Expanded Techniques inCognitive Behavioral TherapyLEANNE CARLSON, PH.D, HSPP 8395 KEYSTONE CROSSING, SUITE 104 INDIANAPOLIS, INDIANA 46038 WWW.LEANNECARLSONPHD.COM EMAIL: LEANNE.CARLSON1207@GMAIL.COM

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