National Education Alliance for Borderline Personality Disorder

www.borderlinepersonalitydisorder.comwww.bpdforum.com

Special thanks to the National Institute of Mental Health (NIMH) for its conference grant support

Dialectical Behavior TherapyPerry D. Hoffman, Ph.D.

Special thanks to Alan E. Fruzzetti, Ph.D. for the contribution of some of his slides.

Dr. Fruzzetti is the author of “The High Conflict Couple”

What is Dialectical Behavior Therapy

4

Dialectical Behavior Therapy Dialectical Behavior Therapy (DBT) is a Comprehensive, (DBT) is a Comprehensive,

MultiMulti--component, component, PrinciplePrinciple--driven Treatmentdriven Treatment

based on a skills model based on a skills model of treatment.of treatment.

Marsha Linehan, Ph.D.

Developer of Dialectical Behavior Therapy

Marsha Linehan, Ph.D.DBT

8

Why is DBT So ValuedWhy is DBT So Valued

DBT: Evidence-Based Treatment

• More than 50 studies• More than 14 randomized controlled trials• Adults (including elderly) & adolescents• Women and men• Outpatient, inpatient, day tx., forensics• BPD, BPD features, mixed personality disorders• Suicide attempts, parasuicidal behaviors• Substance abuse, eating disorders, depression,

dissociation, panic & other anxiety disorders

10

What Outpatient Studies ShowWhat Outpatient Studies ShowDBT better than comparison treatments:DBT better than comparison treatments:•• Decreased: Decreased:

–– number of selfnumber of self--injuriesinjuries–– Psychiatric inpatient days, ER visitsPsychiatric inpatient days, ER visits–– AngerAnger–– Overall psychological distress & disorders, etc.Overall psychological distress & disorders, etc.–– Overall costs & efficiencyOverall costs & efficiency

•• Increased:Increased:–– Treatment retention (decreased dropout)Treatment retention (decreased dropout)–– Social adjustmentSocial adjustment–– Global adjustmentGlobal adjustment

11

Cost EfficiencyCost Efficiency•• More efficient: uses few resourcesMore efficient: uses few resources•• Clear oneClear one--year cost savingsyear cost savings•• Several studies suggest DBT costs about Several studies suggest DBT costs about

50% of treatment as usual50% of treatment as usual•• Savings comes primarily from lower Savings comes primarily from lower

inpatient, emergency, and medical inpatient, emergency, and medical utilizationutilization

•• Treatment with high Treatment with high utilizersutilizers saves moresaves more•• Cost savings compounds over timeCost savings compounds over time•• Has been replicated multiple timesHas been replicated multiple times

12

Provider Satisfaction!Provider Satisfaction!

•• Provider preference: reduced burnout, Provider preference: reduced burnout, more consistent with values more consistent with values

•• Therapists report increased satisfaction Therapists report increased satisfaction from prefrom pre-- to postto post--training in DBTtraining in DBT

•• Provider satisfaction predicts patient Provider satisfaction predicts patient outcomes, and viceoutcomes, and vice--versaversa

13

Who Can Benefit from DBT: Who Can Benefit from DBT: Diagnostic IssuesDiagnostic Issues

14

Emotion Dysregulation DisordersEmotion Dysregulation Disorders

•• Borderline Personality DisorderBorderline Personality Disorder•• Other personality disordersOther personality disorders•• Many anxiety disordersMany anxiety disorders•• Many affective disordersMany affective disorders•• Many substance use, eating disordersMany substance use, eating disorders•• Multiple other Axis I problemsMultiple other Axis I problems•• Many interpersonal difficultiesMany interpersonal difficulties

Borderline Personality Disorder

16

BPD is the prototype emotion BPD is the prototype emotion dysregulation disorder.dysregulation disorder.

Name change considerationName change considerationEmotion Regulation DisorderEmotion Regulation Disorder

What do we know about Borderline Personality Disorder?

Facts in the General Population▲ ~5 in 100 people

▲ More common than bipolar disorder

▲ More common than schizophrenia

▲ Disproportionately high use of medical resources6% of all medical visits

10% psychiatric outpatients20% psychiatric inpatient admissions

▲ High mortality ~ 10% of persons with BPD kill themselvesCongressional Briefing on Borderline Personality Disorder May 8, 2007

More Facts

▲ BPD is linked to biologically- based, emotionally hypersensitive temperament

▲ Genetic predisposition - it is estimated that 30% to 50% of personality temperament is inherited

▲ BPD is much more treatable than previously thought

▲ 50% of patients remit by 2 years

The Course of Disorder

▲ Age of onset: adolescence and early adulthood

▲ Progression of symptoms: ~ 60 to 75% affected show symptom reduction over time, especially with effective treatment

▲ Prognosis: positive predictors: early detection; effective treatment

negative predictors: impulsivity (decreases with age); substance abuse; early sustained abuse

Congressional Briefing on Borderline Personality Disorder May 8, 2007

Criteria for BPD

DSM-IV Personality Disorders10 in Total

A. Cluster A (odd/eccentric)1. Paranoid2. Schizoid3. Schizotypal

B. Cluster B (dramatic/emotional/impulsive)1. Antisocial2. Borderline3. Histrionic4. Narcissistic

C. Cluster C (anxious/fearful)1. Avoidant2. Dependent3. Obsessive-Compulsive

D. Personality Disorder Not Otherwise Specified

Borderline Personality Disorder (DSM-IV)

1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).

Borderline Personality Disorder (DSM-IV)

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Acute Symptoms• Self-injury, suicide efforts, quasi-psychotic thoughts

• Resolve relatively quickly

• Are the best markers for the disorder

• Are often the main reason for inpatient stays

Adapted from: Zanarini MC, et al. Am J Psychiatry. 2007;164:929-935.

Temperamental Symptoms• Angry feelings and acts. distrust and suspiciousness,

abandonment concerns

• Resolve relatively slowly

• Are not just specific to BPD

• Are associated with ongoing psychosocial impairment

Adapted from: Zanarini MC, et al. Am J Psychiatry. 2007;164:929-935.

In total, there are over 256 ways the disorder can present

And, if that is not enough…

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CoCo--morbidity/Comorbidity/Co--occurring Disordersoccurring Disorders

•• DepressionDepression•• Substance useSubstance use•• Eating disordersEating disorders•• Panic disorderPanic disorder•• PTSDPTSD•• Social phobiaSocial phobia•• GADGAD•• DissociationDissociation•• Violence & Violence &

aggressionaggression

•• Bipolar disorderBipolar disorder•• Attention deficit disorderAttention deficit disorder•• Conduct disorderConduct disorder•• Oppositional/defiant Oppositional/defiant

disorderdisorder•• Other Cluster B disordersOther Cluster B disorders•• Other Personality Other Personality

DisordersDisorders

ASPDASPD

AnxietyAnxiety

BPDBPD

AVPDAVPDHPDHPD

NPDNPD

STPDSTPD

PTSDPTSDBip-IIMDDMDD

Borders on Disorders

Borderline personality disorder rarely stands alone

Prevalence of Disorders Commonly Occurring with

Borderline Personality DisorderIn the General

Population (1 Yr.) With BPD

▲ Major Depressive Disorder 10.5% ~ 80%

▲ Substance use Disorders 6% 64%

▲ Anxiety/panic Disorders 7% 68%

▲ PTSD ~ 3% 56%

▲ Eating Disorders .05% 21-26%

▲ ADHD 5% 25%

Borderline personality disorderis an emotion dysregulation disorder as well

as having four more dysregulationsfive in total.

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Borderline Personality Disorder1. Emotion Dysregulation

Affective labilityProblems with anger

2. Interpersonal DysregulationChaotic relationshipsFears of abandonment

3. Self DysregulationIdentity/difficulties with sense of selfSense of emptiness

4. Behavioral DysregulationSuicidal and non-suicidal self-injuryImpulsive behavior

5. Cognitive DysregulationDissociative behavior/transient paranoia

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Targets are the Behaviors, Targets are the Behaviors, Skills are the SolutionsSkills are the Solutions

•• Emotion Emotion Dysregulation Dysregulation Emotion Regulation SkillsEmotion Regulation Skills

•• Behavioral Behavioral Dysregulation Dysregulation Distress Tolerance SkillsDistress Tolerance Skills

•• Interpersonal Interpersonal Dysregulation Dysregulation Interpersonal SkillsInterpersonal Skills

•• Cognitive & Self Cognitive & Self Dysregulation Dysregulation Mindfulness SkillsMindfulness Skills

Genesis of Borderline Personality Disorder

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Theory:Theory:BioBio--social or Transactional social or Transactional

Model for the Model for the DevelopmentDevelopment and and MaintenanceMaintenance of Borderline of Borderline

Personality (and other Disorders Personality (and other Disorders of Emotion Dysregulation)of Emotion Dysregulation)

Biosocial Theory of BPD

Results in Intense EmotionsResults in Intense Emotions

Biological Dysfunction in the Biological Dysfunction in the Emotion Regulation SystemEmotion Regulation System

EnvironmentalEnvironmentalFactorsFactors

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Emotion Vulnerability: Emotion Vulnerability: Three Factors:Three Factors:

1.1. High sensitivityHigh sensitivity–– High level of discrimination of stimuli with High level of discrimination of stimuli with

an emotional valencean emotional valence2.2. High reactivityHigh reactivity

–– When discriminated, reactions are When discriminated, reactions are extremeextreme

3.3. Slow return to baselineSlow return to baseline–– Slow return leaves the individual Slow return leaves the individual

vulnerable to the next emotional stimulusvulnerable to the next emotional stimulus

The Brain

Neuroimaging Studies

▲ Studies consistently show smaller volumes in the amygdala of adult patients with BPD

▲ Neuroimaging studies revealed dysfunctional brain networks that seem to mediate most of the symptoms of BPD

The Environment

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Invalidating EnvironmentInvalidating Environment(Invalidating)

PervasivePervasive communication that validcommunication that validresponses of the individual, responses of the individual, especially private ones (e.g., especially private ones (e.g., emotions, thoughts, wants) are emotions, thoughts, wants) are incorrect, inaccurate, faulty,incorrect, inaccurate, faulty,inappropriate or otherwise invalidinappropriate or otherwise invalid

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Invalidating EnvironmentInvalidating Environment

1. Rejects the thoughts of the person1. Rejects the thoughts of the person2. Punishes emotional displays and 2. Punishes emotional displays and

intermittently reinforces emotional intermittently reinforces emotional escalationescalation

3. Oversimplifies ease of problem 3. Oversimplifies ease of problem solving and meeting goalssolving and meeting goals

Environmental Influenceon the Maintenance

of the Disorder

46(Fruzzetti, Shenk, & Hoffman, 2005)

Low Emotion

Vulnerability

Consistent Validating

Responses

Modest Heightened Emotional Arousal

Accurate Expression

Validating Responses

Event

Healthy Transactions and Emotion Regulation

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Healthy Emotional Processing Healthy Emotional Processing •• ““BumpBump”” into stimulus into stimulus primary emotional primary emotional

responseresponse•• Notice and allow the primary emotionNotice and allow the primary emotion•• Approach it with interest and selfApproach it with interest and self--validationvalidation•• Others validate, offer instrumental supportOthers validate, offer instrumental support•• ProblemProblem--solve the situation, if neededsolve the situation, if needed•• Arousal goes down (natural course)Arousal goes down (natural course)•• Go on with life; Go on with life; ““negativenegative”” countercounter--

balanced by balanced by ““positivepositive””•• ““BumpBump”” again, and againagain, and again……

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What Goes WrongWhat Goes Wrong•• Too many big negative Too many big negative ““bumpsbumps”” (too few +)(too few +)

–– Improve job, relationships, living situation, etc.Improve job, relationships, living situation, etc.•• Avoid situations, ignore reactions (suppress, Avoid situations, ignore reactions (suppress,

selfself--invalidate)invalidate)–– Exposure (and response prevention)Exposure (and response prevention)

•• Get judgmental about another, or selfGet judgmental about another, or self•• Jump to secondary emotionJump to secondary emotion•• Cut off primary emotional arousal processCut off primary emotional arousal process•• Others invalidate, increase demandsOthers invalidate, increase demands•• Get stuck in primary or secondary emotionGet stuck in primary or secondary emotion

49(Fruzzetti, Shenk, & Hoffman, 2005)

Event

Vulnerability (sensitivity, reactivity,

etc)

Pervasive History of Invalidating

Responses

Heightened Emotional Arousal*

“Inaccurate” Expression

Invalidating Responses

Judgments

Transactional Model for Emotion Dysregulation

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Transactional Model: Factors Influence Transactional Model: Factors Influence Each Other (ReciprocalEach Other (Reciprocal))

Individual Emotion Vulnerability & Dysregulation

Invalidating Responses

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Summary on Severe DistressSummary on Severe Distress

1.1. Combination of all three:Combination of all three:a)a) SensitivitySensitivityb)b) ReactivityReactivityc)c) Slow return to baseline Slow return to baseline PLUSPLUS

2.2. Inability to modulate emotions (lack of Inability to modulate emotions (lack of skillful selfskillful self--management)management)PLUSPLUS

3. Invalidating social/family environment3. Invalidating social/family environment

But, there is great hope!

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Dialectical Behavior TherapyDialectical Behavior Therapy

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Core DialecticCore Dialectic

Acceptance/ Acceptance/ ValidationValidation

Change/ Change/ Problem SolvingProblem Solving

DialecticsDialectics

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Comprehensive Treatment:Comprehensive Treatment:Modes and Functions of DBTModes and Functions of DBT

Standard DBT Modes

▲ Individual Psychotherapy

▲ Group Skills Training

▲ Telephone Consultation

▲ Therapist’s Consultation Meeting

▲ Ancillary TreatmentsMedicationAcute-inpatient psychiatric admissionFamily psychoeducation

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DBT Functions & Modes of Therapy1. INDIVIDUAL THERAPY Improve motivation (Focusing

on chain analysis of antecedents and consequences of primary targets/solutions).

2. SKILLS TRAINING (Skills Acquisition) Enhance capabilities

3. Phone Consultation Assure generalization to natural environment

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DBT Functions & Modes of Therapy

4. CONSULTATION TEAM MEETING Enhance therapist capabilities and motivation to treat effectivelyTherapists’, Supervision, Continuing Education, Staff Incentives

5. STRUCTURE THE ENVIRONMENT to allow progressAdmin. or Treatment Setting, Family & Social Environment

Important DBT Tenets

Assumptions

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Dialectical Assumptions:Dialectical Assumptions:

•• There is no one or any absolute truthThere is no one or any absolute truth•• Everyone is doing the best they canEveryone is doing the best they can•• Everyone needs to try harderEveryone needs to try harder•• Interpret things in the most benign way possibleInterpret things in the most benign way possible

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Dialectical Assumption: PatientsDialectical Assumption: Patients

•• Patients want to improvePatients want to improve•• Patients must learn and use new behaviors in all Patients must learn and use new behaviors in all

relevant contextsrelevant contexts•• Patients cannot fail in DBTPatients cannot fail in DBT•• Patients may not have caused all of their own Patients may not have caused all of their own

problems, but they have to solve them anywayproblems, but they have to solve them anyway•• Patients need to do better, try harder, and/or be Patients need to do better, try harder, and/or be

more motivated to changemore motivated to change•• The lives of suicidal, borderline individuals are The lives of suicidal, borderline individuals are

unbearable as they are currently being livedunbearable as they are currently being lived

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Dialectical Assumptions: TherapistDialectical Assumptions: Therapist

•• The therapeutic relationship is a real relationship The therapeutic relationship is a real relationship between equal human beingsbetween equal human beings

•• Therapists treating borderline patients need supportTherapists treating borderline patients need support•• DBT therapists can failDBT therapists can fail•• DBT can fail even when therapists do notDBT can fail even when therapists do not

Starting the Treatment

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Stages of Treatment,Stages of Treatment,andand

Treatment Targets by StageTreatment Targets by Stage

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Overarching DBT Goals are Not:Overarching DBT Goals are Not:

•• Keeping the client aliveKeeping the client alive•• Keeping the client out of the hospitalKeeping the client out of the hospital•• Reducing the overall cost of care for the Reducing the overall cost of care for the

clientclient

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Overarching DBT Goal:Overarching DBT Goal:Creating a Life Worth LivingCreating a Life Worth Living

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PrePre--Treatment AssessmentTreatment Assessment•• Inclusion/exclusion criteriaInclusion/exclusion criteria•• Problem assessment (what stage of treatment: Problem assessment (what stage of treatment:

primary targets, secondary targetsprimary targets, secondary targets•• Client expectations, goals and desiresClient expectations, goals and desires•• Contingencies affecting participationContingencies affecting participation•• Analysis of problems in previous treatments Analysis of problems in previous treatments

(failures, dropout, prior therapy(failures, dropout, prior therapy--interfering interfering behaviors, etc.)behaviors, etc.)

•• Social/family/work environment factorsSocial/family/work environment factors

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Getting Started in PreGetting Started in Pre--TreatmentTreatment

•• Do the treatment before starting the treatment Do the treatment before starting the treatment (structure & process)(structure & process)

•• Orienting and explicitly committing to:Orienting and explicitly committing to:–– goalsgoals–– diary cardsdiary cards–– treatment target hierarchytreatment target hierarchy

Treatment Hierarchies

STAGE 1 focuses on suicidal behaviours, therapy intefering behaviors andbehaviors that interfere with the quality of life, together with developing the necessary skills toresolve these problems.

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

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

Summary of Stages

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Stage 1Stage 1Severe Behavioral Severe Behavioral DyscontrolDyscontrol Behavioral ControlBehavioral Control

Primary TargetsPrimary Targets–– Decrease:Decrease:

•• LifeLife--threatening behaviors: suicide, selfthreatening behaviors: suicide, self--injury, injury, homicide, aggression/violence, child neglecthomicide, aggression/violence, child neglect

•• TherapyTherapy--interfering behaviorsinterfering behaviors•• QualityQuality--ofof--life interfering behaviorslife interfering behaviors

–– Increase Behavioral Skills & SelfIncrease Behavioral Skills & Self--ManagementManagement•• MindfulnessMindfulness•• Interpersonal EffectivenessInterpersonal Effectiveness•• Emotion RegulationEmotion Regulation•• Distress ToleranceDistress Tolerance

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LifeLife--Threatening BehaviorsThreatening Behaviors

•• SuicideSuicide--related behaviorsrelated behaviors•• SelfSelf--injurious behaviorsinjurious behaviors•• ChangesChanges in suicide ideation and in suicide ideation and

communication about suicidecommunication about suicide•• Aggressive and violent behaviorAggressive and violent behavior•• Child abuse and neglectChild abuse and neglect•• Other lifeOther life--threatening behaviorsthreatening behaviors……

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TherapyTherapy--Interfering Behaviors: Patient Interfering Behaviors: Patient

•• Behaviors that interfere with therapy processBehaviors that interfere with therapy process–– Not attending sessions (individual, group, etc.)Not attending sessions (individual, group, etc.)–– Not collaborating in treatmentNot collaborating in treatment–– Not complying with agreements (e.g., agreedNot complying with agreements (e.g., agreed--

upon solutions in chain analysis)upon solutions in chain analysis)

•• Behaviors that interfere with other patientsBehaviors that interfere with other patients

•• Behaviors that will likely burn out the therapist or Behaviors that will likely burn out the therapist or other team membersother team members–– Behaviors that push therapistsBehaviors that push therapists’’ limitslimits–– Behaviors that reduce therapistsBehaviors that reduce therapists’’ motivationmotivation

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QualityQuality--ofof--Life Interfering BehaviorsLife Interfering Behaviors

•• Severe dysfunctional behaviors that interfere with Severe dysfunctional behaviors that interfere with employment, education, etc.employment, education, etc.

•• Health/illness related dysfunctional behaviorsHealth/illness related dysfunctional behaviors•• Lack of stable housingLack of stable housing•• Other severe mental health problems (e.g., other Other severe mental health problems (e.g., other

severe DSM Axis I & IV Disorders) severe DSM Axis I & IV Disorders) •• High risk sexual behaviorHigh risk sexual behavior•• Extreme financial problems that interfere with Extreme financial problems that interfere with

nutrition, safety, or life stabilitynutrition, safety, or life stability•• Criminal behaviors that increase the risk of Criminal behaviors that increase the risk of

incarcerationincarceration•• Extreme dysfunctional interpersonal behaviorsExtreme dysfunctional interpersonal behaviors

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Stage 1 GoalsStage 1 Goals

•• SafetySafety–– Elimination of suicidal and selfElimination of suicidal and self--injurious injurious

behaviors, aggression, other lifebehaviors, aggression, other life--threatening threatening behaviorsbehaviors

•• StabilityStability–– TreatmentTreatment–– HousingHousing–– One or more relationshipsOne or more relationships–– Meaningful daily activities (e.g., working, Meaningful daily activities (e.g., working,

taking care of family, education)taking care of family, education)

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Therapist AgreementsTherapist Agreements

•• Maintain confidentialityMaintain confidentiality

•• Obtain consultation regularlyObtain consultation regularly

•• Make every reasonable effort to conduct Make every reasonable effort to conduct competent and effective therapycompetent and effective therapy

•• Obey standard ethical and professional guidelinesObey standard ethical and professional guidelines

•• Be available to the patient for weekly therapy Be available to the patient for weekly therapy sessions, phone consultations, and provide sessions, phone consultations, and provide therapy backtherapy back--up as neededup as needed

•• Respect the integrity and rights of the patientRespect the integrity and rights of the patient

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TherapyTherapy--Interfering Behaviors: TherapistInterfering Behaviors: Therapist

Some examples:Some examples:•• Behaviors that unbalance therapy (e.g., Behaviors that unbalance therapy (e.g.,

too extreme acceptance or change)too extreme acceptance or change)•• Judgmental behaviorsJudgmental behaviors•• Not attending to own motivation Not attending to own motivation •• Providing too little or too much nurturanceProviding too little or too much nurturance•• Reinforcing dysfunctionReinforcing dysfunction•• Any disrespectful behaviorAny disrespectful behavior

Cornerstones of the Individual Therapy

Diary Card

Dialectical Behavior Therapy Diary Card

Week Starting:_______________EMOTIONS: Today I Felt… (Use Scale of 0-5)

MT W TH F S S

Anger

Disgust

Empty (Alone)

Fear (Tense, Anxious, Panicky)

Interest

Love (Joy, Happiness)

Physically Bad

Sad (Depressed, Hopeless)

Shameful/Guilty

Unreal/Disconnected

URGES & BEHAVIORS: Today I Felt An Urge To: (Use A Scale of 0-5*If you Acted on the Urge)

Target 1 Target 2 Target 3 Personal Targets

M

T

W

Th

F

S

S

DESCRIBE WHAT WAS IMPORTANT TODAY (Especially related to your targets and your use of skills)

M T W TH F S S

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Diary CardDiary CardFunctions:Functions:•• Keeps targets clear and monitored (daily)Keeps targets clear and monitored (daily)•• Assessment (interval/episode)Assessment (interval/episode)

–– Monitor therapy progress on primary targetsMonitor therapy progress on primary targets–– Monitor secondary targets, skillful alternativesMonitor secondary targets, skillful alternatives

•• Used in session to set agenda (and improves Used in session to set agenda (and improves chain analysis)chain analysis)

•• Reminder to practice skills; blocks avoidance Reminder to practice skills; blocks avoidance and escapeand escape

•• Facilitates improvement (selfFacilitates improvement (self--monitoring)monitoring)

Chain Analysis

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Behavioral Chain AnalysisBehavioral Chain Analysis

PROMPTINGEVENT

VULNERABILITIES

PRIMARY TARGET (PROBLEM BEHAVIOR)

REINFORCINGCONSEQUENCES

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Chain Analysis Steps in DetailChain Analysis Steps in Detail1.1. Identify primary target (including diary card)Identify primary target (including diary card)2.2. Identify secondary (treatable) targets and Identify secondary (treatable) targets and

understand determinants of behaviorunderstand determinants of behavior3.3. Focus on emotion, discriminating between Focus on emotion, discriminating between

primary and secondary emotionsprimary and secondary emotions4.4. Identify acceptance & change solutionsIdentify acceptance & change solutions5.5. Use behavior therapy strategies to incorporate Use behavior therapy strategies to incorporate

solutions collaborativelysolutions collaboratively6.6. Employ teaching, orienting, validating Employ teaching, orienting, validating

strategiesstrategies7.7. Get commitment to new Get commitment to new behavior(sbehavior(s))

88

Example: Chain Analysis of CuttingExample: Chain Analysis of Cutting

TRIGGER:INVALIDATION

VULNERABILITIES: LONELY, TIRED, REACTIVE

CUTTING, Thursday at 4:30

RELIEF

PRIMARY EMOTION: SADNESS

JUDGMENTS or SELF-INVALIDATION “I’M WORTHLESS”

SECONDARY EMOTION:

SHAME

89

Behavioral Chain Analysis: Changing Behavioral Chain Analysis: Changing Behavior & Breaking the Old PatternBehavior & Breaking the Old Pattern

PROMPTINGEVENT

VULNERABILITIESPROBLEMBEHAVIOR

CONSEQUENCES

SKILLFULBEHAVIORS

REINFORCING

90

Example: SolutionsExample: Solutions

PROMPTINGEVENT

VULNERABILITIESPROBLEMBEHAVIOR

OBSERVE & DESCRIBE

RELIEF

ALLOW PRIMARY EMOTION

SELF-VALIDATE

SOOTHE ACTIVATE

91

Treatment Targets: Treatment Targets: Links on the ChainLinks on the Chain

•• Situational linksSituational links–– specific to the present chain onlyspecific to the present chain only–– lower lower generalizabilitygeneralizability–– prioritize only when this chain is common, prioritize only when this chain is common,

lethal, highest order target and easier to treat lethal, highest order target and easier to treat than a more common linkthan a more common link

•• Common linksCommon links–– links that show up on multiple chains (same links that show up on multiple chains (same

primary target or others)primary target or others)–– higher higher generalizabilitygeneralizability

92

Stage 2 Stage 2 Quiet Desperation, Quiet Desperation, Emotional ExperiencingEmotional Experiencing

Misery, andMisery, and Validating Validating EnvironmentEnvironment

Truncated EmotionsTruncated Emotions SelfSelf--ValidationValidationPrimary TargetsPrimary Targets–– Decrease PTSDDecrease PTSD--related problemsrelated problems–– Decrease general avoidance of emotion cuesDecrease general avoidance of emotion cues–– Decrease secondary emotional reactions Decrease secondary emotional reactions –– Decrease selfDecrease self--invalidationinvalidation–– Decrease relationship conflictDecrease relationship conflict

GoalsGoals–– Increased emotional identification, Increased emotional identification,

experiencing, and expression; selfexperiencing, and expression; self--validationvalidation–– Connection to family Connection to family member(smember(s) & others) & others–– More validating social/family environmentMore validating social/family environment

93

Stage 3Stage 3Problems in LivingProblems in Living & Individual Well& Individual Well--BeingBeing

DissatisfactionDissatisfaction Relationship SatisfactionRelationship SatisfactionMutual EnhancementMutual Enhancement

Primary TargetsPrimary Targets–– Increased self respectIncreased self respect–– Solving problems in living/Solving problems in living/–– Modifying dysfunctional interaction patternsModifying dysfunctional interaction patterns

GoalsGoals–– Self Respect Self Respect –– Self EfficacySelf Efficacy–– Problem solving/problem management skillsProblem solving/problem management skills–– Connection with own valuesConnection with own values–– Acceptable quality of lifeAcceptable quality of life

94

Stage 4 Stage 4

IncompletenessIncompleteness ContentmentContentment& Intimacy& Intimacy

Goals:Goals:––Enhanced self awarenessEnhanced self awareness––Enhanced mindful engagement in livingEnhanced mindful engagement in living––Acceptance & closeness of self and Acceptance & closeness of self and othersothers

•• Behavioral toleranceBehavioral tolerance•• Relational mindfulnessRelational mindfulness•• WillingnessWillingness

––Synthesis of intimacy & autonomySynthesis of intimacy & autonomy

95

Understanding EmotionsUnderstanding Emotions

Emotion Regulation Disorder

96

Primary and Secondary EmotionsPrimary and Secondary Emotions

•• Primary emotions: initial response, Primary emotions: initial response, normative, typically adaptive, effectivenormative, typically adaptive, effective

•• Secondary emotions: emotional response Secondary emotions: emotional response to primary emotion itself; through overto primary emotion itself; through over--learning, secondary emotional responses learning, secondary emotional responses may even become a problematic initial may even become a problematic initial emotional responseemotional response

•• Goal or strategy: treat primary emotions; Goal or strategy: treat primary emotions; ignore/extinguish/refocus away from ignore/extinguish/refocus away from secondary emotionssecondary emotions

97

Secondary Emotional ReactionsSecondary Emotional Reactions

SadnessSadnessFearFearGuiltGuiltJealouslyJealouslyShameShameFrustrationFrustration

Anger Anger or or ShameShame

Mediated by Mediated by judgmentsjudgments

JudgmentJudgment

98

Example: AngerExample: Anger

•• Anger as a primary emotionAnger as a primary emotion–– normative, justifiednormative, justified

VERSUSVERSUS•• Anger as a secondary emotionAnger as a secondary emotion

–– nonnon--normative or unjustified (or destructive)normative or unjustified (or destructive)–– escape response from a different (primary) escape response from a different (primary)

emotionemotion

99

Example: ShameExample: Shame

•• Shame as a primary emotionShame as a primary emotion–– normative, justifiednormative, justified

VERSUSVERSUS•• Shame as a secondary emotionShame as a secondary emotion

–– nonnon--normative or unjustified (or destructive)normative or unjustified (or destructive)–– escape response from a different (primary) escape response from a different (primary)

emotionemotion

100

Change Negative EmotionsChange Negative Emotions

•• Use anger or shame as a Use anger or shame as a ““signalsignal”” for missing for missing a primary emotion (selfa primary emotion (self--invalidation)invalidation)

•• Identify the primary emotion (from the Identify the primary emotion (from the antecedent chain)antecedent chain)

•• ““TreatTreat”” the primary emotion (e.g., the primary emotion (e.g., identification, labeling, selfidentification, labeling, self--validation, validation, description, acceptance or change skills)description, acceptance or change skills)

•• Acknowledge the secondary emotion, then Acknowledge the secondary emotion, then ignore itignore it……focusing instead on the primaryfocusing instead on the primary

101

Change Strategies: Change Strategies: Behavior TherapyBehavior Therapy

102

Skills Training is Necessary Skills Training is Necessary When the Solution is Not in When the Solution is Not in

the Patientthe Patient’’s Repertoires Repertoire

103

Skills as Solutions: Use Behavior Therapy Skills as Solutions: Use Behavior Therapy To Implement SolutionsTo Implement Solutions

PROMPTINGEVENT

VULNERABILITIESPROBLEMBEHAVIOR

OBSERVE & DESCRIBE

RELIEF

ALLOW PRIMARY EMOTION

SELF-VALIDATE

SOOTHE ACTIVATE

Skill TrainingSkill Training

Goals of Skills Training

To learn and practice adaptive emotion regulation skills to replace maladaptive behaviors*

* Note use of word maladaptive and not ineffective

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Skill TrainingSkill Training

Traditional Individual Skill Modules:Traditional Individual Skill Modules:•• MindfulnessMindfulness•• Distress ToleranceDistress Tolerance•• Emotion RegulationEmotion Regulation•• Interpersonal EffectivenessInterpersonal Effectiveness

Format:Format:•• Homework Review (Skill strengthening, Homework Review (Skill strengthening,

Generalization)Generalization)•• New Skill EducationNew Skill Education

Skill Acquisition Skill Application Skill Generalization

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Skill Generalization in DBTSkill Generalization in DBT•• Transfer new skills to the relevant life situationTransfer new skills to the relevant life situation

–– Generalization planning & homeworkGeneralization planning & homework–– Rehearsal Rehearsal –– Phone consultation (therapist or other)Phone consultation (therapist or other)

•• Manage crises effectively without escalation Manage crises effectively without escalation (or external intervention)(or external intervention)–– Use skills, shaping toward goalsUse skills, shaping toward goals–– Continuity with individual DBT therapistContinuity with individual DBT therapist–– May be individual DBT therapist or other (e.g., May be individual DBT therapist or other (e.g.,

crisis team)crisis team)

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Skill OverviewsSkill Overviews

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Core Mindfulness SkillsCore Mindfulness SkillsWise MindWise Mind

•• ““WhatWhat”” Skills (any one at a time)Skills (any one at a time)–– Observe (just notice)Observe (just notice)–– Describe (put words on what you notice)Describe (put words on what you notice)–– Participate (act from wise mind; stop evaluating)Participate (act from wise mind; stop evaluating)

•• ““HowHow”” Skills (all three simultaneously)Skills (all three simultaneously)–– NonNon--Judgmentally (neither good nor bad)Judgmentally (neither good nor bad)–– OneOne--Mindfully (inMindfully (in--thethe--presentpresent--moment)moment)–– Effectively (focus on what works visEffectively (focus on what works vis--àà--vis long vis long

term goals)term goals)

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Distress Tolerance SkillsDistress Tolerance Skills

•• Crisis survival strategies: tolerate Crisis survival strategies: tolerate distress because the alternative will distress because the alternative will make the situation worsemake the situation worse

-- DistractDistract-- SelfSelf--soothesoothe-- Improve the momentImprove the moment-- Pros and consPros and cons

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Distress Tolerance, contDistress Tolerance, cont

•• Guidelines for accepting realityGuidelines for accepting reality–– Observing your breathObserving your breath–– HalfHalf--smilingsmiling–– AwarenessAwareness–– Radical acceptanceRadical acceptance

•• Turning the mindTurning the mind•• WillingnessWillingness

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Emotion Regulation SkilEmotion Regulation Skillsls

•• Understand emotionsUnderstand emotions•• Reduce emotional vulnerabilityReduce emotional vulnerability•• Decrease emotional sufferingDecrease emotional suffering•• Change by acting opposite to painful Change by acting opposite to painful

emotionsemotions

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Dialectics of Dialectics of Interpersonal EffectivenessInterpersonal Effectiveness

•• Understanding your goalsUnderstanding your goals•• Structuring the interactionsStructuring the interactions

Samples of DBT Skills

Core Mindfulness SkillsTaking Hold of Your Mind

Core Mindfulness Skills

What Skills: How Skills:

Observe Non-judgmentally

Describe One-mindfully

Participate Effectively

Core Mindfulness SkillsWhat Skills:

Observe: Just notice the experience. Have a teflon mind. Watch your thoughts come and goDescribe: Put words on the experience. Describe to yourself what is happeningParticipate: To become one with your experience completelyletting yourself enter the moment

Core Mindfulness SkillsHow Skills:

Non-judgmentally: See but don’t evaluate. Accept each moment. Just the facts. Don’t judge your judgingOne-mindfully: Do one thing at a time. Concentrate yourmindEffectively: Focus on what works. Act skillfully

Interpersonal Effectiveness

Priorities for Interpersonal Effectiveness

• Objectives Effectiveness– Getting your objectives or goals in a situation

• Relationship Effectiveness– Getting or keeping a good relationship while

achieving your objectives

• Self-Respect Effectiveness– Keeping or improving self-respect and liking

for yourself while achieving your objectives

DEAR MAND= Describe the current situation

E= Express your feelings and opinions

A= Asset yourself by asking for what you want

R= Reinforce or reward the person

M= (stay) Mindful. Keep your focus on your objective

A= Appear confident and effective

N= Negotiate. Be willing to give to get. Offer/ask for

alternative solutions

Distress Tolerance Skills

• Guidelines for Accepting Reality

• Willfulness vs Willingness

• Opposite Action

Radical Acceptance• Freedom from suffering requires ACCEPTANCE

from deep within of what is. Letting yourself go completely with what is. Let go of fighting reality.

• Pain creates suffering only when you refuse to ACCEPT the pain.

• Deciding to tolerate the moment is ACCEPTANCE

• ACCEPTANCE is acknowledging what is

• To ACCEPT something is not the same as judging it good

Willingness vs Willfulness

• Willingness Cultivate a WILLING response to each situation. Willingness is doing just what is needed in each situation. It is focusing on effectiveness

• Willfulness is Sitting on your hands when action is needed refusing to make changes that are neededWillfulness is giving up

Emotion Regulation

Goals of Emotion Regulation Skills

Understand emotions you experience

Reduce emotional vulnerability

Decrease emotional suffering

Components of Emotions

Face and body language

Expression with words

Brain change(neurochemical)

Physical changes

Action urges

PromptingEvent 1

Prompting Event 2

Interpretation

Aftereffects Emotion name

Changing Emotions by Acting Oppositeto the Current Emotion

Fear: Do what are afraid of over and over. Approach events, places, tasks people you are afraid of

Guilt: Repair the problem. Make things better. Commit to avoiding the mistake in the future

Sadness: Get active, approach don’t avoid

Anger: Gently avoid the person you are angry with rather than attacking. Do something nice rather than mean or attacking.

Telephone Coaching

Skills Coaching• Recognizes that problems most often occur out

of the individual therapy session.

• Is used NOT as a therapy session, but as a way to provide coaching through a difficult moment.

• Skills coach can be but need not be the individual therapist.

• Skills are generalized to real life situations.

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Telephone Strategies to Aid Telephone Strategies to Aid GeneralizationGeneralization

•• Accepting patientAccepting patient--initiated phone calls for initiated phone calls for crises, problems, or relationship repaircrises, problems, or relationship repair–– Phone calls and suicidal behavior: Phone calls and suicidal behavior:

the the ““2424--HourHour”” rulerule

–– Types of callsTypes of calls•• Problem solving (skill generalization, in crisis Problem solving (skill generalization, in crisis

situation or other generalization situation)situation or other generalization situation)•• Checking in (using therapist as a stimulus)Checking in (using therapist as a stimulus)•• Repairing the relationship Repairing the relationship

•• TherapistTherapist--initiated phone callsinitiated phone calls

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Targets for Telephone CallsTargets for Telephone CallsWith primary DBT therapistWith primary DBT therapist•• Increase generalization of skills (coaching)Increase generalization of skills (coaching)•• Decrease crisis behavior (also generalization)Decrease crisis behavior (also generalization)•• Maintain/improve relationshipMaintain/improve relationshipWith skills trainer:With skills trainer:•• Decrease therapy interfering/destroying Decrease therapy interfering/destroying

behavior, by coaching skills and validatingbehavior, by coaching skills and validating•• Refer client back to primary therapistRefer client back to primary therapist

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DBT StrategiesDBT Strategies

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Acceptance and ValidationAcceptance and Validation

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What is Acceptance? Validation?What is Acceptance? Validation?•• AcceptanceAcceptance is is notnot putting energy into putting energy into

changing the person/her experience per sechanging the person/her experience per se•• Instead:Instead:

–– TolerateTolerate–– Appreciate context Appreciate context –– UnderstandUnderstand–– Participate or allow the experienceParticipate or allow the experience

•• ValidationValidation is the communication of is the communication of acceptance, understanding, or legitimacy, of acceptance, understanding, or legitimacy, of the person or his/her behavior & experiencethe person or his/her behavior & experience

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Validation: Roles of TherapistValidation: Roles of Therapist•• As a stimulus for improvementAs a stimulus for improvement•• To balance change strategies (dialectically)To balance change strategies (dialectically)•• Reinforce progress (shaping, skillfulness)Reinforce progress (shaping, skillfulness)•• PotentiatePotentiate skill useskill use•• Strengthen selfStrengthen self--validationvalidation•• Keep session moving/prevent getting stuckKeep session moving/prevent getting stuck•• Communicate acceptance and strengthen Communicate acceptance and strengthen

the therapeutic relationshipthe therapeutic relationship•• Bring arousal downBring arousal down

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Levels or Types of Verbal ValidationLevels or Types of Verbal Validation1.1. Staying Awake: unbiased listening andStaying Awake: unbiased listening and

observing, paying attentionobserving, paying attention2.2. Accurate reflection (verbal & nonAccurate reflection (verbal & non--verbal)verbal)

3.3. Articulating the patientArticulating the patient’’s s unverbalizedunverbalized emotions, emotions, thoughts, or behavior patternsthoughts, or behavior patterns

4.4. Validation in terms of previous learning or Validation in terms of previous learning or biological dysfunctionbiological dysfunction

5.5. Validation in the present context: normative Validation in the present context: normative (and normalizing)(and normalizing)

6.6. Radical Genuineness: patient is not fragile,Radical Genuineness: patient is not fragile,but is an equal human beingbut is an equal human being

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Applications of Validation in DBTApplications of Validation in DBT

•• Therapist validation of patientTherapist validation of patient•• Therapist selfTherapist self--validationvalidation•• Teaching patient validation of othersTeaching patient validation of others

–– interpersonal skillsinterpersonal skills•• Teaching patient selfTeaching patient self--validationvalidation

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Observing LimitsObserving Limits•• GenuinenessGenuineness•• Dialectically balancing therapist and patient Dialectically balancing therapist and patient

benefitsbenefits–– sometimes must stretch limitssometimes must stretch limits–– sometimes must tighten limitssometimes must tighten limits

•• With consultationWith consultation•• Deal with limits in session Deal with limits in session

–– provide rationale (dialectical validation)provide rationale (dialectical validation)–– provide soothingprovide soothing

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DBT Consultation TeamDBT Consultation Team

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DBT: Community of DBT: Community of Therapists Treating a Therapists Treating a

Community of PatientsCommunity of Patients

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Therapist NonTherapist Non--Judgmental Stance: Judgmental Stance: Requires mindfulness and Requires mindfulness and emotion regulation, emotion regulation, plusplus

team consultation & supportteam consultation & support

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Consultation TeamConsultation Team•• A permanent function of DBTA permanent function of DBT

–– DBT is a team treatment, delivered as a programDBT is a team treatment, delivered as a program–– Acceptance and change of the therapist, teamAcceptance and change of the therapist, team

•• Multiple perspectives availableMultiple perspectives available•• Opposition is valued, not avoided (no Opposition is valued, not avoided (no ““rightright””))•• Synthesis is desirableSynthesis is desirable•• Support and validation are essentialSupport and validation are essential•• Enhancing treatment skills to help maintain Enhancing treatment skills to help maintain

motivation, staying freshmotivation, staying fresh

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Consultation TeamConsultation Team

How to Promote anHow to Promote anEffective Consultation TeamEffective Consultation Team

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1. DBT Consultation Agreements1. DBT Consultation Agreements•• To accept a dialectical philosophy To accept a dialectical philosophy •• To consult with the patient on how to interact with To consult with the patient on how to interact with

other therapists and not to tell other therapists how other therapists and not to tell other therapists how to interact with patient to interact with patient

•• That consistency of therapists with one another That consistency of therapists with one another (even across the same patient) is not necessarily (even across the same patient) is not necessarily expectedexpected

•• That all therapists are to observe their own limits That all therapists are to observe their own limits without fear of judgmental reactions from other without fear of judgmental reactions from other consultation group members consultation group members

•• To search for nonTo search for non--pejorative, phenomenological pejorative, phenomenological empathic interpretation of patientempathic interpretation of patient’’s behavior s behavior

•• That all therapists are fallibleThat all therapists are fallible

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2. Leadership2. Leadership

•• Essential to have leadershipEssential to have leadership•• Fixed leadershipFixed leadership•• Rotating leadershipRotating leadership•• Shared leadershipShared leadership•• Targets: Targets:

–– program coordinationprogram coordination–– keep team on task, focused, engaging in keep team on task, focused, engaging in

targets, dialecticaltargets, dialectical

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3. Structure3. Structure•• Formal Formal

–– AgendaAgenda–– Rotating mindfulness exercise/practiceRotating mindfulness exercise/practice–– Leadership (fixed or rotating)Leadership (fixed or rotating)–– Limit administrative time/discussion (except Limit administrative time/discussion (except

during program development)during program development)–– Schedule for case consultation (supervision?)Schedule for case consultation (supervision?)–– Formal or informal adherence ratingsFormal or informal adherence ratings–– Therapists have explicit targets (e.g., diary Therapists have explicit targets (e.g., diary

cards for own targets)cards for own targets)

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Structure, continueStructure, continuedd•• Formal, continuedFormal, continued

–– MembersMembers’’ roles defined (change over time)roles defined (change over time)•• Group off task/deviating from agendaGroup off task/deviating from agenda•• Dialectical breakdownDialectical breakdown

–– Acceptance/validation vs. change/problem Acceptance/validation vs. change/problem solvingsolving

–– Focus on being right instead of effectiveFocus on being right instead of effective•• Monitoring judgmentsMonitoring judgments•• Breach in consultation team agreementsBreach in consultation team agreements•• Breakdown in focus (unmindful behavior)Breakdown in focus (unmindful behavior)•• Treating team member in nonTreating team member in non--V6 mannerV6 manner•• PrePre--mature solutionsmature solutions

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4. Process4. Process

•• MindfulnessMindfulness•• Radical acceptance of situation, each other Radical acceptance of situation, each other

as team membersas team members•• Ongoing V6 (team members not fragile) Ongoing V6 (team members not fragile)

interaction processinteraction process–– Honesty (with grace & skill)Honesty (with grace & skill)–– Acceptance Acceptance –– What is a What is a ““riskrisk””? Define it carefully.? Define it carefully.

•• Disclosure/validation reciprocity: create a Disclosure/validation reciprocity: create a validating team environmentvalidating team environment

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Sample AgendaSample Agenda•• Mindfulness practiceMindfulness practice•• Set meeting agendaSet meeting agenda•• Crisis management/skill generalization & supportCrisis management/skill generalization & support•• Skill group update, supervisionSkill group update, supervision•• Burnout monitoring Burnout monitoring •• Targeted individual supervision with video/audioTargeted individual supervision with video/audio•• Targeted supervision with verbal updateTargeted supervision with verbal update•• Short, descriptive updates (minimal feedback)Short, descriptive updates (minimal feedback)•• InIn--depth case conceptualizationdepth case conceptualization•• Transitions: accept new patient, change stage, Transitions: accept new patient, change stage,

termination, droptermination, drop--outout•• Administrative issues (announcements)Administrative issues (announcements)

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Important to Note:Important to Note:

•• Implicit is the clear agreement that all Implicit is the clear agreement that all members of the DBT team agree to members of the DBT team agree to practice DBT, not some other treatment, practice DBT, not some other treatment, even if another treatment is easier, is even if another treatment is easier, is more in the repertoire of one or more more in the repertoire of one or more individuals, everyone is hopeless, or individuals, everyone is hopeless, or another approach seems like a good idea another approach seems like a good idea for any reasonfor any reason

The Environment

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Balance Consultation Strategy With Balance Consultation Strategy With Intervening in the EnvironmentIntervening in the Environment

Consultation with the Patient:Consultation with the Patient:•• Teach the patient to be effective on Teach the patient to be effective on

his/her own behalf withhis/her own behalf with–– Social networkSocial network–– Professional networkProfessional network

Environmental Intervention:Environmental Intervention:•• Intervene on her/his behalf when the Intervene on her/his behalf when the

shortshort--term gain is greater than the shortterm gain is greater than the short--term + longterm + long--term lossterm loss

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Environmental InterventionEnvironmental Intervention

Necessary when:Necessary when:•• The patient cannot do what is needed on The patient cannot do what is needed on

her/his own behalf (or the environment will her/his own behalf (or the environment will not accept it from the patient) and the not accept it from the patient) and the outcome is very importantoutcome is very important

•• The life of the patient or another is at stakeThe life of the patient or another is at stake•• The patient is a minor (legal/ethical)The patient is a minor (legal/ethical)•• It is humane to do so and unlikely to cause It is humane to do so and unlikely to cause

harm to the patientharm to the patient

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Helpful StrategiesHelpful Strategies•• Orient the professional network to DBT in Orient the professional network to DBT in

general, and DBT consultationgeneral, and DBT consultation--toto--thethe--patient patient strategies in particularstrategies in particular

•• Orient the client to these strategiesOrient the client to these strategies•• Include client as much as possible even Include client as much as possible even

when intervening on her/his behalfwhen intervening on her/his behalf•• Neither criticize nor defend other Neither criticize nor defend other

professionalsprofessionals

Letter to Marsha Linehan, Ph.D.

Hi! I am in DBT. I am an Orthodox religious Jewish woman, so the DBT has some interesting application in my life.

Firstly, I want to thank you personally for all the skills Ihave learned. I've been in treatment for close to a year;only when I began DBT about ten weeks ago did I see a tangible difference in my life, coping skills, and evendepression. Many of the things we learned can be summed up as "Why didn't I think of it myself??" But since it's part ofan official curriculum, it's much easier to take seriously,actually implement, and therefore have results. So, thankyou.

Now I'd like to share with you how some of theconcepts DBT parallel Jewish thought so beautifully:

In model of emotions, we speak about interpretations.When we interpret things in a positive way, we don'tget so emotionally involved, and it is able to passuneventfully. In Judaism, where interpersonalrelationships are worked on in a real way, we have theconcept of judging others favorably. Last night I toldmy husband that I interpreted something in a goodway, and therefore wasn't upset with the person who itseemed insulted me. He replied, "In Hebrew that's

called Dan L’kaf Zechus (judging favorably).”

Another example: In Opposite Action you talk aboutActing opposite to what you really feel, therebystrengthening the positive emotion. Maimonides (avery great Jewish Rabbi from nearly a millennium ago)discusses something very similar. There is a phrase inHebrew – Adam Nif’al al pi peulosav – man isinfluenced by his actions. There is a fundamental prayer which we say twice daily. Part of It reads

“V’ahavta es Hashem Elokecha” – You shouldlove God..

All the scholars have a very real question on thiscommandment: We can be commanded how to act, buthow on earth can we be commanded what to feel? AndThe answer is – Work on actions which will promotelove of God. We are commanded to do loving actions(such as praying, fulfilling His will…) and automaticallywe will carry out the commandment to love Him.

Also, in Judaism there is a lot of stress on mprovi“middoscharacter traits. One very fundamental way that we aretaught to change negative emotions is to go to theopposite extreme. There is a quote from our sages,“Which is the correct path? The middle path.” And theway to get there is by aiming for the other end, eventuallysettling in the middle. This fits in very well in DBT whereyou discuss acting opposite to your emotion (quite similarto my second example).

It may be interesting to note that some Orthodox peoplehesitate to go into therapy for they are afraid that the skillstaught would conflict with our values.

Now that I am in DBT, I know that there is no reason tohave such a fear. It’s a basic character improvement,which is central to our religion. Thank you!!

Valuable Web Sites

Contact for Intensive DBT Trainingwww.behavioraltech.com

For free audio and video streaming www.borderlinepersonalitydisorder.com

To join site for professionals www.bpdforum.com