Thursday, August 2, 2012
Tuesday, July 31, 2012
Reasons for Living Scale
Data Entry Initials: ___________ Client’s ID # & Initials: _________________________
Date: ______________________ Date: _________________________
Second Entry: _______________ Assessment: _________ Session: ________
Date: ______________________
Reasons for Living Scale Copyright 1996 M. M. Linehan page Page 1 of 3 Yellow 07/19/04
UNIVERSITY OF WASHINGTON
BEHAVIORAL RESEARCH & THERAPY CLINICS
Linehan et. al., 1983
INSTRUCTIONS: Many people have thought of suicide at least once. Others have never considered it. Whether
you have considered it or not, we are interested in the reasons you would have for
thought were to occur to you or if someone were to suggest it to you.
On the following pages are reasons people sometimes give for
know how important each of these possible reasons would be to you at this time in your life as a reason to
yourself. Please rate this in the space at the left on each question.
Each reason can be rated from 1 (Not At All Important) to 6 (Extremely Important). If a reason does not
apply to you or if you do not believe the statement is true, then it is not likely important and you should put a 1.
Please use the whole range of choices so as not to rate only at the middle (2, 3, 4, 5) or only at the extremes (1, 6).
In each space put a number to indicate the importance to you of each reason for
1. Not At All Important (as a reason for
all).
2. Quite Unimportant
3. Somewhat Unimportant
4. Somewhat Important
5. Quite Important
6. Extremely Important (as a reason for
important).
Even if you never have or firmly believe you never would seriously consider killing yourself, it is still
important that you rate each reason. In this case, rate on the basis of
be an alternative for you
____________________________________________________________________________________
In each space put a number to indicate the importance to you of each for
1. Not At All Important 4. Somewhat
not committing suicide if thenot committing suicide. We would like tonot killnot killing yourself.not killing myself, or, does not apply to me, I don't believe this atnot killing myself, I believe this very much and it is verywhy killing yourself is not or would never.not killing yourself.Important
2. Quite Unimportant 5. Quite Important
3. Somewhat
____________________________________________________________________________________
_____ 1. I have a responsibility and commitment to my family.
_____ 2. I believe I can learn to adjust or cope with my problems.
_____ 3. I believe I have control over my life and destiny
_____ 4. I have a desire to live.
_____ 5. I believe only God has the right to end a life.
_____ 6. I am afraid of death
Unimportant 6. Extremely Important
*04202a*
04202a RFLS
NIMH 3 B 1999-2003
1. Not At All Important 4. Somewhat
Important
2. Quite Unimportant 5. Quite Important
3. Somewhat
____________________________________________________________________________________
Unimportant 6. Extremely Important
Reasons for Living Scale \\www\internetpub\Publications\RFL48.doc Copyright 1996 M. M. Linehan page 2 of 3
Yellow 07/19/04
_____ 7. My family might believe I did not love them
_____ 8. I do not believe that things get miserable or hopeless enough that I would rather be dead
_____ 9. My family depends upon me and needs me
_____ 10. I do not want to die
_____ 11. I want to watch my children as they grow
_____ 12. Life is all we have and is better than nothing
_____ 13. I have future plans I am looking forward to carrying out
_____ 14. No matter how badly I feel, I know that it will not last
_____ 15. I am afraid of the unknown
_____ 16. I love and enjoy my family too much and could not leave them
_____ 17. I want to experience all that life has to offer and there are many experiences I haven't had yet which
I want to have
_____ 18. I am afraid that my method of killing myself would fail
_____ 19. I care enough about myself to live
_____ 20. Life is too beautiful and precious to end it
_____ 21. It would not be fair to leave the children for others to take care of
_____ 22. I believe I can find other solutions to my problems
_____ 23. I am afraid of going to hell
_____ 24. I have a love of life
_____ 25. I am too stable to kill myself
_____ 26. I am a coward and do not have the guts to do it
_____ 27. My religious beliefs forbid it
_____ 28. The effect on my children could be harmful
_____ 29. I am curious about what will happen in the future
_____ 30. It would hurt my family too much and I would not want them to suffer
_____ 31. I am concerned about what others would think of me
_____ 32. I believe everything has a way of working out for the best
_____ 33. I could not decide where, when, and how to do it
_____ 34. I consider it morally wrong
_____ 35. I still have many things left to do
_____ 36. I have the courage to face life
_____ 37. I am happy and content with my life
_____ 38. I am afraid of the actual "act" of killing myself (the pain, blood, violence
_____ 39. I believe killing myself would not really accomplish or solve anything
_____ 40. I have hope that things will improve and the future will be happier
_____ 41. Other people would think I am weak and selfish.
NIMH 3 B 1999-2003
1. Not At All Important 4. Somewhat
Important
2. Quite Unimportant 5. Quite Important
3. Somewhat
____________________________________________________________________________________
Reasons for Living Scale \\www\internetpub\Publications\RFL48.doc Copyright 1996 M. M. Linehan page 3 of 3
Yellow 07/19/04
_____ 42. I have an inner drive to survive
_____ 43. I would not want people to think I did not have control over my life
_____ 44. I believe I can find a purpose in life, a reason to live
_____ 45. I see no reason to hurry death along
_____ 46. I am so inept that my method would not work
_____ 47. I would not want my family to feel guilty afterwards
_____ 48. I would not want my family to think I was selfish or a coward
Reasons for Living Scale \\www\internetpub\Publications\RFL48.doc Copyright 1996 M. M. Linehan page 3 of 3
Yellow 07/19/04
Monday, July 30, 2012
Interview
with JoAnn Heap
Q: How do you handle conflict,
which is so common, when a client storms out or shuts down?
A: Focus on the here and now,
clients cannot process the past, they also have great difficulty processing
past emotions. Focus on how the
client currently feels, where they feel it in their body. Share with client that it is normal to
feel that way, and how they managed that feeling. Also ask what they could have done differently to manage
feelings. JoAnn reiterated that
psychodynamic processing has a place after clients can regulate emotions, not
go home and cut or experience suicidal ideation. DBT provides clients with the tools , skills and knowledge
to manage their emotions and struggles in a healthy way, so that they can
process painful past events with a therapist who has a psychodynamic
approach.
JoAnn also shared that she shocked
her clients, especially her adolescent clients because she “never gave up on
them”. She discussed expressing
intense belief that they patient will overcome and acquire skills. She emphasized that this will always
demand patience on the therapist’s end since we tend to so desperately want our
clients to magically feel better as quickly as possible.
Q: How do you promote motivation to
help clients stop parasuicidal behavior?
A: Firgure out what they want. Maybe they don’t know so she helps them consider common
areas of concern like peer or familial relationships. JoAnn said girls commonly state that they want a boyfriend
or an improved relationship with their current boyfriend. She said she emphasizes that she wants
to work on that area of concern with them. States that DBT is a research proven therapy. Typically asks a client: Can you see yourself
accomplishing your goal while cutting?
Also state- “cutting may scare him”, “Im worried about working with you
if you are cutting yourself”, “I would be horrified to lose you”. “Are you getting what you want
now”? “Have you ever done anything
hard? “ If discontinued the use of drugs or alcohol WOW emphasize how difficult
you know that must have been and how impressed you are by their strength. How that strength will help them on
this journey. Consider and ask, “What do you think will get in the way of you
meeting your goal” “I have a lot
to teach you”.
EMPHASIZE ITS GOING TO BE HARD
Q: What are 1 or 2 important lessons you have learned as a DBT
therapist?
A: Apologizing to the client or patient when you make a
mistake. JoAnn reiterated that she
has made many mistakes and that I will make many mistakes too, which will be
okay. Always recognize and
apologize for mistakes with clients.
When you are feeling stuck with a patient, when you feel you aren’t
helping them or making progress in some way JoAnn emphasized the importance of
sharing that feeling with a client as long as you had a plan of attack to solve
issue. She said whether you go
home and plan an alternative way to address issue or ask client if it is okay
with them to allow a session to be observed by her colleagues and provide suggestions. She discussed how important staff and
supervision consultations were in DBT because this work can be frustrating and
clients will disappoint me as a therapist.
Most difficult part of being a DBT
therapist: worrying about clients and their SI. JoAnn emphasized how easy it is to lose sleep over client’s
wellbeing. She also stated that as
a therapist who cares a great deal for her clients, typically “does too much
work for their patients”. This
means that we tend to want to see improvement in our clients so bad that we forge
ahead or engage in therapy before the client is ready or motivated. JoAnn said she learned that by telling
clients that she does not believe they are ready for therapy, really causes
clients to say YES I am lets get started! Revere psychology is apparently a useful skill for DBT
therapists.
Q: When a client says, “I love you”
or “You are the best therapist I have ever had”, how do you address these
comments?
A: JoAnn said she would validate these feelings and not feel concerned
about the client’s boundaries. She
said she would remind client that it is her goal for the client not to need her
that they are working together so that the client does not need therapist. Emphasize the strengths and abilities
are already within the client, that the therapist is simply facilitating the
process. She said she would
address physical expressions of love but not verbal.
Case Example Discussion
Pt discuss hurt and disappointment
in parent because they were physically, verbally and emotionally abusive to
them their entire life. JoAnn said
to focus on describing that. “I think your mom was doing the best she could,
but something was missing concerning her ability to appropriately provide care
to you. Your mother lacked the
skills, tools, knowledge, or emotional capability to provide you the love and
guidance you needed. Therapy can
teach you things that your mother could not. You are not your mother.”
Still
would like to learn more about boundaries and appropriateness concerning
sharing personal examples and stories with clients. “I would be terrified to lose you if you cut” It would hurt me deeply if you
committed suicide”
Sunday, June 24, 2012
Processes of Change in DBT: What Happens In and Out of the Session Video
Dialectical Behavior Therapy: The State of the Art and Science Conference
Seattle, WA
Alan E. Fruzzetti, PhD
http://public.streamhoster.com/resources/Flash/JWFLVMediaPlayer/Flashplayer.aspx?media_url=rtmp%3a%2f%2ffss27.streamhoster.com%2fvideo4nea%2fSeattle2011%2fFruzzetti2.flv&pwidth=460&pheight=320&autostart=false&pmiuri=
Sunday, May 20, 2012
DBT in Clinical Practice Chap. 1
Dialectical Behavior Therapy in Clinical Practice
Chapter 1: Overview of DBT
- Individuals with BPD represent 14-20% of inpatients and 8-11% of outpatients (Widiger & Frances, 1989, Wildiger & Weissman, 1991)
- Treatment progress can be slow and sporadic
- Therapists can struggle with their own emotional reactions when a client is recurrently suicidal and both rejects the help that the therapist offers and demands help that therapist cannot give
- DBT considers suicidal behavior to be a form of maladaptive problem solving and uses well-researched cognitive-behavioral therapy techniques to help clients solve life problems in more adaptive ways.
Biosocial Theory
- Pervasive biological emotional dysregulation is hypothesized to be developed and maintained by both biological and environmental factors
- Biology- individuals are thought to be more vulnerable to difficulties regulating their emotions due to differences in the central nervous system (due to genetics, events during fetal development, or early life trauma)
- Invalidating environments communicate that the individual's characteristic responses to events (particularly emotional responses) are incorrect, inappropriate, pathological, or not to be taken seriously.
- By punishing communication of negative experiences and only responding to negative emotional displays when they are escalated, the environment teaches the individuals to oscillate between emotional inhibition and extreme emotional communication.
- I found this theory valuable and could think of multiple cases in which adolescents with a working diagnosis of personality disorder NOS or BPD were raised in environments that were not conducive to emotional expression. Their emotional expressions were shut down, not validated, and ignored by their families, only acknowledged during explosions or suicide attempts.
- For clients, it is difficult to know whether to blame oneself or others: either one is able to control one's own behavior (as other believe and expect) but won't, and therefore is "manipulative", or one is unable to control one's emotions, as a lifetime of experiences shows, which means that life will always be a never ending nightmare of dyscontrol.
- When the person tries to fulfill expectations that are out of line with true capabilities, he or she may fail, feel ashamed, and decide that being punished or even being dead is what is deserved.
- Therapist must validate the uncontrollable, helpless experience of emotional arousal
Stages, Goals, and Targets of Treatment
- Pretreatment: client and therapist explicitly and collaboratively agree to the essential goals and methods of treatment and obtain engagement in therapy
- Stage 1- Targets: 1. Suicidal/homicidal or other imminently life-threatening behavior 2. therapy -interfering behavior by the therapist or the client 3. behavior that severely compromises the client's quality of life (eg Axis 1 problems, serious problems with relationships, legal system, employment/school, illness, and housing) 4. Deficits in behavioral capabilities needed to make life changes
- Training to target deficits- regulate emotions, tolerate distress, respond skillfully to interpersonal situations, observe, describe, and participate without judging, with awareness and focusing on effectiveness. and manage their own behavior with strategies other than self punishment
- These skills are intended to decrease identity confusion, emptiness, and cognitive dysregulation; interpersonal effectiveness addressing interpersonal chaos and fears of abandonment; emotion regulation skills reducing labile affect and excessive anger; and distress tolerance helping to reduce impulsive behaviors, suicidal threats, and intentional injury.
- many clients who are not out of control still experience tremendous emotional pain due to either post traumatic stress or other painful experiences that leave them alienated or isolated from meaningful connections to other people or to a vocation.
- Stage 2- Goal: to have nontruamatizing emotional experience and connection to the environment
- Stage 3- client synthesizes what has been learned, increases his or her self-respect and an abiding sense of connection and works toward resolving problems in living.
- Stage 4: focuses on the sense of incompleteness that many individuals experience. In this stage goals typically fall outside the realm of typically therapy and into a spiritual practice
- Progress of therapy is not linear and the stages typically overlap. Therapists must commonly revisit past stages throughout sessions
- This section was fairly straightforward but also barely touched the surface of what these stages of treatment entailed. I wonder how is stage 2 carried out? Does the therapist use a form of behavioral activation model focused around engaging in meaningful relationships, or formulating behavioral goals to work towards discovering a client's vocation? Also, how does a therapist structure and carry out stage 4? Is this stage skipped if the client is uninterested in exploring a spiritual lifestyle?
DBT as Problem Solving
- Whenever one of the targeted problem behaviors occurs, the therapist and the client conduct an in-depth analysis of events and situational factors before, during and after that particular instance of the targeted behavior.
- The goal of this chain analysis is to provide an accurate and reasonably complete account of the behavioral and environmental events associated with the problem behavior.
- As the therapist and the client discuss a chain of events the therapist highlights dysfunctional behavior, focusing on emotions, and helps the client gain insight by recognizing the patterns between this and other instances of problem behavior. Alternative responses that would have lead to positive outcomes are discussed
Skills Training
- DBT skills training is provided on a weekly basis for approximately 2 1/2 hours.
- Four skills training modules are taught over the course of approximately 6 months, allowing for completion of all skills, twice within a standard DBT outpatient group. Skills include:
- Emotion regulation training teaches a range of behavioral and cognitive strategies for reducing unwanted emotional responses as well as impulsive dysfunctional behaviors that occur in the context of intense emotions by teaching clients how to identify and describe emotions, how to stop avoiding negative emotions, how to increase positive emotions, and how to change unwanted negative emotions.
- Distress Tolerance: teaches a number of impulse control and self-soothing techniques aimed at surviving crises without using drugs, attempting suicide, or engaging in other dysfunctional behavior.
- Interpersonal effectiveness: teaches a variety of assertiveness skills to achieve one's objective while maintaining relationships and one's self respect.
- Mindfulness skills: focusing attention on observing oneself or one's immediate context, describing observations, participating, assuming a non judgemental stance, focusing awareness and developing effectiveness.
Validation
- DBT stresses communicated validation in the client's emotions, thoughts and actions.
- A DBT therapist must search for strengths, normality, or effectiveness inherent in the client's responses whenever possible and teach the client to self validate
- Example: Cutting one's arm in response to overwhelming emotional distress is valid, given that it often produces relief from unbearable emotions. It is also invalid: it is not normative, it prevents developing other means of emotion regulation, it causes scars, and alienates others* (thoughts in italics below)
- Unless the client believes that the therapist truly understands his or her dilemma and exactly how painful it is, he or she will not trust that the therapist's solutions are appropriate or adequate
- I think this aspect of DBT is very important. I appreciate that it emphasizes the importance of validating the client's emotions and helping them feel as though they aren't "crazy" as many people label those with BPD. I just wonder: the point in which the text mentioned the negative consequences of cutting such as "not normal, causes scars, and alienates others", are these consequences a therapist would discuss with a pt who engages in self harm behavior? Wouldn't these negative and critical consequences shame or cause the client to feel worse about themselves? At my placement, many of our clients harm themselves and we allow the patients to discuss in group therapy the pros and cons of cutting but we never tell a client they should not cut or that they alienate others by their self harming actions, because we do not want to further shame the client. I also know that targeting suicidality and self harm behaviors are the first issues covered in DBT after the engagement and contract stage, but has enough of a positive working relationship been built to discuss the negative consequences of cutting without the patient or client thinking the therapist is judging them? What are your thoughts on this Mary?
DBT as Dialectics
- Dialectics is both a method of persuasion and a worldview or set of assumptions about the nature of reality
- The whole dialogue of therapy constructs new positions where the quality of one's life doesn't give rise to wanting to die. Suicide is one way out of an unbearable life. However building a life that is genuinely worth living is an equally valid positions. The constant refrain in DBT is that a better solution can be found.
- GREAT EXAMPLE: Therapist: So what you're saying is that if you saw a person in a lot of emotional pain, say your little niece, and she was feeling as badly as you were that night you burned your arm, she was feeling as devastated by disappointment as you were that night, you'd burn her arm with a cigarette to help her feel better. Client: No I wouldn't. Therapist: Why not? Client: I just wouldn't. Therapist: I believe you wouldn't but why not? Client: I'd comfort her or do something else to help her feel better. Therapist: But what if she was inconsolable, and nothing you did made her feel better? Besides you wouldn't burn her that badly. Client: I just wouldn't do it. Its not right. Id do something but not that. Therapist: That's interesting, don't you think?
- The existence of "yes" gives rise to "no" and "all" to "nothing"
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