DBT lowers the emotional intensity in BPD
"Everyone has to find their own skills." Interview with DBT expert Petra Ludäscher
27 Sep “Everyone has to find their own skills.” Interview with DBT expert Petra Ludäscher
SOUL LALA met DBT (Dialectical Behavioral Therapy) expert Petra Ludäscher at the Fresenius University in Cologne. The psychological psychotherapist with a doctorate has been teaching there in the bachelor's and master's degree in psychology since 2017. Since her own student days, she has been dealing with the topics of borderline personality disorder, DBT skill training, post-traumatic stress disorders and the associated neurobiological phenomena. During her studies and as part of her diploma and doctoral thesis, she worked in the research area on DBT and borderline personality disorder. In addition to research activities at the Clinic for Psychosomatics and Psychotherapy at the Central Institute for Mental Health in Mannheim, she is a DBT therapist and skills trainer. Since 2019 she has been a provisional supervisor for DBT therapists in training.
Anja: Who invented DBT?
Petra Ludäscher: DBT was originally developed by Marsha Linehan and her research group in Seattle, USA. The working group is also still working on further developments of the disorder-specific psychotherapy approach. Central to this disorder-specific approach is the balance between change and acceptance (“dialectical”). In addition to individual therapy and supervision, the skills concept and the associated four original modules (stress tolerance, dealing with feelings, interpersonal skills and mindfulness) are of central importance. In the working group around Prof. Dr. Martin Bohus in Freiburg, there were already further developments in the 90s and 00s such as the inclusion of the tension curve in skill training or later the “self-worth” module in the skills manual and training. The latter developments are still very widespread, mainly in German-speaking countries.
A: What are skills?
L: Skills are simply translated - skills. A skill, as we teach it today as part of skill training, is something that everyone does, that helps those affected and, above all, that does not harm in the long term. The question often arises in skill groups whether, for example, self-harm or the consumption of substances or alcohol are not skills, because these behaviors also relieve tension in some people for a short time. However, we do not refer to this as a skill, because it often makes the problems more intense over time, rather than less. That means that a skill is in the DBT by definition T everything that helps and does not harm in the long term, i.e. is not dysfunctional.
A: Who uses skills?
L: We all use skills. The application of skills is not specific to people who meet the criteria for a mental disorder - or borderline disorder. All people use skills because a skill is everything that helps and does not harm in the long term. Most people know, for example, the situation that you are in bed, the alarm clock goes off and you don't feel like getting up at all. In order to get up now anyway, I need skills. We call this “acting in the opposite direction” in the DBT. I act opposite to my feeling or opposite to my first thought, opposite to my initial impulse to act.
What do I need for that? For example, I need a list of pros and cons. What are the pros? What speaks against staying where you are? For example, the fact that I have slept in, speaks against the fact that I then miss the lecture or lose my job in the long term if I lie down often or at all. Many people then get up and start the day. The more difficulties I have in getting up, the more or more intensive skills I will probably have to use in order to be able to act “in the opposite direction” at all.
Another example that many people probably know. You're on a plane and there is turbulence, which makes most people feel queasy or even a little scared. For such a situation there is, for example, the “Cheerleading” skill. Cheerleading means I cheer myself on in some way. For example, I say to myself: "Very few planes crash.", "It is very unlikely that we will crash now.", "The stewardesses are still very relaxed." etc. These are all sentences to calm myself down and, in this respect, skills - in this case cognitive, that is, intellectual skills.
A: Interesting! I didn't even know that there were also cognitive skills. So far I have always associated the term skills with an action.
L: There are four levels of skills. Cognitively, physiologically / physically, emotionally and at the action level. Above all, patients with a borderline personality disorder or post-traumatic stress disorder experience conditions that we call dissociative states. In these moments they do not feel their body well or the perception becomes blurred, the pain sensation is often less. Those affected are often helped by strong body stimuli, which can be classified into the category of physiological / physical skills. Some put pebbles in their shoes or clamp a rubber band around their arm to let it click. Still others put ice cubes on their skin or smell ammonia to counteract dissociation. In the skills group, patients learn to recognize dissociative early warning signs. Early warning signs could be that the voice seems further away to me, that I am still having difficulty listening, or that I cannot memorize the content while reading. The latter phenomenon is of course known to everyone to some extent. In the case of pathological dissociation, however, the person concerned loses control - so it is extremely difficult to return to directed attention and perception. So that the dissociation does not become even stronger, one works against the dissociation with anti-dissociative skills as soon as the early warning signs occur.
The more problems someone has, the more they have to look at what kind of skills (cognitive, emotional, behavioral, physiological) they need for specific moments in order to endure the situation. This is particularly useful with patients who obviously have difficulties in some area. Many people with borderline personality disorder have high levels of tension, in which they lose control behaviorally (impulsive reaction) and experience very extreme states cognitively. Negative basic assumptions (“I'm worthless”, “It would be better if I weren't there”) are then often activated and can no longer be regulated. In this high tension area, many experience emotional chaos, ride emotional roller coaster and then need high-stress skills that make it possible to survive these extreme states and regain control.
A: What would such a high stress skill be, for example?
L: Sport is one thing, running, or as I said, strong body stimuli such as a contrast shower, hedgehog ball, cold water. Some need even stronger stimuli. We once had a bucket full of ice water in the psychiatric ward that you could dip your head into. The hedgehog ball is very common because there are many stimuli that can be used with it. It goes from feeling it on the skin to creating pain stimuli.
You can also use your imagination. The person concerned imagines something that will help him out of the situation. Patients often enter a so-called skill chain with the skill “taking vacation”. The patient leaves the uncomfortable situation and does skills in another place. For many, this is the beginning of a skill chain. A skill chain consists of many skills that are automatically trained one after the other. First we leave the situation, then we splash cold water on our faces, for example in the toilet, and then I run up and down the stairs. Just like taking a "real" vacation, you come back to the situation after a short time. It is important for the skill chain that it includes skills that can be performed anywhere. Exercise or a shower change helps many, but I can't do that always and everywhere. That said, I need at least one skill chain that I can do anywhere.
The aim of such a chain is that it is carried out in a loop until the person concerned is somewhat in control again. At the latest, the last link in the chain would then - in DBT language - be below the tension level of 70. This is an area in which the person concerned has some control over thoughts, feelings, and impulses for action. Then, in the long term, it is about teaching skills to improve the handling of feelings. It is often misunderstood that skills in DBT only include so-called high-stress skills for distraction, such as the hedgehog ball or strong body stimuli. The module "Stress tolerance / high-stress skills" is only one of a total of 5 modules in the DBT skills manual. In the long term, of course, the aim is to improve the regulation of emotions, which is mainly dealt with in the module “Dealing with Feelings”. One goal here would be, for example, that one does not get into a high - uncontrolled - area of tension in the first place, or not so often. That is often a long-term goal within a year or two.
Central to the module “Dealing with Feelings” is first of all that those affected learn to perceive and name feelings. For this purpose, the so-called emotional network is developed for activated feelings. That means we look at different components of the feeling: What is / was the first impulse to act? What is / was the physiological response in this situation? How is the facial expression? What is the function of this feeling? What are thoughts that may have triggered the feeling? What does this feeling mean to me? Is it appropriate to follow the intensity and type of feeling, or would it be better to tone down the feeling and act against the feeling?
Borderline patients in particular are very reluctant to deal with feelings because they usually experience being confronted with unpleasant and also very strong feelings. This means that many of those affected are more accustomed to "pushing away" feelings and distracting themselves from them in various ways - sometimes functional, sometimes dysfunctional.
In addition to the modules stress tolerance and dealing with emotions, those affected also learn skills in the areas of “self-worth”, “interpersonal skills” and “mindfulness” in skill training.
A: What does a skills training typically look like?
L: It often takes around 1-2 years for someone to be able to handle the regulation of emotions in a stable manner. The skills training takes place stationary, for example 2 hours per week over a period of 3 months. The focus here is mostly on stress tolerance. It is mainly about the area of high voltage, but also about the area of “dealing with feelings”. All patients who are discharged from a DBT ward should have a skill chain in their pocket. An outpatient group usually takes place for two hours once a week and the recommended participation runs for two years. As a rule, you go through the entire skills manual twice within this period and that makes sense, because especially at the beginning the focus is still on stress tolerance and only after about 6 months do many begin to perceive their feelings and dare to deal with them put.
But that does not mean that the skills training cannot work beforehand. The stress tolerance skills help some sufferers very early on in therapy. We found that after three months of inpatient DBT therapy in more than 60% of the participants, the problem behaviors - especially self-injuries - are reduced or no longer occur. At the behavioral level, we can make a change quite quickly. What has to be worked out in the long term is the regulation of emotions.
A: How does the therapist provide outpatient support?
L: The therapist responds more individually to the individual patient and should encourage the use of skills. In individual therapy, for example, the processing of individual basic assumptions is more in the foreground or the confrontation and handling of individually difficult situations and memories. The DBT individual therapist applies strategies from cognitive behavioral therapy and tries to create a DBT-specific balance between achieving change goals and promoting acceptance and mindfulness. On the change side - similar to CBT - cognitive and paradoxical interventions are also used, on the acceptance side above all validation and mindfulness.
A: What would a cognitive intervention be?
L: For example, a cognitive intervention is a guided questioning. For example: how do you come to the conclusion that you are worthless? Who is telling you that? Etc. Or a change of perspective such as taking the position of the patient. Why don't you cut yourself more often if that helps you? This is called advocatus diaboli - a paradoxical intervention - and is used to get the patient to think. Why am I actually doing this? There are many cognitive interventions that come from cognitive behavioral therapy. At the beginning of the therapy, a hierarchy of goals is established. This is specified subject-related and discussed with the patient, depending on what he needs and what is causing him problems. Each of them is about individual topics and I can't and shouldn't address that so individually in a skills group.
In the outpatient DBT, patients usually have the therapist's telephone number and have the opportunity to call to receive skill coaching. How do I get out of this crisis now? Which skills would help me now? This phone call lasts about 10 minutes and the therapist usually does nothing other than skills coaching. How high is your tension? Where are they? What are you doing now? What have you already tried? What haven't you tried yet? This is an integral part of outpatient DBT.
A: Which skills are used for which illness?
L: There is definitely a difference in training in the area of PTSD and borderline. As a treatment team, you have to be alert to the needs of the patient. If a patient is in skills training and says that she has nothing to do with the term tension, I would question whether the diagnosis is correct or whether the diagnosis PTSD or depression could no longer be true. This means that the tension concept in the DBT - at least in German-speaking countries - is specific for borderline patients. At the beginning of the skill training, a central goal is to learn, using early warning signs, to mentally, emotionally, physiologically, and physically assess the tension on the four levels in order to then counteract this on the respective level. That is individually different. For those affected with post-traumatic stress disorder, the modules dealing with feelings, accepting reality and interpersonal relationships are more of central importance, rather than high-stress skills. In people with an eating disorder, we would be more likely to teach skills that are specific to the eating disorder. The experience in the high stress area over 70 is very borderline-specific, the associated modules have been developed explicitly for borderline patients.
A: How does everyone find their individual skills?
L: Everyone has to try and test that. At the beginning we tell the patient: Just try it out. In a group, you can be inspired by other patients and make recommendations to each other. It can happen that a skill that helps one patient really well brings another into even greater tension and that would of course not be a suitable skill for this person.
A: Thank you very much for the interview.
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