Chain analysis, bread and butter of DBT chain analysis, you have to do this in a large part of the treatment of DBT.
Not only is this your strategy for assessing the patient by spreading their behavior out chronologically over a continuum and saying this happened, then this happened, then this happened, then this happened, then the problem behavior happened, then this happened, then this happened.
To me as a trained as a doctor, like somebody comes in with abdominal pain, or when did it begin?
Well, what what were you doing before that, then what did you do? Did that make a better? Did that make it worse? Did you take any medicine for that, you know, blah, blah, blah, you know, it's chain analysis. Chain analysis is nothing that unique to behaviorism. Anyone who assesses a leaking faucet is doing behavioral chain analysis, you know, what, when did it start? What What was going on? Then? What else? Could it be trying to see the pattern?
Chain analysis is you start by identifying the target behavior, then you have to assess the controlling variables, what is causing this behavior of eating disorders to happen again and again, cutting substance abuse, dissociation, dissociative episodes, traumatic responses, interpersonal dysfunctional behaviors, assess those things, always asking what's the function of this behavior? Which basically means, what's keeping it going?
What's keeping this behavior going? And usually we don't know, even if it's obvious, in fact, if it's obvious, we probably especially don't know, we think, Oh, well, it's because of this is sort of obvious. Well, if it was obvious, probably somebody would have moved in and been able to change it by now, it's probably something that's not so obvious.
So you have to kind of crack the shell open your mind into kind of Zen beginner's mind and say, I don't know anything. Let me figure it out by going through the details of the chain, with my mind open all the time to which is, which are the most important variables here that are making this behavior happen? again, and again, and again, even though it's ruining this person's life, you think chronologically, left to right. That doesn't mean you're dragging the patient through time chronologically, but that's how your mind is organized in the back.
Like I it's a template, going from left to right earlier to later. And, and in my mind, about three quarters of the way to the right of my arbitrary sequence is the problem behavior. Because I want to get a bunch of stuff before it. And I want to get some stuff after it. So it's kind of like arbitrary, that I'm picking a chunk of behavior, a sequence of behavior within which is embedded the problem behavior, and I'm going to be figuring it out.
And even if my interview with the patient leads me to go to the right end of the chain first, and the left hand later, or the middle of the chain first and then the left, and then the right, I'm still organizing it, in my mind, left to right, that helps keep it on the same template. And then next time I see the patient, and there's a similar behavior that we're analyzing, I've already got a template.
Now I'm wondering how many of the things that this week are going to be the same things in the chain as last week, you start to narrow down, which are the variables that keep happening that might explain this behavior, and what am I missing? So you're in you're thinking chronologically left to right, but in a in a good way of doing chain analysis, you're actually interacting more fluidly more conversationally, you're getting what comes.
And I'll talk about that when we go through that video, you analyze a chunk of behavior, obviously, you're not going to analyze the whole chain, the whole chain started, you know, like, when man evolved. So you're not going to do that. Or even when the person was born, or even the past year, you're going to use a chunk of behavior leading up to the problem behavior that includes enough variables to do a meaningful analysis of, but not so much that you're flooded in one session.
This is not forever. I did do once, by the way, my first DBT application was to develop a long term inpatient DBT program in White Plains, New York. And they're at the end of a horrible week of a lot of problem behavior, a lot of self harm. I announced on Friday that we were staying in a group meeting throughout until we had analyzed what the problem was on the unit. And we put up butcher paper around all the walls of the unit and we started doing a chain analysis, starting as back as far as any staff member or patient thought we should start.
And we ended up with something that I wish I had videoed or taken a photograph of because it was just like a hundreds of variables. And but over time, we all started to agree Oh, When Dr. So and so left the unit, everything changed. And we hadn't thought of that until we started to lay it out, we thought, Oh, yeah, we were doing pretty well until Dr. So and so left.
And you know what nurse so and so left at about the same time, and they were two linchpins of this unit. So that was very important on this unit.
And then we started to change. And patients notice that but they had never put it into words. And as we started to make more sense of it, it started to feel like we're going to be able to get control of this.
So analyze a chunk of behavior. And behavioral chain analysis tells a story. The reason I say this is that, as somebody who started out as a psychoanalytic therapist, sometimes if you do DBT, in too chunky away, like getting all the details and getting the controlling variables, the patient feels that they've been dragged through a technological procedure, where you actually still don't know them, you just know the sequence of behavior. So to do this in a really good way, you want to have an attachment with the patient, that's mutual, you certainly want the patient attached to you, if possible, you want to have a lot of respect, a lot of validation going on, and keep going through it.
And you want it to feel like you're not involved in a chunk by chunk analysis, you're involved in a story, because people's minds are organized in stories, in narratives in metaphors.
So that's the avenue in you can't go in and try to spread out a human being over a chain. Or your patients will start to say to you, as our inpatients would say to us, what are you going to do, you're going to hit me over the head with another chain, when that was their language, and I started to think there's something wrong with us, we don't want to be hitting them over the head with a chain.
I mean, we want to just be getting the story. So I emphasize this because you just want to get the story. And then the patient's much more willing, because you're getting it. Okay, oops. And I'll just say before we go into a video, that this is not a very good slide, because there's, I don't even know if you can read it on your slide with these five things are.
But when you're doing the chain, I've always found it useful the way it's organized around five sequential categories of variables, you've got vulnerability factors. This thing has vulnerability factors, which is everything that happened before the trigger, before the prompting event, all those things that happened that rendered the person vulnerable to the trigger, they didn't get much sleep, they were drinking, they were tired.
All these things will identify it in the video, like what they were for the young woman that we're gonna look at, then comes the trigger or prompting event, prompting event, the thing that sort of broke the camel's back, the thing that after the things that led up to it and rendered the person vulnerable. The thing that's identifiable that really was when the story turned, then there's the links in the chain. Following the prompting event, link by link by link, there could be a lot of those.
And they they're basically the actions of the patient. They're the emotions of the patient. They're the thoughts of the patient. And they're the variables happening in the environment of the patient. They're sort of events going on around the patient, those four categories of things, you know, actions, thoughts, emotions, and then contextual events going on are the links because you want to get the story link by link. And you want the story to make sense to you.
Either way, there's no one out there Linehan or anyone else that can tell you what you should get in that, that those links. You've got to satisfy your own best ability to understand a story. And if somebody is telling you a story, and you don't get how they got from one link to another link, that could be a very important moment, where you say, wait a minute, I don't I don't understand. How did. How did you get from that to that? I don't quite get that.
Well, I just do that.
Okay, my patient once who told me she got really angry, and that's why she's slugged her boss at the pizza place that she was working after getting out of the state hospital, that she slugged her boss in the head, knocked him on the ground very proudly, because he was a jerk. I said, So why'd you do that? I was angry. Now, there's something missing there. I said, Well, does that mean every like if you get angry at me or you're going to slug me in the head? I want to know this in advance. You know, I could use you know, hockey equipment or something like that. If we have to get through that, you know, like freedom from what Reichman might have done in chestnut Lodge, to go in and sit with a patient. That's going to beat her up and spit on her and stuff.
Like now? No, I don't know.
Of course I don't slug anybody. Every time I get mad, I'm mad most of the time.
Alright, so that's something else in this chain. Something else missing here? Well, yeah, he smirked at me smirked at you. And now that's a specific thing. So show me what that would be like. And she showed me her face and I. I said, Could I try it and you tell me if that was it without slugging me. And so I smirked and she smirked. And we got the smirking, Link down. And she said, If someone's smirks at me, they deserve to be hit.
Okay, Where'd that come from? Well, that's another story.
So, you know, you start you find out the real dirt. by realizing you don't, it doesn't make sense. And you ask that other link in between the links, and you start to find the hidden link. That's, that is like, let's say in working with PTSD, the models of trying to get the whole story that peak to trauma story is often what's met trauma therapists are called the hotspot in the chain. These are the hotspots and they're usually not the spots that you're told about the first time through a chain.
So you have to go digging, problem behavior comes up, and you tried to get specific about it, and you get the consequences of the problem behavior. And you're really interested in those consequences that might have reinforced the problem behavior, not just every animal. So what happens the residual consequences, like this young woman with the eating disorder, when I got that part of her chain, after she does her bingeing and purging, she doesn't feel a ton better by now, because it's been going on for years. And it's part of a whole deep sense of there's things wrong with her. So it activates that. But in the short run, it makes her feel that she knows what she's doing. She goes from not knowing what she's doing to knowing what she's doing with the simple act of binging and purging.
Once you get that you realize, well of course she binges and purges, we got to find another way for her to go from not knowing what she's doing to knowing what she's doing. And that's why I recommended, let's try a couple strategies.
So the consequences are the things that especially seem to be driving the behavior.
