the shaping game: integrating dbt, act & fap
DESCRIPTION
The Shaping Game: integrating DBT, ACT & FAP . SANDRA GEORGESCU, PSY.D. & Paul Holmes Psy.D. 1st - an apology Then, some compliments. All boxes everywhere. Classifying client presentation based on categories in the DSM is ….. - PowerPoint PPT PresentationTRANSCRIPT
The Shaping Game: integrating DBT, ACT &
FAP
SANDRA GEORGESCU, PSY.D.& Paul Holmes Psy.D.
• 1st - an apology
• Then, some compliments
All boxes everywhere
• Classifying client presentation based on categories in the DSM is …..
• Classifying different treatment packages based on developer/lab is….
• Yet most of us see folks whose presentation doesn’t neatly fit into the criteria AND use interventions that are more or less consistent with each package
This talk
• Is about the integration of behavioral interventions across DBT, FAP & ACT to: Meet client needs where they are at Provide ongoing care & shaping
behavior over time Stimulate thinking outside the package
box (but within the theoretical community)
Some assumptions….
• If you are here, you have known “difficult, multi-problem” clients and have struggled
• Are at least somewhat familiar with all three treatment packages
• Have struggled (or are just curious about how) to integrate techniques
• Are friendly to the ACBS mission and functional/contextual approach
some behaviors/solutions are “louder” or more disturbing than others…..
Quick…
• Notice and jot down a few reactions…. What comes to mind?
This is Jeanne & she’s in distress
Do you know this person?
How Todd spends his nights…
From an FC perspective…
• Different strokes for different folks… Drinking, binging, cutting, crying, panic Sexing, dissociating, changing the subject, Violence, inactivity/passivity, over-activity, Work-a-holism, intellectualization, burning, Fighting, impression management, blaming, Ruminating, worrying…..
• Are functionally equivalent, yet our contexts require different levels of intervention
Strosahl (2004) says
• Behavior differs in degree not in kind!
• Distinctive features: Behaviors are pervasive Responses gain habit strength Behaviors are resistant Self-defeating
• & the crisising takes on a life of its own….
Distress
• In medicine = an aversive state in which an animal is unable to adapt completely to stressors and their resulting stress and shows maladaptive behaviors Institute for Laboratory Animal Research (1992). Recognition and alleviation of pain and distress in laboratory animals
• Psychologically: situationally evoked intense emotions, which usually scare us and prompt us into action to terminate itHolmes & Georgescu (in preparation). Acceptance Based DBT.
• We all experience this some of the time (e.g. panic)
& then there are folks
• Who handle distress quite well• Who handle distress ok• And who seem to develop patterns
of chronic distress…. Or seem to experience distress
constantly, become preoccupied with being distressed and fail to ever address the source
So that they are constantly reacting to their reactions
Chronic Distress
• What is it?• In medicine
Use of the term is associated with heart failure & put forth by Dr. Denollet in the Netherlands
Has been linked with “type D personality” (not a mental illness)
Defined by 2 emotional states: negative affectivity (worry, irritability, gloom) social inhibition (reticence and a lack of self-
assurance)
Behaviorists’ take
• On Chronic Distress Ongoing preoccupation with distress
which we have evaluated as “intolerable” and prompts us to work harder, faster, in more drastic ways to control, reduce or eliminate the “intolerable”
Evaluative reaction to reactions Emotion-phobia - much like panic
disorder but overly vigilant to one’s emotions
Hpersensitivity to emotions!
A frequent occurrence
Trigger
Intense emotion
Judgment about emotion
Urges to self injure
Fear & panic re: urges
Action
In about 2 minutes!
Case example
• 40 year old white female with a history of sexual abuse, rejection, isolation, & crisising behavior
• Has had multiple hospitalizations residential care for cutting and suicidal gestures
• She comes to you for outpatient treatment to work on trauma from sexual abuse
Theories applied
• Emotional Dysregulation √ Heightened sensitivity to emotions Increased intensity Slow return to baseline
• Fusion & Experiential Avoidance √• Interpersonally reinforced self-
injury/crisis behavior √
How our treatments see it….
• DBT: emotional dysregulation pain + acceptance = pain
pain + non-acceptance = sufferingTarget skill deficit
• ACT: experiential avoidancedirty vs clean pain
Target functional class• FAP: interpersonally reinforced over
time/people Target CRBs
Treatment Request
“I want to work on my trauma and sexual abuse history so I can stop feeling this way”
Using Control Flexibly
• Depending on the consequences of target behaviors, aim for control in the service of eventual flexibility Start with where the client is….
• It’s a shaping game: “loud” behaviors may require to be brought under control so that they can be shaped flexibility
• Commitment, skill coaching and accountability
• Sometimes offering fewer options is the effective thing to do
What Tx Packages Offer
• DBT - based on skills deficit model & targets emotional dysregulation
• Requires & assumes commitment to skills use throughout
• Provides hierarchy Self-injurious, other injurious Therapy interfering behavior Quality of life interfering behavior Skills generalization
Packages Offer cont’d
• ACT - based on RFT targets experiential avoidance as
functional class Assumes choice throughout
• FAP - based on behavioral principles Provides framework for targeting in
session moment to moment behaviors
• Prioritization is functionally based
Common ingredients
• All involve acceptance & defusion (implicitly or explicitly)
• All are functional/ contextually based (functional analysis as home base)
• All prioritize treatment targets• All use the therapeutic relationship• All provide a context for life-style
change • All target behavioral/psychological
flexibility in the long run
Building up the straw man
And exposing her to choice
• The louder & more pervasive the presenting behavior (e.g. the stronger the reaction it elicits across environments), the more likely the need for shaping of new/alternate behaviors (skills) that are more “functional”
• Commitment, coaching & accountability
Mapping Behavioral Processes
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
DBT Mindfulness/FAP
DBT Commitment/Skills Training
Start here!
& here!
Stage IStage II
F A P
Arbitrary lines in the sand
_____________________________________________________
Stage I DBT ACT (Stage II DBT)
•Self/other destructive•Relationship damage
• Q of Life damage
CommitmentChoice
Values
thre
sho l
dtime
pliancetracking
augmenting
Acceptance Based DBT Stage I
• Replaced cognitive restructuring Mindfulness/
defusion Willingness Functional
assessment
• Introduced Values During commitment
conversation In Emotion Regulation
• Renamed skill areas Living in the present Living with Distress Living with Emotions Living with Others
ACT as stage II DBT
• Slow progression from committing to choose (skills) to choosing to commit
• Armed with skills (& ++ present moment awareness), shift from working on the one’s problematic solution to working on “the problem”
• Greater interpersonal risks Trust, Love & Companionship (CBR2)
• Increased psychological (& behavioral) flexibility
Practically Speaking
• Flexible therapeutic dance Commitment (or not) by choice for some,
perhaps not all behaviors Articulating values across life domains Facing past demons in the present with the
safety of a new behavioral repertoire Choice in mindfulness; experiential exercises;
living a vital life
Successive approximations
• Required structured mindfulness exercises• Attention control
Attention
• Practice like one would a fire drill - over & over
•With timeWith time…. A choice, based on utility… • more experiential exercises (eyes on)
Successive approximations
• Invalidation, self-invalidation, reactivity to one’s own experience
With time & work… With time & work… • Validation, self-validation,
mindfulness of experience, action• Other validation & relationship
flexibility
Successive approximations
• Self under public control - I am who you say I am… self-as content - I’m wrong….With practice… With practice… self-as-process via mindfulness,
behavior chains Self under private control
I though XI felt XI did XI could have used X skill
ACT as Stage II DBT…… self-as context
I still use…
• A hierarchy…Self-injurious, other injuriousTherapy interfering behavior
Limits of the therapist (my CRB1)Quality of life interfering behaviorCommitted Action
Now for some practice!
• Pick a client… who struggles LOUDLY! Identify target behaviors for Stage I (DBT) Prioritize using DBT’s hierarchy Outline a “commitment talk” Outline CRB1 & CRB2 that you will target
• Prepare transition: Imagine it’s a year later and that the loudest behaviors have What choices would you offer them? What commitments would you still hold them to? Outline CRB1 & CRB2 (are they different?)
Role play!
• 1st Role-play the commitment conversation when
they enter treatment: what will you tell them?• Then,
Role play the initial ACT (as Stage II) session: what choices will you giveoffer them?
When/how will you integrate the DBT skills previously learned?
• & Don’t forget the FAP How are the CRB1 & CRB2 different across time?
My Client
• Committed to “building a life worth living” before working on trauma
• Targeted self-injury, in session hostility & skill use (esp. overuse of telephone consultation)
• Increased behavioral activation (job, living situation & friendships)
• Choosing to commit at every step• Targeted experiential avoidance more
broadly: ACT for trauma