular to parasuicide, in a way that shows interest and concern but which avoids reinforcing the behavior.

At GATEWAYS for Youth & Families we regularly utilize 'case management strategies'. This is another way of saying we promote self-reliance. The basic idea is that the client should be encouraged, with appropriate help and support, to deal with her own problems in the environment in which they occur. Therefore, as far as possible, the counselor does not do things for the client but encourages the client to do things for herself.