Shireen Rizvi Addresses NJ-ACT on DBT’s Chain Analysis
For Dysregulated Emotions and Behaviors
By Lynn Mollick
Eighty-one NJ-ACT members attended Dr. Shireen Rizvi’s February 2nd DBT workshop. Dr. Rizvi focused on using Chain Analysis to identify interventions for dysregulated emotions and behaviors.
DBT uses Chain Analysis to address suicidal and parasuicidal acts, but Chain Analysis is also useful for reducing bingeing, drug and alcohol lapses, temper outbursts, impulsive or criminal acts, and avoidance behaviors. In fact, Chain Analysis can be applied to any dysregulated behavior including therapy-interfering behaviors such as cancelling sessions, failing to do homework, attacking the therapist, or changing the subject during therapy. Chain Analysis identifies the following sequential links:
1. The patient’s vulnerabilities
2. The prompting event
3. Interpersonal, behavioral, cognitive and emotional links between the prompting event and the dysregulated behavior
4. The dysregulated behavior
5. Positive consequences, usually immediate
6. Negative consequences, usually delayed
Therapist and patient collaborate in developing the chain. The therapist’s style should be supportive and inquisitive despite patients’ frequent reluctance to participate. Therapists should explain that Chain Analysis offers patients a new way to understand their dysregulated emotions and behaviors and will identify interventions for overcoming these problems.
Dr. Rizvi recommends using the term “Chain Analysis” explicitly and doing a full chain before making any interventions. She also recommends writing out the chain and making sure that the patient goes home with a copy.
Dr. Rizvi recommends identifying chain links in the following sequence:
1. Describe a specific instance of the dysregulated behavior. What was its duration, intensity, and frequency? Example: How did the patient self-injure? Where on the body, how many times, and how severely? Where did she do it? What instrument did she use? The description should be specific enough for an actor to reproduce the behavior.
2. Look for the prompting event. When patients say “I don’t know why I did this -- it just happened,” ask “When did you first have the urge,” or “What events preceded the dysregulated behavior,” or ”What was different today?” If the prompting event was in the past, ask “What happened today that made you think of that?”
If the dysregulated behavior is an avoidance, ask “When did you first notice the thought to avoid,“ “What feelings were you experiencing at that moment?” and “What did you do instead?” Then put these behaviors into the chain.
3. Vulnerabilities are traits and states that make the dysregulated behavior more likely to occur, for example, being hungry, angry, lonely, tired, or not having taken medication. Underlying problems like ADHD and personality disorders are also vulnerabilities, but it is best to focus on vulnerabilities that are amenable to change rather than vulnerabilities that are difficult or impossible to change.
4. Cognitions, emotions, patient behaviors, other people’s behaviors, environmental stimuli, and physiological reactions that are links between the prompting event to the dysregulated behavior. Each link is an opportunity for the following types of interventions.
A) Skill training to teach skills the patient lacks.
B) Exposure to teach acceptance of anything the patient avoids.
C) Cognitive modification to correct dysfunctional beliefs that are links in the chain.
D) Contingency management to reduce reinforcement of dysregulated behaviors.
To choose an intervention ask “Which link do you think is most important?” or “Getting rid of which link would prevent the dysregulated behavior?” Choosing the best intervention often requires balancing what is needed with what is possible. You always want the patient to achieve some success, even if you don’t address the most important dysregulated behavior initially.
5. What are the positive and negative consequences of the dysregulated behavior? With self-injury, immediate physical pain is a positive consequence because it is preferable to emotional pain. (Shame over self-injury occurs later.) With substance abuse, the immediate rush or tension relief is more powerful than any delayed negative effects. And concerned people in a patient’s life sometimes reinforce dysregulated behaviors with attention.
Dr. Rizvi described a patient who self-injured every day. Making changes in the chain leading up to the self-injury did not improve the problem. So the therapist applied a positive consequence for an alternate, functional behavior – an additional therapy session if the patient did not self-injure for a week. This intervention immediately stopped the self-injury..
Chain Analysis is an empirical process. If an intervention does not improve the dysregulated behavior, a new intervention should be planned and/or further Chain Analysis should be performed. Chain Analysis is not restricted to DBT; it can be used with any form of cognitive behavior therapy.
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