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DBT LBC Certification Study Guide Questions and
Correct Answers| Latest Update
According to Linehan, BPD clients possess 6 behavioral patterns. These are: emotional vulnerability, self invalidation, unrelenting crisis, inhibited grieving, active passivity, and apparent competence Linehan's criteria for BPD is most similar to Millon What % of BPD client's engage in self-injurious behaviors? 70-75% Kreitman introduced this term meaning nonfatal, intentional self injurious behavior resulting in actual tissue damage, illness, or risk of death; or 2) ingestion of any drugs or substance not prescribed or in excess to the prescription with intent to cause harm or death. This term includes both SI gestures and self injurious behaviors with little or not intent to cause death. parasuicide 4 differences between CBT and DBT:
- Emphasis on acceptance and validation of behavior as it is in the moment
- Emphasis on TIBs
- Emphasis on the therapeutic relationship
- Focus on dialectical processes
The term "dialectics" as applied to behavioral therapy has come to imply 2 contexts of usage:
- fundamental nature of reality and persuasive dialogue and relationship.
- Treatment approach or strategies used by the therapist to effect change. Dialectics as a worldview has 3 traits:
- interrelatedness and wholeness
- Principles of Polarity (within dysfunction there is function, wise mind, finding value in one's pt of view, looking for the function within the present moment)
- Thesis, Antithesis, Synthesis: Principles of Continuous Change Borderline splitting is defined as tendency to get stuck in either the thesis or the antithesis, unable to move to a synthesis. Either/or thinking The environment- person system is comprised of the: environmental sub-system (social support, life change, suicidal, suicidal consequences) demographic factors (age, sex, and race), and behavioral subsystem ( cognitive, over motor, and physiological affective system) Grotstein proposed bpd is a disorder of self regulation
- it tells the person that they are wrong 2) it attributes her experiences to socially unacceptable characteristics or personality traits consequences of invalidating environments
- emotional labeling is not learned, 2) distress intolerance and unrealistic goals/ expectations are instilled, 3) extreme behavioral displays are used to get needs met, 4) lack of trust of one's own emotional and cognitive interpretations are instilled what are the 3 types of invalidating family systems
- perfect family
- chaotic family
- typical family This family type struggles with multiple issues within the family system, needs of the child are ignored and invalidated, there is volatile responses, etc Chaotic Family This family type cannot tolerate the negative emotions of the child. This can be due to high work demands, self-centeredness, intolerance of negative emotions, and naive fears of spoiling the child. This family system has sympathy for their child but unknowingly can invalidate by offering over simplified solutions to their child, ie pray about it perfect family
This family system exists within the western cultures and supports the idea of cognitive control with focus on achievement above all else. Self-control is move important. Typical family system Active Passivity is similar to _____ focused coping; ie the tendency to respond to stressful events with efforts to reduce the negative emotional reaction by distracting or seeking comfort from others. Emotion What factors contribute to apparent competency:
- person's competence is variable and conditional
- person struggles with ability to be vulnerable with others
- person's reaction to interpersonal relationships; ie the difference in behavior of the person in a therapeutic relationship versus other outside relationships The core strategies of DBT are: problem solving (change) and validation (acceptance) There are 2 types of validation strategies (ie core strategies):
- wisdom within the client's maladaptive behaviors based on the client's historical context
- the therapist belief in the client's ability to build a LWL
How many DBT assumptions are there? 8 What are the DBT assumptions?
- People are doing the best they can
- People want to do better
- People need to try harder and be more motivated to change
- Clients cannot fail treatment
- Therapist treating BPD must seek support
- We did not cause all of our problems but we have to solve them anyways
- The lives of SI clients are unbearable as they are being lived currently
- Client must learn new behaviors in all relevant contexts "Unwavering centeredness" is defined as believing in oneself, in therapy, and in oneself. It is the calmness in the storm. "Compassionate flexibility" is defined as Ability to adapt to changes within the therapeutic relationship as needed. This includes admitting mistakes, observing and extending limits as needed.
The balance "unwavering centeredness" and "compassionate flexibility" requires the therapist observe limits and conditions while being flexible in response to changing, adapting, etc. "Nurturing" includes: teaching, coaching, assisting, strengthening, and aiding the patient "Benevolent demanding" includes: therapist recognition of the client's on strengths and capability , reinforcement of their adaptive responses, and not taking care of them The dialectical position to take with benevolent demanding and nurturing is: Pushing the client forward while supporting them. Patient agreements include:
- 1 year commitment to DBT
- 4 missed shows in a row
- Attendance agreement
- SI agreement
Consistencies with other members of the treatment team are not expected and each member of the team does not have to teach the same thing nor agree on proper rules of the therapy. Consistency Agreement The case conceptualization group agrees that therapists are to observe their own limits nor judge others limits. Observing Limits Agreement Therapist agree to search for a nonpejorative interpretation of clients behaviors phenomenological empathy agreement Explicit agreement that all therapist are jerks. Fallibility agreement There are 5 subcategories of SI-related behaviors which are targeted in DBT:
- SI Crisis behaviors
- Parasuicidal acts (nonfatal, intentional self-injurious behaviors)
- SI ideation and communications
- SI- related experiences and beliefs (idea it is a problem-solving technique)
- SI- related affect Reducing Parasuicidal acts is important because:
- best predictor of subsequent SI
- damages to the body
- actions based on the intent to harm oneself are incompatible with therapy
- It is hard to express care for a client if you do not address self-harm There are 3 categories of client TIBs:
- Behaviors that interfere with the client receiving therapy
- Behaviors that interfere with other clients receiving therapy
- Behaviors that burn out the therapist Examples of behaviors that interfere with the client receiving therapy
- Nonattentive- cancellations, threatening to drop out, dropping out, excessive admittance into HOS, acting SI during inpatient stays 2 Noncollaborative- inability or refusal to work in therapy, not talking in therapy, arguing incessantly 3 Noncompliant behaviors- not completing diary cards, not keeping agreement, refusing treatment agreements
- accept the facts of the trauma
- reduce stigmatization, self-invalidation, self-blame associated with the trauma
- reduce denial phases and intrusive stress responses
- synthesizing the "abuse dichotomy"
- increase self respect What is the target of stage 2 of dbt decrease ptsd what are the stage 3 targets increase respect for self and achieve individual goals Hierarches of target behaviors within target classes in outpatient individual therapy: suicidal behaviors
- suicide crisis behaviors
- Parasuicidal acts
- intrusive suicidal urges, images, and communications
- Suicidal ideation, expectations, emotional responses
Hierarches of target behaviors within target classes in outpatient individual therapy: therapy interfering behaviors
- Patient or therapist interfering behaviors likely to destroy therapy
- Immediately interfering behaviors of patient or therapist
- Patient or therapist interfering behaviors functionally related to suicidal behaviors
- Patient therapist interfering behaviors similar to problem behaviors outside of therapy
- lack of progress in therapy Hierarches of target behaviors within target classes in outpatient individual therapy: Quality of Life Interfering Behaviors
- Behaviors causing immediate crisis
- Easy to change (over difficult to change) behaviors
- Behaviors functionally related to higher order targets and to patients goals. Hierarches of target behaviors within target classes in outpatient individual therapy: Increasing behavioral skills
- Skills currently being taught in skills training
- Skills functionally related to higher order targets
- skills not learned yet
4 and dialectical strategies, core strategies, stylistic strategies, and case management strategies Dialectical strategies are pervasive and inform the entire treatment Core strategies are problem solving and validation strategies Stylistic strategies specify interpersonal and communication styles Case management stategies have to do with how the therapist interacts and responds with the social network in which the patient is enmeshed The dialectical focus of the therapist involves 2 levels of therapeutic. behavior:
- the therapist is alert to the dialectical tensions and balances within the treatment relationship itself. The therapist pays attention to the relationship by combining balances and change strategies.
- the therapist teaches and models dialectical behaviors A dialectical stance has a number of characteristics:
- speed (keep the client off balance so they never get a strong foothold)
- the therapist must be awake, observing, and sensing each movement of the client.
- The therapist must move with certainty, strength, and total commitment Dialectical strategies checklist: T balances tx strategies within each session
- T balances acceptance and change strategies
- T nurtures P by demanding they help themselves
- T balances persistence and stability with flexibility
- T balances focus on capabilities with focus on limitations and deficits
- T moves with speed, keeping P off balance
- T is awake, responsive to P's movements
- T takes positions whole-heartedly Dialectical strategies checklist: T models dialectical thinking and behaviors
T presents an extreme propositional statement, asks the patient if they believe the statement, and then plays the role of the devil's advocate to counter attempts by p to disprove the proposition. This technique is used in the first several sessions to gain a strong commitment What is "extending" (dialectical strategy) T takes P more seriously then they take themselves for example " if you don't give me my game boy i will kill myself." and T responds "We need to take this seriously, hospitalization" How does T "active wise mind?" (dialectical strategy)
- convince client this is possible for them
- Provide P with examples of how they have already activated wise mind as its the calm following the storm
- lead p through exercises for example mindfulness skills T makes lemonade out of lemons (dialectical strategy) for example P gets fired and T responds "O how wonderful" view of issues in everyday life are opportunities to use skills Allowing natural change (dialectical strategy)
the idea here is given P exposure to change for example different appointment times T assessed dialectical P and their social environment (dialectical strategy) idea here is not to assume but to assess. discover "what i am missing" what are the 3 steps in validation
- active observing (V1 and V3) (third ear and eye) 2 reflection (V2) "is this right?"
- Direct validation (V4) Why is validation needed?
- to balance change strategies
- needed to teach P how to validate themselves Emotional Validation Strategy Checklist: T provides opportunities for emotional expression; T empathizes and accepts P's feelings.
- T listens with a nonjudgemental and sympathetic attitude to emotional express of P
