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PROVIDING DIALECTICAL BEHAVIORAL THERAPY TO PEOPLE WITH GAMBLING
DISORDERS
Michael Goldman, MA, LPC, PCGC, CRADC, CEAP
847-832-9500
https://mgoldmancounseling.com
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WHAT WE’LL COVER
I. History
II. Description
III. How DBT and Gambling Disorder (GD) work together
IV. Types of truth
V. Three components
VI. Wrap-up
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W H A T D O E S T H E G D C L I E N T L O O K L I K E ?
Picture a client with a GD. What do some
of their psychological/emotional challenges
look like?
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HISTORY
Developed by Marsha Linehan in 1993
Tried unsuccessfully treating adult women with chronic suicidal behaviors with CBT alone in the 1970’s
Those patients found the focus on change very invalidating & dropped out of treatment
ML modified her approach to be more validating and retain patients
The APA stated that DBT is effective as a tool for treating people with GD
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HISTORY-CONTINUED
ML had a personal history or trauma, mental illness (BPD) &
psychiatric treatment
She looked at research involving Holocaust survivors and at
resilience
The findings were that finding positive meaning in a difficult
situation and acceptance was essential in emotional success
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WHAT IS IT?
DBT combines CBT with MBSR (Kabat-Zinn)
Mindfulness is paying attention in a particular way with intention
and without judgment
This may help reduce negative rumination which can lead to
relapse
This is taught first
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WHY DBT WORKS FOR THOSE WITH A GD
Many people with a GD lack distress tolerance, emotional regulation , and interpersonal skills
They may have high emotional reactivity, high sensitivity & slow to return to baseline
Emotional storms may lead to relapse
DBT is focused on dealing with these challenges
One of the philosophies of DBT is that people are doing the best they can in the moment but can find ways to do better
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GD & DBT
Acceptance is the key ingredient to the person with a GD as well
as for the provider (they must accept that relapses may
occur often)
The patient’s unhealthy behavior helped them to survive but with
bad side effects
The provider must recognize that gambling is the patient’s survival
tool and taking that away from them is very frightening
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TYPES OF MIND
People have different ways of processing information
The three types of mind are: emotional, rational, wise
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EMOTIONAL MIND
Located in the Amygdala
Devoid of logic
Being very judgmental will increase this
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RATIONAL MIND
Logical, devoid of emotion
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WISE MINDED
Synthesis of both
Both necessary for good decision making
Jonah Lehrer’s book How We Decide (2009)(Man with damaged
Amygdala)
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CHOICES
According to DBT principles, people have four choices when
faced with a difficult situation:
1. Do nothing differently
2. Change the source of the stress
3. Change cognitive perception of situation
4. Radically accept the situation
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CHANGE
According to DBT you can not change until you become aware
Once you become aware, you’ve begun to change
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CHANGE METAPHOR
The progression of change is well illustrated by the Portia Nelson
pothole metaphor:
1. I don’t see the pothole and I fall in
2. I pretend not to see it and I fall in
3. I see it but still fall in (but get out quickly; but not my fault)
4. I walk around it
5. I walk down a different street
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TYPES OF TRUTH
DBT recognizes that truth has a lot to do with a person’s ability to
change. There are 3 types:
1. Absolutism- Truth is black or white; no in-between
2. Dialectics- There’s truth in all perspectives but not all
perspectives are true
3. Relativism- Truth is in the eye of the beholder
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PERSPECTIVE
To change perspective you must get different points of view
If there are 4 people on 4 different mt. tops, they will view things
differently
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FUNCTIONS OF THERAPY
Therapy should:
1. Enhance and maintain client’s motivation to change
2. Enhance their capabilities to change
3. Ensure new capabilities are generalized to new situations
4. Structure the therapy so that change can take place
5. Enhance therapist's motivation to treat client
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FEAR OF CHANGE
Patients who didn’t want to discuss something rewarded therapists
who allowed the topics to be changed by being warm
and engaging
DBT is organized to address problems sequentially so that
therapy doesn’t keep switching to the “crisis du jour”
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MODES OF THERAPY
DBT uses individual & group therapy, skills building, telephone
contact & consultation
Treatment increases motivation, analyzes problem behavior, &
develops behavioral alternatives
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PRIORITIES
The priorities of therapy, in order:
1. Staying alive
2. Staying in treatment
3. Building a better quality of life through the acquisition of new
behaviors and skills
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THREE COMPONENTS TO DBT
Emotional regulation
Distress tolerance
Interpersonal effectiveness
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EMOTIONAL REGULATION
We don’t control our emotions but, rather, change our response to them
ER helps client understand feelings and decrease emotional
vulnerability and suffering
They learn to recognize and accept feelings before they can let go of them
They learn to describe situations rather than judge them
They must be mindful of HALT with can lead to emotional
dysregulation
Which type of person with a GD may be in most need of ER?
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ER STRATEGIES
IMPROVE:
I- Imagery- imagining relaxing scenes or other things that are pleasant
M- Meaning- finding positive meaning in what they are feeling
P- Prayer
R-Relaxation
O- One thing, in the moment, being in the present
V- Vacation- taking a break from the stressors
E- Encouragement- positive affirmations
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OTHER ER TOOLS
Diary cards- Daily tracking of negative behaviors, i.e. relapse, that
originate from emotional storms
Chain analysis- what prompted the event, the interpretation of the
event, body sensations, action urge, action, emotional name
Building positive experiences- finding healthy behaviors that
produce positive emotions
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DISTRESS TOLERANCE
Focus on Radical Acceptance (Should vs. The-way- it-is worlds)
RA starts with the therapist- must be non-judgmental, describing behavior without giving it a value, teaching client to do the same
Acknowledging transient nature of emotions
Use of empathy helps turning of the mind
Is this distress danger or discomfort?
Compassion for self means learning not to be afraid of negative emotions but rather learning to accept and even embrace them
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ACCEPTS
A- Activities (positive ones)
C- Contribute- helping others
C- Comparisons- comparing one’s woes with those less fortunate
E- Emotions- use of humor or happiness to counter-act destructive emotions
P- Push away- put problems on back-burner;
T- Thoughts- allow mind to focus on something else
S- Sensations- do something else that produces intense feelings other than the
ones being experienced now, i.e. go for a fast run, take a cold shower
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INTERPERSONAL EFFECTIVENESS
DBT helps client understand how their negative behavior
interferes with social goals
Improving IE includes improving self esteem and assertiveness
while decreasing impulsivity and reactivity
It also includes maintaining sense of self and of relationships with
others
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REDUCING JUDGEMENTALNESS
Why do people judge?
1. We assume other person understands us (mental short-hand)
2. To control others (not effective)
3. To control own behavior (also not effective)
Kabat-Zin describes developing a “beginner's mind”
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COGNITIVE DISTORTIONS
Different types of cognitive distortions that reduce IE:
1. All or nothing thinking
2. Over generalization
3.Mental filter- dwelling on one negative feature of a situation
4. Jumping to conclusions
5. Mind reading
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COGNITIVE DISTORTIONS-CONTINUED
6. Negative fortune telling
7. Catastrophizing
8. Minimization
9. “Should” statements
10. Personalization
11. Thought fusion
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EFFECTIVE BEHAVIORS
Strategies that improve IE:
1. Emotional modulation
2. Self-validation
3. Realistic judgment
4. Active problem solving
5. Balancing demands & priorities
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EFFECTIVE BEHAVIORS-CONTINUED
6. Learning to ask for help aligning behaviors with goals
7. Assertiveness- includes objectives, self-respect, & relationship
effectiveness
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OBJECTIVES EFFECTIVENESS
1. Standing up for what you want
2. Requesting others to do things in a way that they do it
3. Setting boundaries- learning to say no appropriately
4. Resolving interpersonal conflict effectively
5. Using effective communication skills
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SELF-RESPECT EFFECTIVENESS
Characteristics include: honesty, truthfulness, integrity, sticking to
one’s values commitment, persistence, and avoiding self-
destructive behaviors like people-pleasing, acting like a
victim, relapsing and other short-term at the expense of
long-term gain behaviors
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RELATIONSHIP EFFECTIVENESS
1. Balancing what’s good for the individual with what’s good for
the relationship
2. Effective compromising- negotiable vs. non-negotiable
3. Learning how to validate others
4. Be attentive
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POSITIVE RESPONSES
Responses can be constructive vs critical; assertive vs passive
Example: A man walks in and tells wife he got a promotion:
1. Constructive- Assertive: “That’s great honey. Tell me all about it.”
2. Constructive –Passive: “That’s nice”
3. Critical-Passive: “Well my boss said he couldn’t run our department without me.”
4. Critical- Assertive: “Don’t get a big head about it. You can be so egotistical”
Which of these four statements improve IE?
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IMPROVING SELF-PERPETUATING CYCLESNegative self-perpetuating cycle:
Changing the paradigm:
Early narcissistic wounds
Negative self-esteem
Future triggers reinforce negative belief system
Fear of worthlessness leads to negative behavior
Negative interpersonal relationship outcomes
Use of MBSR/CBT strategies
Neg. trigger/thoughts/ feelings seen as transient; use of “Beginners Mind”
T/F do not reinforce negative belief system
Ability to separate actions from essence; behaviors become more constructive
Better interpersonal relationship outcomes; improved self-esteem
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WHY ARE DOGS SO GOOD AT DBT?
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THEY ARE MINDFUL
Mind full versus mindful
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THEY ARE GOOD AT MEDITATING
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GOOD AT EMOTIONAL REGULATION
They don’t hold grudges and forgive easily; can be joyful quickly
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GOOD AT INTERPERSONAL RELATIONSHIPS
They help people who struggle with distress tolerance
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RESOURCES
Skills Training Manuel for Treating Borderline Personality
Disorder, Marcia Linehan, 1993
DBT Skills Workbook: Practical DBT Exercises, McKay,
Wood, Brantley, 2007
Linehan Institute site: www.behavioraltech.org-
Linehan UofW site:http://faculty.washington.edu/linehan/
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WRAP-UP
Questions?
Thank you!!