Ch 10: Dialectical Behavior Therapy
Terms in this set (52)
Borderline Personality Disorder is marked by 5 (or more) of the following...
1. Frantic efforts to avoid real/imagined abandonment
2. A patter of unstable & intense interpersonal relationships characterized by alternating between extremes of idealization & devaluations
3. Identify disturbance: markedly & persistently unstable self-image or sense of self
4. Impulsivity in at least 2 areas that are potentially self-damaging
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
Marsha M. Linehan
-Developed DBT in the late 1970s to treat individuals with borderline personality disorder (BPD)
-Primary work has been with suicidal clients, substance abuse, & BPD
Dialectical perspective of reality & experience
The world is in continuous change & ever shifting, and individuals are constantly in transition
Linehan created DBT after her clinical work indicated that persistently suicidal clients had...
-A high incidence of being raised in invalidating environments resulting in demands for a therapeutic environment of unconditional acceptance
-A treatment solely focused on change tended to be unacceptable to these clients, who often felt invalidated & criticized & dropped out of treatment
-But treatments focused entirely on acceptance nullified the seriousness of the client's suffering & the urgent need to produce change
Linehan built DBT around philosophy that...
Encourages the balance and fusion of both acceptance and change
Acceptance based interventions (validation strategies)
Communicate to the clients that they are both acceptable as they are and that their behaviors, including those that are self-harming, make sense in some way
Counselors help clients discover...
They have sound judgment & they are capable of learning how and when to trust themselves
Give the counselor a means to balance acceptance & change when emotions run high, as they often do in the treatment of clients diagnosed with BPD
Dialectical strategies & a dialectical world view with an emphasis on wholeness & synthesis...
Enable the counselor to blend acceptance & change in a manner that results in progress, momentum, & flow in individual sessions & across the entire treatment intervention
Three primary theories create the foundation of the treatment
1. Behavior theory
2. Biosocial theory of BPD
3. The theory of dialectics
The DBT model emphasizes...
-The identification of stimuli which trigger dysfunctional behaviors through previously learned associations & the outcomes which shape the development & maintenance of a behavior
-The function of behavior and the context in which behavior occurs
Its ability to explain the development of thought & experience over time
Behaviors are viewed as...
Maintained by some combination of deficits in skills, cued responding, reinforcement, or thought processes (experiencing past trauma not as important as addressing current stimuli that maintain trigger behavior)
Primary behavioral interventions
Skills training, exposure, contingency management, & cognitive restructuring
Linehand suggests that BPD develops when...
-A child who is biologically susceptible to difficulties regulating emotions is placed in environments perceived as interpersonally lethal or invalidating
-These children are more sensitive to emotional stimuli, have more intense emotional reactions, and return slowly to baseline
Constantly trivializes, blames, & assigns socially desirable characteristics to an individual's cognitive, behavioral, & emotional responses despite the fact that the responses make sense in the context of facts, circumstances, norms, or events
The borderline individual's intense emotional reactions...
Elicit invalidating behavior of caregivers, which then elicits further emotional dysregulation & it becomes a vicious cycle
Dysregulation across the individual's emotional system
Characterized broadly by difficulty in regulation physiological arousal as well as difficulty in turning attention away from emotional stimuli
The individual struggles with...
Fears of abandonment & chaotic relationships, confusion about identity, values or feelings in addition to a chronic sense of emptiness
Rigid thinking, irrational beliefs, paranoid ideation, & isolation (may occur in BPD individuals)
-Impulsivity or suicidality is common
-It's an attempt to regulate emotions
DBT's major constructs
-Integrates CBT acceptance based on "Eastern psychological & spiritual practices"
-Emphasizes the importance of psychotherapeutic relationship,validation of the client, the impact of having been raised in an invalidating environment, & confrontation of resistance
Main components of DBT
Affect regulation, distress tolerance, improvement of interpersonal relationships, & mindfulness training
DBT biosocial theory of BPD
-Views the disorder as primarily one of pervasive emotional dysregulation, a result of both highly emotional vulnerability & deficits in the ability to regulate emotions
-Linehan views dysfunctional behaviors in individuals with BPD as either an attempt by the individual to regulate intense affect or as an outcome of emotional dysregulation.
-Thus, for example clients may deliberately harm themselves as a means to distract attention away from emotionally salient stimuli thereby reducing anguish; or they may be lashing out when feeling overwhelmed.
DBT model assumes that...
Individuals with BPD lack key interpersonal & self regulation skills & that personal & environmental factors may block the use of appropriate responses to stressors or reinforce maladaptive responses
Source of emotion dysregulation in individuals with BPD
Viewed as resulting from the perfect storm of biological anomalies combined with an invalidating environment; these biological irregularities in BPD are believed to be caused biological or genetic factors or childhood events
Linehan believes that an invalidating environment communicates to individuals that...
Their interpretations & perceptions of their experiences are fundamentally wrong. The child therefore doesn't learn to accurately label internal experience or to regulate emotional arousal. Also conveys to individuals that their experiences are due to unacceptable & undesirable character traits.
Client learns to tolerate painful emotions without enacting self destructive behaviors. It doesn't focus on maintaining a stable, consistent environment but rather aims to help clients become comfortable with change
Emotional disregulation & validation
By helping clients accept their emotions, facilitating the development of strategies for emotional recognition & regulation, & decreasing emotional avoidance, clients improve their ability to cope with stress & regulate their emotions
When the counselor combines an emphasis on validation with an equal emphasis on change...
Clients were more likely to be cooperative & less likely to become disturbed & introverted
Types/Levels of validation
-Most fundamental: staying attentive to the other person (being respectful of thoughts, feelings, & behaviors)
-Helping the client regain confidence by assuming the behavior makes sense
-Treating the client with dignity & respect
Four Skills Model
2. Interpersonal Effectiveness
3. Emotion Regulation
4. Distress Tolerance
Involves increasing awareness of self & context through observation, explanation & involvement, & the capacity to control the focus of one's attention on the current moment
*Pay attention non-judgmentally to the present moment
*Identify effective responses to distress
*One of the first skills taught
Interpersonal response patterns taught in DBT skills training are very comparable to those taught in many assertiveness or interpersonal problem solving classes. They include strategies for asking for what one needs, saying no, & coping with interpersonal conflict
*Maximize likelihood that person's goals met in specific situation
Skills include identifying & labeling emotions, identifying obstacles to change emotions, reducing vulnerability & increasing positive emotional events
Skills represent a natural development from mindfulness skills. They have to do with the ability to accept, in a non-judgmental fashion, both oneself & the current situation
Suggests that reality is made of interrelated parts that can't be defined without reference to the system as a whole & that the whole must also recognize its parts. The system & its parts are in a constant state of change & any change impacts the systems
Goals of Counseling & Psychotherapy
-DBT organizes treatment into stages & targets & with very few exceptions, adheres exactly to the order in which problems are addressed
-The organization of the treatment into stages & targets prevents DBT from being a treatment that, week after week, addresses the crisis of the moment
-It has a rational progression that first addresses behaviors that could lead to the client's death then behaviors that could lead to premature termination of the counseling process, & finally behaviors that demolish the quality of life & the need for alternative skills
-The counselor adopts a "dialectical" position, highlighting both the need for change and the difficulties with change. This approach increases commitment & allows both the counselor & client to identify obstacles which may need to be addressed
-After obtaining a commitment to participate in counseling, clients participate in a structured therapeutic process organized into 4 stages of counseling & 4 targets
Stage I: Moving from being out of control of one's behavior to being in control
The goal is for the client to move from behavioral dyscontrol to behavioral control so that there is a normal life expectancy
4 Targets for Stage I
1. Eliminate self-harm
2. Reduce resistance
3. Improve quality of life
4. Teach life skills (4 skills)
Stage II: Moving from being emotionally shut down to experiencing emotions fully
DBT addresses the client's repressed emotional functioning. The goal is to help the client move from a state of quiet desperation to one of full emotional experiencing
Stage III: Building an ordinary life, solving ordinary life problems
Focuses on problems in living, with the goal being that the client have a life of ordinary happiness & unhappiness. Clients work on common problems like marital/partner conflict, job dissatisfaction, career goals, etc.
Stage IV: Moving from incompleteness to completeness/ connection
Promoted specifically for clients for whom a life of ordinary happiness & unhappiness fails to result in spiritual fulfillment or a sense of connectedness to a greater whole
Linehan hypothesizes that successful counseling intervention must meet 5 critical functions
The counseling must:
1. Improve & preserve the client's incentive to change
2. Boost the client's capabilities
3. Ensure that the client's new capabilities are generalized to all relative environments
4. Enhance the counselor's motivation to treat clients while also enhancing the counselor's skills
5. Structure the environment so that the treatment can take place
DBT consists of 3 parts
1. Individual counseling sessions are scheduled weekly & last between 60 & 90 minutes
2. Weekly 2.5 hour group counseling sessions are conducted. The skills training group is intended to boost the capabilities of the client
3. Counselors provide phone coaching between sessions to assist clients in overcoming challenges & consistently implementing appropriate responses
Strategies that increase commitment to therapy
Treatment contracts, motivational strategies to adhere to goals, dialectical strategies such as devil's advocate to engage client's in taking some ownership of the process, and the use of metaphors which are often less threatening or confrontational for these clients that require a great deal of validation
Problem solving strategies
Behavioral chain analysis to identify triggers which lead to dysfunctional behaviors
To balance asking for change, acceptance strategies are utilized. These strategies assist the client in learning to validate themselves, to strengthen the therapeutic relationship, and are a form of feedback
Facilitates comfort with movement between change & acceptance
As a brief intervention
-Not designed to be one: the client makes a commitment to one year of treatment consisting of weekly pschoeducational skills training group, weekly sessions with an individual counselor, and telephone contacts with the counselor on an as needed basis when crises arise
-Miller & colleagues have adapted DBT for suicidal adolescent outpatients (1 year to 16 weeks); pilot data suggests promising treatments
-Most studies involve a minimum year of treatment
Mental health issues
-DBT is 1st therapy that's been empirically proven to be successful for treating BPD
-Individuals with self-injurious behaviors such as cutting, suicidal thoughts, gestures, & even attempts have shown positive response to DBT intervention
-Also effective treating depression, bipolar disorder, PTSD, anxiety, eating disorders, or alcohol & drug problems
-BPD is a difficult disorder to treat with a lengthy developmental history which is frequently slow to change
-Effects of premature termination of treatment haven't been fully explored
-The approach is highly structure & specific with regard to interventions & it doesn't fit all populations
-Studies' sample sizes have been small & highly specific thus limiting generalizability
-Not enough people trained