Dialectical Behavior Therapy Workshop with Sara Dhuse, PhD.

I have been privileged over the last 4 years to work with and be mentored by Mrs. Sharon Dhuse.  She has been serving Baptist Theological College (BTC) for the last 10 years with her husband as a second career missionary.  After serving many years as a social worker in the foster care system in Chicago, she is now investing her life in training Christian workers here in Cebu.  Since this will be her last semester here in Cebu, we thought it appropriate to invite her daughter to Cebu to share her training and skills.  And thankfully Dr. Sara R. Dhuse accepted our invitation to share her gifts with us.  

BTC hosted an all-day seminar Dialectical Behavior Therapy Workshop on August 17, 2013.  We had about 40 attendees including pastors, Compassion case workers, social workers, guidance counselors and counselors working with trafficked children here in Cebu.  The following is a short summary of the material presented:

Dialectical Behavior Therapy (DBT) is a very structured model of counseling that teaches the clients to be self-aware and keep track of target behaviors and emotions, as well as urges to do self-harm.  It also teaches skills to evaluate their situation and do chain analysis in order to cope well with stress, regulate their emotions and improve their relationships with others.  This method combines standard cognitive-behavioral techniques and a person-centered model of intervention and mindfulness activities. 

The methodology is based on the assumptions that these clients lack the skills they need to:

• understand and regulate their emotions (Emotion Regulation Skills)
• cope with distress (Distress Tolerance Skills)
• communicate effectively with others (Interpersonal Effectiveness Skill)
• pay attention in their lives and make good decisions (Core Mindfulness Skills)

Dialectical Behavior Therapy (DBT) was originally created by Marsha Linehan to treat people diagnosed with Borderline Personality Disorder, but it has also been found helpful for any person with emotional dysregulation problems.  Recent research has found DBT to also be helpful for individuals with substance abuse, bulimia, binge-eating, depression and anxiety.  It has also been adapted for use with children and adolescents. 

People with Borderline Personality Disorder usually have problems with:

• Emotional dysregulation (intense emotions)
• Chaotic relationships and fear of abandonment
• Impulsivity with suicide attempts, self-harm and other damaging behaviors
• Lack of sense of self and feelings of emptiness
• Dissociation

Most people who suffer from emotional dysregulation have been exposed to invalidating environments where: Normal expression of emotion is ignored; Extreme displays of emotion are intermittently enforced; And complicated problems are presented as easy to solve.  In treatment, the crucial point where healing can occur is when a therapist creates a validating environment.

In the creation of this validating environment a therapist must pay attention to the dialectical transaction.  (Dialectical means incorporating two different views that appear opposite and find ways to integrate both, which is called synthesis).  There are three dialectical patterns that we usually engage in:

• Emotional vulnerability vs. self-invalidation
• Active passivity vs. apparent competence
• Unrelenting crisis vs. inhibiting grieving

What would a dialectical transaction of emotional vulnerability vs. self-invalidation look like?  The client might start with self-invalidation, saying something like, “I should not be afraid.”  The counselor would validate that statement, but also open the possibility that it’s ok to be afraid by saying something like, “I see that you’re not afraid, but I also notice that you hesitate when say that so I wonder if you might have a little fear.  Many times people that are in that situation has a tendency to be afraid.”  This will help the client toward self-validation which leads to the emotional vulnerability piece, beginning to open the client to the vulnerability of their emotion of fear.  Then the client can begin to be honest enough to accept his need instead of staying in self-invalidation (when the person denies, ignores or cannot accept what they truly feel or think about themselves).  Emotional vulnerability is a must to healing and allowing clients to accept their real situation without judging themselves is a key factor in achieving this.  How does this look in counseling?  Accepting a person with unacceptable behavior can result in this person knowing he or she is loved and accepted and not forced to change.  This will help them begin to overcome their resistance to change. 

The personal acceptance of the therapist is also very important here.  She needs to acknowledge and embrace her personal limitations and feeling of inadequacy.  Without this internal work she will be blaming and projecting her own discomfort and intolerance to the very person she is trying to help, and this person will feel judged and unaccepted by her.  The personal acceptance of the therapist translates into safety and emotional validity to her client.  When the client feels safe and accepted by the therapist they will also learn to accept themselves.  Then they can begin the work of understanding who they are, developing self-control by regulating emotional reactions and choosing to live their lives congruent with their values and with purpose.  Their experience with their therapist transfers to their current relationships.  As they trust their therapist, they learn to trust themselves with their progress, and eventually they can create a new validating environment for themselves and for others around them. 

People that choose Dialectical Behavior Therapy as a model of intervention require their clients to be in a one year DBT program.  DBT has four modes of intervention: Weekly Individual therapy;  Weekly Skills Group; Skills Coaching and Consultation Group.  Since this is a skill based approached the clients learn to pay attention to what is going on inside and outside of them.  This is done by developing mindfulness skills.  They also learn to focus on target behaviors for change with Diary Cards that are checked weekly by the therapist.

In the structure of individual session, the therapist leads you to these 3 main processes

1.  Review Diary Card

2.  Set Agenda  -  The agenda is based on the hierarchy:

• Life Interfering Behavior
• Therapy Interfering Behavior
• Quality of Life Interfering Behavior
• Topics Client would like to discuss

3.  Chain Analysis – a thorough step-by-step description of the chain of events leading up to and following an unhelpful behavior.  Basically asking the questions: “What made you do that? And what made you do the things that led up to that?  What was the result?  And what was the result of that result?”  These questions help the client identify the cycles of unhealthy behavior in which they are engaging.

Dr. Dhuse presented a very helpful paradigm for us mental health practitioners here in Cebu.  Thanks so much!!

Understanding People in Crisis

When the word crisis is mentioned we usually imagine an event or a situation such as an accident or emergency with feelings of panic and being out of control.  Actually, crisis is a normal part of life.  There are three types of crises: 

1. A developmental crisis is- a natural part of life where as we grow older we change from infancy to adulthood.  The psychosocial theory of Erik Erikson identifies the specific psychosocial crises we go through during each stage of our life span.  Each crisis demands a resolution.  Failure to resolve the crisis has significant impact on the continued development of personality.   
2. An evolutional crisis is a crisis that happens as we enter into a new role or relationship.  The forming of new systems of behavior and interaction that govern the new relationship or role is very stressful and can lead to a crisis     
3. A situational crisis is caused by an event or unexpected circumstance that impairs a person’s level of functioning.  

Crisis is a perception of an event or a situation as being overwhelmingly difficult so much so that it exceeds one’s personal resources, and the use of customary coping mechanisms no longer works (Gilliland & James, 1988, p.3.).  Crisis is different from stress.  Stress is a normal reaction, which involves physiological and psychological response to difficult situations.  We normally feel anxious during these times of stress.  Prolonged stress is dangerous to one’s health because stress causes emotional and physical strain on one’s body, which eventually affects the immune system.  Stress can result in ulcers, asthma, skin rashes, high blood pressure, heart attacks, etc.    

When does stress become a crisis?

            *If you click on the chart, you can see the whole thing

A normal stress can become a crisis due to how the person perceives the situation or event and how he views himself in relationship to his stressors.  Negative perceptions start one on the road to crisis.  The negative perceptions can be due to cognitive distortions or just very difficult circumstances.  

*Changing how the person perceives his problem is the key to crisis intervention.

 

If the perception is negative, it results in a negative self-evaluation, which leads to negative emotions (subjective emotional distress increases).  In turn, negative emotions can make the person more ineffective in problem-solving.  This negatively impacts their ability to use adequate coping strategies.  Coping methods fail to work and the level of functioning is lowered in all areas:  psychologically, emotionally, spiritually, socially and occupationally.  Normal function is impaired and can be recognized as lower than before the precipitating event occurred.   Other psychological dysfunctions may occur.  The stressful situation has become a crisis.

Later when the person is already in a lower functioning level and another crisis-triggering event  happens or even a minor stress, the person can become overly reactive and sensitive.  A whole slew of negative perceptions and negative emotions accumulated from previous stressors come back overwhelming the person.  This is how a minor stress can turn into a crisis.  The minor stress is “the straw that breaks the camel’s back.”  When a person has been carrying a heavy load for a long time, any additional load can cause the person to break down. 

 

Therefore a crisis is an acute emotional reaction to a powerful event or situation (called a precipitating event) that disrupts the person’s equilibrium and exceeds the person’s coping mechanisms and problem-solving techniques.  

Precipitating event:  An actual event in a person’s life that triggers a crisis state.  It can be situational or developmental.  We usually think of the precipitating event as the crisis itself, but psychologically speaking, the crisis is in the person’s response to the event.  For a highly stressed person, a minor stress can be a precipitating event.

Kristi Kanel suggests an ABC Model of Crisis Intervention

• A - The counselor must develop and maintain rapport with the individual in crisis.  This is done by attending to the person and listening empathetically, paraphrasing and reflecting feelings.
• B - The counselor helps the person in crisis identify the nature of the crisis and alter their thinking patterns and perceptions of the situation by giving support and validation.   
• C - The counselor helps the person identify effective ways of coping with the crisis, which includes resolution and finding support.

            *If you click on the chart, you can see the whole thing

Changing the perception of the situation (the determining factor that turns stress, disappointment or loss into a crisis) requires one to pay attention to the person, listen, and empathize with person.  Do not judge the person for overreacting or tell him that he is not acting in faith just needs to trust God more.  Instead, allow the person to talk about the situation, to describe how he thinks about it, how he feels about himself and God for allowing this situation to happen.  Allow him to grieve over his loss.  Explore the different emotions that this person feels, examine the degree of the intensity of this emotion, and what thoughts produce these emotions.  Examine how he perceived himself during the situation and how he perceives himself now.  Reframe these negative evaluations of the event by normalizing the situation and his reaction and helping the person to gain new insight into the situation. 

While problem-solving and exploring alternatives, consider the person’s resources and network of support.  Guide and empower the person to tap into those resources.  Teach the person adequate skills to be able to find some sense of control and courage to face his problem.  Here are some of the aspects where you will assess present resources that can help this person:

• Material resources:  Tangible things such as money, transportation, clothes and food.  How can these things help the person to cope with their crisis?
• Personal resources:  Intangible things such as intelligence, ego strength and physical health.  How are these things impacting the person’s handling of their stresses?
• Social resources:  A person’s friends, family and co-workers.  The more resources one has, the better the person will weather a crisis.  Who are people in the person’s life that he can count on in hard times that are willing to help?
• Spiritual resources:  The faith and beliefs of a person, including faith in God, the “theology” of their struggle and suffering, their spiritual disciplines and their spiritual community

Common Counseling Mistakes (part 1)

Counseling is a learning process where an objective and empathic listener provides unconditional acceptance and confidentiality that allows the hurting person to have space, time, and safety to examine personal issues, grieve over their losses, and embrace private pain.  It is also a place where defenses are challenged, maladaptive belief systems are examined and opportunities are provided for corrective emotional experiences.  The counselee is encouraged to take responsibility for his or her own behavior and is helped to make better decisions that would bring more fullness of life.  The goal of counseling is to help the counselee become what he or she is potentially capable of becoming.

While at Alliance Graduate School of Counseling, I had the privilege of studying under Dr. John Cheydleur.  In his book Called to Counsel* (Tyndale, 1999), Dr. Cheydleur addresses 12 specific counseling mistakes that lay counselors and non-professional Christian counselors tend to make.  He also suggests ways to avoid or correct these mistakes.  I will summarize his 12 points here:

1.  Patronizing or Cliché Responses 

A cliché response is a stereotypical expression that has lost its original meaning and impact through overuse.  

Example: 

Counselee:  I really struggle with my work.  I feel like I give all my time and energy, but I just don’t feel that my boss cares about me and my family.

Counselor:  I think you are just too discouraged – you have to keep in mind that sweet is the pleasure after pain.

A patronizing response is an attempt to encourage the counselee by emphasizing the positive.  It puts the counselee higher than he is or higher than what he thinks he can achieve.  The problem is that this is not how he sees himself at that moment (even though what the counselor sees or has observed may be true.) 

Example:

Counselee:  I want to quit my job.  It is very difficult; I don’t think I can bear the pressure they are putting on me.

Counselor:  I know it is difficult, but you can do it.  Don’t you remember you were able to complete the project that no one else at your job could do? 

Explanation:  On the cognitive level these responses makes sense to the well-meaning counselor.  However, psychologically the counselee gets confused because of the incongruence of how others perceive him and how he actually feels deep inside.  For the counselee, it deepens his struggle.  Some counselees would learn to hide by riding on to the encouraging comment and keeping a mask that shows that he is strong enough to face the challenges of life instead of admitting his insecurities and fears.

On a superficial level, these responses seem caring of the counselor, but on a psychological level, they are an attempt to control and limit the counselee’s feeling and expression of painful emotions.  Because of the inability of the counselor to understand how to help the person go deeper in examining the problem, they cut the counselee from the opportunity to express him or herself that could bring some emotional healing.

How to correct these mistakes: 

Instead of cutting the person off with patronizing or cliché responses, let the person talk.  And show that you care by reflecting not only the content, but also the emotion with which the person is struggling.

2.  Questions and Probes Too Soon

In good counseling practice, the counselee needs to be able to hear what he feels and thinks about his situation.  By bombarding the client with too many questions (probes), the counselor appears to be an expert on an awareness level, but on the psychological level, the counselor is very controlling and overly anxious.  By stacking questions, the counselor prevents the client from discussing areas that are important to him.  Another problem that arises from asking too many questions is that the counselor might lead the counseling in the direction the client is not yet ready to face. Probing too soon also inappropriately narrows the focus of the interview.

How to correct this mistake: 

Instead of asking so many questions, the counselor should:

·         Pay attention and listen

·         Slow down and allow the client to talk freely

·         Reflect and clarify statements to keep on track with the counselee’s process.

3. Giving Advice Instead of Lending Information

A major mistake commonly made by new or untrained counselors is to confuse the necessary process of introducing new information to the client with the negative process of giving advice.

When we give advice, we assume the role of an expert. (i.e.  “Follow what I say because I know what is best for you.”)  We assume (incorrectly) that we completely understand the person, his feelings, fears, hesitations, the nature of his struggle, and the obstacles he will face when following through with our advice. 

Reasons why counselors should NOT give advice:

·         Most of the time when receiving advice the person feels coerced to follow you and may come to resent you for making him do certain things. 

·         Some counselees actually like this because they are so dependent on other people thinking for their lives that they don’t want to take time to ponder it on their own.  Through advice giving, the counselor can just reinforce their tendency to not own their own thoughts and feelings in a way that is required to make a personal decision.  The counselor can empower them to blame others for their lives.  Later you hear them say, “I just followed your advice.  Look what happened…”  (and they are implying, “How do you feel now? You made a mess of my situation.”)

·         Others will listen to the advice of the counselor, but will not do it.  When asked why, they will present an alibi, like what if it will not work?

How to correct this mistake: 

·         Evaluate the receptivity of the client before giving new information.

·         Avoid using “you should” statements.

·         Always try to give the counselee two or three alternatives so that he has to choose for himself what he thinks is the best alternative.

·         It is always good to process the counselee to see their perspective on the issue.

I will be discussing other common counseling mistakes in upcoming posts  . . .

*Cheydleur, John R. 1999. Called to Counsel. Wheaton. Illinois: Tyndale