DBT Expert Interviews: From Trauma to Eating Disorders

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DBT Skills for Emotional Dysregulation in Psychosis: A Clinical Case Study

By Dr. Kirby Reutter, Ph.D., DBTC, LMHC, MAC & Margaret Mullen, LCSW.

This presentation is an excerpt from the online course DBT Expert Interviews: From Trauma to Eating Disorders“.




Greetings and welcome to the first of 3 segments in this interview series with Maggie Mullen on the topic of DBT and psychosis. Maggie is a prominent psychotherapist in California and the author of The DBT Therapy Skills Workbook for Psychosis Disorder.

In the first segment of this interview, Maggie uses a fictional client, Sandra, as a case study to explain how they would conduct their first DBT session with a client presenting with psychotic symptoms.

Starting with a chain analysis, Maggie explains a variety of DBT skills that they might teach Sandra, including the following: self-soothing skills, distraction skills, pros and cons, self-validation, and the STOP acronym.

Next, Maggie explores the vicious cycle between emotional dysregulation and psychotic episodes as well as the importance of DBT emotion regulation skills in breaking this cycle.

Finally, Maggie also discusses some practical tips for teaching mindfulness skills to this population. Throughout this segment, Maggie emphasizes the need to make skills work as concrete as possible when working with symptoms of psychosis.

A Clinical Case

Kirby: Is there a case example that you would like to share?

Maggie: I’ll read through this case. Sandra is who we’re going to be talking about today. She is a 35-year-old pansexual black cisgender woman and she is diagnosed with schizoaffective disorder and has a history of multiple hospitalizations for manic episodes and suicide attempts.

Sometimes she self-harms in the form of cutting her legs and punching herself to try to get her voices to stop. Sandra works full-time as a library assistant at the local library and lives in a multi-generational household with her family.

She has support from her parents and grandparents, but they’re feeling burned out with her due to the highs and lows of her behavior and moods recently. She currently has a partner and their relationship is also up and down.

Sandra comes into your most recent session and shares that she got into a screaming fight with her mother that morning. Before the fight, she became suspicious that her family had bad intentions toward her. That happened after she saw her mom wringing her hands.

After the fight, she began hearing voices or auditory hallucinations criticizing her and telling her what a bad person she is and she decided to cut herself.

Kirby: What’s the first thing you would do with this patient?

Maggie: The first thing that I would do is a behavior chain analysis. This is a way of looking at the links in the chain of what led up to a target behavior. What were the thoughts, feelings and emotions, body sensations, and behaviors that led her to the point of feeling like she had no other option than to self-harm?

The first step is to assess her emotional vulnerabilities. What are the things that might predispose her to being more emotional that day? Did she eat enough? Did she sleep enough the night before? Is she in physical pain? Did she use any substances? Those are things that tend to make us feel more emotional.

She says that she hadn’t eaten all day and she slept poorly the night before, making it more likely she would be more emotional that day.

The next step is to outline all the links in the chain to understand what were the different pieces that led to her performing that target behavior. Check what her attempts to be skillful are. What did she already do or attempt to do to try to manage her emotions? Was it effective? We must weigh the consequences of what happened.

Sandra might share that she tried to leave the conversation but couldn’t because she kept getting drawn back in. We might look at, was that an effective strategy in that moment? What could she do in the future to become more skilled? Specifically, note areas where she can integrate some specific DBT skills or principles.

We want to make the skills as concrete and easy to use as possible for patients with psychosis. We might start by having her notice that she’s feeling escalated and suspicious of her family. We would use mindfulness. For example, ask her to check in with herself to notice how she’s feeling. Also, ask her to use the distress tolerance skill of STOP. This skill is about stopping the action of what’s happening and taking a step back so she can see the bigger picture.

I might then have Sandra practice some self-validation. This means noticing that she’s feeling afraid and just being able to say that to herself to acknowledge her emotions.

Next, we would look at things that would help Sandra de-escalate herself. She could use self-soothing skills. For example, she could drink a warm cup of tea and listen to her favorite music, or go for a walk in her local park to help calm the fear that she noticed coming up around her mom.

We could also use distraction skills from distress tolerance to take her mind off of her worries. For half an hour, she can let those emotions de-escalate from that intense level.

She could make a pros and cons list to think about whether it was helpful to believe her original thought. Sandra is going to have to come up with her own solutions and we’re going to offer ideas and coach her to get there.

The idea is to prepare Sandra so that she knows how to overcome this situation more skillfully in the future because it’s likely to happen again, given the pattern that she has noticed in her life.

DBT and Emotion Dysregulation in Psychotic Patients

Kirby: How does DBT help psychotic patients that suffer emotion dysregulation?

Maggie: CBT for psychosis was developed with the idea of helping people with psychosis deal with the thoughts particularly associated with psychosis, which then influence their emotional and behavioral world. What I’ve found useful about that modality is that it gives us some tools to do that.

What tends to be missing is the concrete skills and interventions that DBT offers when people are emotionally dysregulated. People with psychosis often get caught in this vicious cycle where their strong emotions make it more likely that their symptoms will worsen and tend to cause their emotions to escalate even more. The patient gets stuck again in this vicious cycle.

If we’re looking at Sandra, maybe she feels really stressed and ashamed in a situation where she got reprimanded at work. As a result, she’s going to be experiencing more emotions. She’s more likely to hear distressing voices and it might be really critical to her. Those voices may say things to her, like “You can’t trust anyone.”

For somebody with psychosis, these voices might make her feel afraid and maybe even angry. The cycle continues where her suspicious thoughts and fearful emotions increase. This may end with her self-harming or isolating herself. It’s a cycle that we work on breaking using DBT skills.

People with psychotic spectrum disorders struggle a lot with emotion regulation. The negative or challenging emotions are consistently associated with an increase in paranoid thinking and their predictor of paranoid episodes.

The relationship between emotions and psychotic symptoms is circular. If we’re able to break that cycle using DBT skills, we will have better outcomes for people than just focusing on thoughts or medication only interventions.

Marsha Linehan, in her original 1993 book, talks about the idea that in order to include people with psychosis when you do DBT, you need to determine if the client has any cognitive impairments that would affect their ability to attend to the grasp skills concepts.

One of the things that I’ve even found, given the changes since 1993, is that people actually can manage these skills when we use them in an adaptive way, even if they have cognitive impairments. Part of my work is on adapting DBT skills to be appropriate for people with psychosis.

They are concrete, very tangible. If clients have many negative symptoms, which might mask their outward emotional expression, we take approaches that will help them verbally express how they feel differently. We work on helping them identify their emotions using mindfulness practice.

Applying Mindfulness to Clients With Psychotic Disorders

Kirby: How do you apply mindfulness to this population?

Maggie: There are a lot of specific adaptations that make mindfulness work really well for people with psychosis.

There is a really strong evidence base for helping people with psychosis using mindfulness. It’s an acceptance-based approach that helps clients to accept symptoms rather than to challenge them. It doesn’t mean that you like them or that they’re okay but you just notice them for what they are before you do anything.

I usually start with 3 minutes rather than the recommended 40 minutes of an eyes closed quiet mindfulness meditation. We do short chunks, depending on the client’s ability to be aware of their surroundings as well as their internal world.

We also offer more guidance than silent time. One of the recommendations for mindfulness in this population is being able to walk them through more steps than we normally would. That guidance should also include specific mentions of psychotic symptoms in a normalizing way.

With a client with psychosis, I’m going to tell them, “If you notice any voices that are taking your attention away from this activity or maybe starting to feel distressing, bring your attention back to your breath.” The idea is to normalize somebody’s experience.

The last adaptation that I often make is being able to focus not just on yourself, if that’s too overwhelming. If somebody is feeling really overwhelmed by intrusive thoughts, distressing voices, paranoia, I make the patient focus on the outward world instead.

For example, have them describe and observe things in the room around them instead of focusing on their breath or something happening internally.

Kirby: How do you help a client take a non-judgmental stance in the latter example?

Maggie: We might start beyond the non-judgmental stance using distress tolerance skills. If you have a voice saying something that’s criticizing or harsh towards you, we need to start de-escalating the emotions that will initially arise.

We might start with distress tolerance. Once we’ve de-escalated slightly, then we work on the non-judgmental stance. This is a key component of mindfulness.

This skill can be really handy because it’s easy to jump to believing the self-critical voice that says there’s something wrong with us or that we’re not okay. When we can take a non-judgmental stance, it can reduce the overall emotional intensity in the situation. This can also encourage that client to be less critical and more thoughtful towards himself in that moment.

I might have that client focus on just observing and describing. “What just happened? What was your experience in your body or your mind when you heard that voice say that to you?”

There are specific strategies associated with psychosis that the client can use as an adjunct. The client can communicate back to the voice and say, “No, I don’t believe that,” or, “Can you come back later another time?” There are ways that we can adapt specifically to voices to make them more gentle with us than they may be normally.

Kirby: In DBT, mindfulness skills and distress tolerance skills are very similar. They overlap a lot and go hand in hand. I like to think of distress tolerance as applied mindfulness.

For example, you can do breathing as a mindfulness exercise but you could also do breathing as a distress tolerance exercise. Sometimes, mindfulness itself is distress tolerance but sometimes you need to do distress tolerance in order to become mindful as a prerequisite.

Maggie: There is some form of mindfulness that usually comes before distress tolerance, just only in the sense of knowing that you’re escalated and need to use distress tolerance skills.

Main Points

  • Even though psychosis has been historically conceptualized as a thought disorder, there is a strong correlation between emotion dysregulation and psychotic episodes. Therefore, emotion regulation work needs to be prioritized within DBT treatment.
  • When teaching DBT skills to clients with psychosis, it’s important to normalize psychotic symptoms and make skills work as concrete and user friendly as possible.
  • When teaching mindfulness skills in particular, it’s especially important to have clients practice in very small time segments of just a few minutes at a time in contrast to longer, more formal, or more traditional meditative practices.
  • Clients are encouraged to practice mindfulness with their own inner psychotic experiences, such as delusions and hallucinations. However, if this is too triggering, they can also practice mindfulness on something more tangible/grounding in their external physical environment.

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