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Dialectical behavioral therapy

Dialectical behavioral therapy (DBT.) is a psychosocial treatment developed by Marsha M. Linehan ^[1] specifically to treat individuals with borderline personality disorder. While DBT was designed for individuals with borderline personality disorder, it is used for patients with other diagnoses as well.

The treatment itself is based largely in behaviorist theory with some cognitive therapy elements as well. Unlike cognitive therapy it incorporates mindfulness practice as a central component of the therapy.

There are two essential parts of the treatment, and without either of these parts the therapy is not considered "DBT adherent."

1. An individual component in which the therapist and client discuss issues that come up during the week, recorded on diary cards and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally. During the individual therapy, the therapist and client work towards improving skill use. Often, skills group is discussed and obstacles to acting skillfully are addressed.

2. The group, which ordinarily meets once weekly for about 2-2.5 hours, in which clients learn to use specific skills that are broken down into 4 modules: core mindfulness skills, emotion regulation skills, interpersonal effectiveness skills and distress tolerance skills.

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Philosophical underpinnings

Biosocial theory

"DBT is based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation. The disorder is characterized by heightened sensitivity to emotion, increased emotional intensity and a slow return to emotional baseline. Characteristic behaviors and emotional experiences associated with BPD theoretically result from the expression of this biological dysfunction in a social environment experienced as invalidating by the borderline patient." ^[2]

Cognitive behavioural therapy

See also: Cognitive behavioural therapy

"One of DBT's several elements is cognitive– behavioural therapy (CBT). DBT espouses the scientific ethos. It makes use of self-monitoring, there is an emphasis on the here and now and much of the therapeutic technique is borrowed from CBT, including the style of open and explicit collaboration between patient and therapist. Furthermore, the treatment has a manual. The ‘bible’ of DBT is Linehan's Cognitive Behavior Treatment of Borderline Personality Disorder (1993a). (She says that her publisher insisted on ‘cognitive behavior treatment’ because they felt that a title including the word dialectical was less likely to sell well, particularly in the USA.) "^[3]

Zen

See also: Zen

"DBT utilizes Zen concepts as a basis to encourage patients to be mindful in the current moment, see reality without delusion, and accept reality and themselves without judgment. This skill, which has its roots in Western contemplative and Eastern meditative practices, is called mindfulness." ^[4]

The Dialectic

See also: Dialectics

"As a world view... dialectics anchors the treatment within other perspectives that emphasize: 1. the holistic, systemic and interrelated nature of human functioning and reality as a whole (asking always "what is being left out of our understanding here?"); 2. searching for synthesis and balance, (to replace the rigid, often extreme, and dichotomous responses characteristic of severely dysfunctional individuals); 3. enhancing comfort with ambiguity and change which are viewed as inevitable aspects of life." ^[5]

The four modules

The purpose of the DBT skills in all four skill sets is to help the client get into a state of mind referred to in DBT as wise mind. Wise mind is the middle ground in the dialectic between rational mind and emotional mind. To be too far on the side of rational mind would mean focusing only things such as facts and figures; ignoring and suppressing emotion. To be too far on the side of emotional mind would mean being so blinded by strong emotions that one would not be able to consider the facts.

Mindfulness

The essential part of all skills taught in skills group are the core mindfulness skills.

Observe, describe, and participate are the core mindfulness what skills. They answer the question, "What do I do to practice core mindfulness skills?"
Non-judgmentally, one-mindfully, and effectively are the how skills and answer the question, "How do I practice core mindfulness skills?"

Mindfulness comes from the Buddhist tradition and can be read about in more detail in the book The Miracle of Mindfulness by Thich Nhat Hanh (among others).

Interpersonal effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.

Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing his/her own situation.

This module focuses on situations where the objective is to change something (e.g., requesting someone to do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.

Distress tolerance

Most approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by religious and spiritual communities and leaders. Dialectical behavioral therapy emphasizes learning to bear pain skillfully.

Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although the stance advocated here is a nonjudgmental one, this does not mean that it is one of approval: acceptance of reality is not approval of reality.

Distress tolerance behaviors are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus willfulness.

Emotion regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavioral therapy skills for emotion regulation include:

Identifying and labeling emotions
Identifying obstacles to changing emotions
Reducing vulnerability to emotion mind
Increasing positive emotional events
Increasing mindfulness to current emotions
Taking opposite action
Applying distress tolerance techniques

^[6]^[7]

Books

The Miracle of Mindfulness by Thich Nhat Hanh ISBN 0-8070-1239-4
Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan ISBN 0-89862-034-1
Cognitive Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan, 1993
Fatal Flaws: An Introduction to Disorder of Personality and Character by Stuart C. Yudovsky

References

^ Marsha M. Linehan, Linda Dimeff, "Dialectical Behavior Therapy in a Nutshell", The California Psychologist, 34, 10-13, 2001. [1]
^ McLean Hospital Psychiatic Update, January 1999. http://www.borderlinepersonality.ca/dbtpromisingtreat.htm
^ Advances in Psychiatric Treatment (2002) 8: 10-16 © 2002 The Royal College of Psychiatrists. Dialectical behaviour therapy for borderline personality disorder. Robert L. Palmer. http://apt.rcpsych.org/cgi/content/full/8/1/10
^ Treatment of Borderline Personality Disorder Using Dialectical Behavior Therapy By Thomas Lynch, Ph.D. and Clive Robins, Ph.D. From The Journal, March 1, 1997, Vol. 8/Iss. 1. http://www.dbtselfhelp.com/html/lynch_treatment.html
^ Dialectical Behavior Therapy (DBT) for Borderline Personality Disorder by Marsha Linehan, Ph.D. http://www.dbtselfhelp.com/html/linehan_dbt.html
^ Stone, M.H. (1987) In Tasman, A., Hales, R.E. & Frances, A.J. (eds) American Psychiatric Press Review of Psychiatry. Washington DC; American Psychiatric Press inc. 8, 103-122.
^ Holmes, P., Georgescu, S. & Liles, W. (2005). Further Delineating the Applicability of Acceptance and Change to Private Responses: The Example of Dialectical Behavior Therapy. The Behavior Analyst Today, 7.(3), Page 301-311BAO