Dialectical
Behavior Therapy for borderline disorder.
Author: Marsha
M. Linehan, Ph.D.
DBT
in a Nutshell
Dialectical behavior therapy
(DBT) is a comprehensive cognitive-behavioral treatment for complex, difficult-to-treat
mental disorders. Originally developed to treat chronically suicidal
individuals, DBT has evolved into a treatment for multi-disordered individuals
with borderline personality disorder (BPD). DBT has since been adapted
for other seemingly intractable behavioral disorders involving emotion
dysregulation, including substance dependence in individuals with BPD and
binge
eating, to other clinical populations (e.g., depressed, suicidal adolescents),
and to a variety of settings (e.g., inpatient, partial hospitalization,
forensic).
DBT is based on a combined
capability deficit and motivational model of BPD which states that (1)
people with BPD lack important interpersonal, self-regulation (including
emotional regulation) and distress tolerance skills, and (2) personal and
environmental factors often both block and/or inhibit the use of behavioral
skills that clients do have, and reinforce dysfunctional behaviors.
DBT combines the basic strategies
of behavior therapy with eastern mindfulness practices, residing within
an overarching dialectical world view that emphasizes the synthesis of
opposites. The term dialectical is also meant to convey both the multiple
tensions that co-occur in therapy with suicidal clients with BPD as well
as the emphasis in DBT of enhancing dialectical thinking patterns to replace
rigid, dichotomous thinking. The fundamental dialectic in DBT is
between validation and acceptance of the client as they are within the
context of simultaneously helping them change. Acceptance procedures
in DBT include mindfulness (e.g., attention to the present moment, assuming
a non-judgmental stance, focusing on effectiveness) and a variety of validation
and acceptance-based stylistic strategies.
Change strategies in DBT
include behavioral analysis of maladaptive behaviors and problem-solving
techniques, including skills training, contingency management (i.e., reinforcers,
punishment), cognitive modification, and exposure-based strategies.
As a comprehensive treatment,
DBT serves the following five functions:
1) enhances behavioral
capabilities,
2) improves motivation to
change (by modifying inhibitions and reinforcement contingencies),
3) assures that new capabilities
generalize to the natural environment,
4) structures the treatment
environment in the ways essential to support patient and therapist capabilities,
and
5) enhances therapist capabilities
and motivation to treat patients effectively.
In standard DBT, these functions
are divided among modes of service delivery, including individual psychotherapy,
group skills training, phone consultation, and therapist consultation team.
Origins
of DBT.
DBT grew out of a series
of failed attempts to apply the standard cognitive and behavior therapy
protocols of the late 1970’s to chronically suicidal patients. These
difficulties included:
-
focusing on change procedures
was frequently experienced as invalidating by the client and often precipitated
withdrawal from therapy, attacks on the therapist, or vacillations between
these two poles;
-
teaching and strengthening new
skills was extraordinarily difficult to do within the context of an individual
therapy session while concurrently targeting and treating the client’s
motivation to die and suicidal behaviors that had occurred during the previous
week;
-
individuals with BPD often unwittingly
reinforced the therapist for iatrogenic treatment (e.g., a client stops
attacking the therapist when the therapist changes the topic from one the
client is afraid to discuss to a pleasant or neutral topic) and punished
them for effective treatment strategies (e.g., a client attempts suicide
when the therapist refuses to recommend hospitalization stays that reinforce
suicide threats).
To overcome these difficulties,
several modifications were made that formed the basis of DBT. First,
strategies that reflect radical acceptance and validation of clients’ current
capabilities and behavioral functioning were added to the treatment.
The synthesis of acceptance and change within the treatment as a whole
and within each treatment interaction led to adding the term "dialectical"
to the name of the treatment. This dialectical emphasis brings together
in DBT the "technologies of change" based on both principles of learning
and crises theory and the "technologies of acceptance" (so to speak) drawn
from principles of eastern Zen and western contemplative practices.
Second, the therapy as a whole was split into several different components,
each focusing on a specific aspect of treatment. The components in
standard outpatient DBT are highly structured individual or group skills
training (to enhance capability), individual psychotherapy (addressing
motivation and skills strengthening), and telephone contact with the individual
therapist (addressing application of coping skills). Third, a consultation/team
meeting focused specifically on keeping therapists motivated and providing
effective treatment was also added.
Behavioral
Targets and Stages of Treatment in DBT.
DBT is designed to treat
individuals with BPD at all levels of severity and complexity of disorders
and is conceptualized as occurring in stages. In Stage 1, the primary focus
is on stabilizing the client and achieving behavioral control. Behavioral
targets in this initial stage of treatment include: decreasing life-threatening,
suicidal behaviors (e.g., parasuicide acts, including suicide attempts,
high risk suicidal ideation, plans and threats); , decreasing therapy-interfering
behaviors (e.g., missing or coming late to session, phoning at unreasonable
hours, not returning phone calls), decreasing quality-of-life interfering
behaviors (e.g., reducing behavioral patterns serious enough to substantially
interfere with any chance of a reasonable quality of life (e.g., depression,
substance dependence, homelessness, chronically unemployed), and increasing
behavioral skills (e.g., skills in emotion regulation, interpersonal effectiveness,
distress tolerance, mindfulness, and self-management). In the subsequent
stages, the treatment goals are to replace "quiet desperation" with non-traumatic
emotional experiencing [Stage 2], to achieve "ordinary" happiness and unhappiness
and reduce ongoing disorders and problems in living [Stage 3], and to resolve
a sense of incompleteness and achieve joy [Stage 4]. In sum, the
orientation of the treatment is to first get action under control, then
to help the patient to feel better, to resolve problems in living and residual
disorders, and to find joy and, for some, a sense of transcendence.
All research to date has focused on the severely and multi-disordered patient
who enters treatment at Stage 1.
Movement,
speed, and flow.
DBT requires that the therapist
balance use of acceptance and change strategies within each treatment interaction,
from the rapid juxtaposition of change and acceptance techniques to the
therapist's use of both irreverent and warmly responsive communication
styles. This dance between change and acceptance are required to
maintain forward movement in the face of a client who at various
moments oscillates between suicidal crises, withdrawal and dissociative
responses, rigid refusal to collaborate, attack, rapid emotional escalation
and a full collaborative effort. In order to movement, speed, and
flow, the DBT therapist must be able to inhibit judgmental attitudes and
practice radical acceptance of the client in each moment while keeping
an eye on the ultimate goal of the treatment: to move the client from a
life in hell to a life worth living as quickly and efficiently as possible.
The therapist must also strike a balance between unwavering centeredness
(i.e., believing in oneself, the client, and the treatment) and with compassionate
flexibility (i.e., the ability to take in relevant information about the
client and modify one’s position accordingly, including the ability to
admit to and repair one’s inevitable mistakes), and a nurturing style (i.e.,
teaching, coaching, and assisting the client) with a benevolently demanding
approach (i.e., dragging out new behaviors from the client, recognizing
the client’s existing capabilities and capacity to change, having clients
"do for themselves" rather than "doing for them."
Randomized
Clinical Trials of DBT
The first DBT randomized
clinical trial compared DBT to a treatment-as-usual (TAU) control condition.
DBT subjects were significantly less likely to parasuicide during the treatment
year, reported fewer parasuicide episodes at each assessment point, and
had less medically severe parasuicides over the year. DBT was more effective
than TAU at limiting treatment drop-out, the most serious therapy-interfering
behavior. DBT subjects tended to enter psychiatric units less often, had
fewer inpatient psychiatric days per patient, and improved more on scores
of global as well as social adjustment. DBT subjects showed significantly
more improvement in reducing anger than did TAU subjects. DBT superiority
was largely maintained during the one-year post-treatment follow-up period.
Since then, two RCTs have been conducted evaluating DBT as compared to
TAU and one study has been conducted comparing DBT to an ongoing parallel
treatment with matched controls. In general, results have largely replicated
the initial RCT. Koons and her associates found that BPD women in
the VA system assigned to DBT had greater reductions in parasuicide acts
and in depression scores than those assigned to TAU and those assigned
to DBT (but not to TAU) also had significant improvements in suicide ideation,
hopelessness, anger, hostility, and dissociation. In our recent application
of DBT to substance dependent individuals with BPD, DBT subjects had greater
reductions in illicit substance use (measured by both structured interview
and urinalyses) both during treatment and at follow-up and greater improvements
in global functioning and social adjustment at follow-up.
(*) Dialectal : way to
talk, state, argue
(*) Dichotomy : divide
in two. Black and white thinking
(*) TAU = treatment-as-usual
(*) RCT = randomised controlled
trial.
(*) VA system = veterans
affairs
published in 2001.
The reference is as follows:
Dimeff, L., & Linehan,
M.M. (2001). Dialectical behavior therapy in a nutshell. The California
psychologist, 34, 10-13.
The California Psychologist
is a publication of the California Psychological Association.
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Warning:
All the informations
on this site are with an aim of helping to understand a "particular" disease
at the very least and puzzle
But more especially
to support peoples who suffer, sick or not. In all cases, it is ESSENTIAL
to have recourse to a therapist specialized
in the disease to confirm or to cancel a diagnosis
Though it is
the name doesn't much matter, which is important, it is to apply "the right"
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