Dialectical behavior therapy

Dialectical behavior therapy (DBT) is a system of therapy originally developed to treat persons with borderline personality disorder (BPD) by Marsha M. Linehan, a psychology researcher at the University of Washington. DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD. Research indicates that DBT is also effective in treating patients who present varied symptoms and behaviors associated with spectrum mood disorders, including self-injury. Recent work suggests its effectiveness with sexual abuse survivors and chemical dependency.

Overview

Linehan created DBT in response to her observation of therapist burnout after coping with non-motivated patients who repudiated cooperation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments and required a climate of unconditional acceptance (not Carl Rogers’ humanistically "positive" version, but Thich Nhat Hanh’s metaphysically neutral one) in which to develop a successful therapeutic alliance. Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction.

DBT strives to avoid having the client/patient see the therapist as an adversary rather than an ally in the treatment of psychological issues. Accordingly, in DBT the therapist aims to accept and validate the client’s feelings at any given time while nonetheless informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives.

Linehan united commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress, in which thesis + antithesis → synthesis, and proceeded to assemble a modular array of skills for emotional self-regulation, drawn from Western (e.g., cognitive behavioral therapy and an interpersonal variant, “assertiveness training”) and Eastern (e.g., Buddhist mindfulness meditation) psychological traditions. Arguably her signal contribution was to elide the adversarial paradigm implicit in the hierarchical modernist therapeutic alliance, using the deconstructive spirit of Hegel and Buddhism to substitute a postmodern alliance based on intersubjective tough love.

All DBT involves two components:

1. An individual component in which the therapist and patient 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 patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
2. The group, which ordinarily meets once weekly for two to two-and-a-half hours, learns to use specific skills that are broken down into four modules: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.

Neither component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.

The four modules

Mindfulness

Mindfulness is one of the core concepts behind all elements of DBT. Mindfulness is the capacity to pay attention, non-judgmentally, to the present moment. Mindfulness is all about living in the moment, experiencing one's emotions and senses fully, yet with perspective. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts.

Skills within the Mindfulness module

The "What" Skills

Observe

This is used to non-judgmentally observe one’s environment within or outside oneself. It is helpful in understanding what is going on in any given situation.

Describe

This is used to express what one has observed with the observe skill. It is to be used without judgmental statements. This helps with letting others know what you have observed.

Participate

This is used to become fully involved in the activity that one is doing. To be able to fully focus on what one is doing.

The "How" Skills

Non-Judgmentally

This is the action of describing the facts, and not thinking about what’s “good” or “bad”, “fair”, or “unfair.” These are judgments because this is how you feel about the situation but isn’t a factual description. Being non-judgmental helps to get your point across in an effective manner without adding a judgment that someone else might disagree with.

One-Mindfully

This is used to focus on one thing. One-mindfully is helpful in keeping your mind from straying into emotion mind by a lack of focus.

Effectively

This is simply doing what works. It is a very broad-ranged skill and can be applied to any other skill to aid in being successful with said skill.

Distress Tolerance

Many current 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 psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.

Distress tolerance skills constitute a natural development from DBT 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 this is a nonjudgmental stance, this does not mean that it is one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.

Skills within the Distress tolerance module

Distract with ACCEPTS

This is a skill used to distract oneself temporarily from unpleasant emotions. The acronym breaks into:

Activities: Use positive activities that you enjoy.

Contribute: Help out others or your community.

Comparisons: Compare yourself either to people that are less fortunate or to how you used to be when you were in a worse state.

Emotions (other): cause yourself to feel something different by provoking your sense of humor or happiness with corresponding activities.

Push away: Put your situation on the back-burner for a while. Put something else temporarily first in your mind.

Thoughts (other): Force your mind to think about something else.

Sensations (other) – Do something that has an intense feeling other than what you are feeling, like a cold shower or a spicy candy.

Self Soothe

This is a skill in which one is comforting, nurturing, kind, and gentle to oneself. You use it by doing something that is soothing to you. It is used in moments of stress or upset.

IMPROVE the Moment

This skill is used in moments of distress to help one relax. The acronym stands for:

Imagery: Imagine relaxing scenes, things going well, or other things that please you.

Meaning: Find some purpose or meaning in what you are feeling.

Prayer: Either pray to whomever you worship, or if not religious, chant a personal mantra.

Relaxation: Relax your muscles, breath deeply, use with Self Soothe.

One thing in the moment: Focus your entire attention on what you are doing right now. Keep yourself in the present.

Vacation (brief): Take a break from it all for a short period of time.

Encouragement: Cheerlead yourself, tell yourself you can make it through this.

Pros and Cons

Think about the positive and negative things about not tolerating distress.

Radical Acceptance

Letting go of fighting reality. Accept your situation for what it is.

Turning the Mind

Turn your mind towards an acceptance stance. It should be used with Radical Acceptance.

Willingness vs. Willfulness

Being willing and open to do what is effective. Let go of a willful stance which goes against acceptance. Keep your eye on the goal in front of you.

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 behavior 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

Skills within the Emotion regulation module

Story of Emotion

Used to understand what kind of emotion one is feeling. To use this, list the following:

1. Prompting event
2. Interpretation of the event
3. Body sensations
4. Body language
5. Action urge
6. Action
7. Emotion name, based on previous items on list.

PLEASE MASTER

Having ineffective health habits can make one more vulnerable to emotion mind. This skill is used to maintain a healthy body so one is more likely to have healthy emotions. It is an acronym that stands for the following:

PhysicaL Illness (treat): If you are sick or injured, get proper treatment for it.

Eating (balanced): Make sure you eat a proper healthy diet, and eat in moderation.

Avoid Mood-Altering Drugs: Do not take non-prescribed medication or illegal drugs. They are very harmful to your body, and can make your mood unpredictable.

Sleep (balanced): Do not sleep too much or too little. 8 hours of sleep is recommended per night for the average adult.

Exercise: Make sure you get an effective amount of exercise as this will both improve body image, and release endorphins (making you happier).

MASTERy (build): Try to do one thing a day to help build competence and control.

Opposite Action

This skill is used when you have an unjustified emotion, one that doesn’t belong in the situation at hand. You use it by doing the opposite of your urges in the moment. It is a tool to bring you out of an unwanted or unjustified emotion by replacing it with the emotion that is opposite.

Problem Solving

This is used to solve a problem when your emotion is justified. It is used in combination with other skills.

Letting Go of Emotional Suffering

Observe and experience your emotion, accept it, then let it go.

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 or her own situation.

The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone 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.

Skills within the Interpersonal effectiveness module

DEARMAN - to get something

Acronym for the skillset used to aid you in getting what you want when you ask:

Describe your situation.

Express why this is an issue and how you feel about it.

Assert yourself by asking clearly for what you want.

Reinforce your position by offering a positive consequence if you were to get what you want.

Mindful of the situation by focusing on what you want and ignore distractions.

Appear Confident even if you don’t feel confident.

Negotiate with a hesitant person and come to a comfortable compromise on your request.

GIVE - giving something

This is a skill that can aid you with maintaining your relationships, whether they are friendships, coworkers, family, romantic, etc. It is to be used in conversations. It is another acronym that stands for the following:

Gentle: Use appropriate language, no verbal or physical attacks, no put downs, avoid sarcasm unless you are sure the person is alright with it, and be courteous and non-judgmental.

Interested: When the person you are speaking to is talking about something, act interested in what they are saying. Maintain eye contact, ask questions, etc. Do not use your cell phone while having a conversation with another person!

Validate: Show that you understand a person’s situation and sympathize with them. Validation can be shown through words, body language and/or facial expressions.

Easy Manner: Be calm and comfortable during conversation, use humor, smile.

FAST - keeping self respect

This is a skill to aid you in maintaining your self-respect. It is to be used in combination with the other Interpersonal Effectiveness skills. It is another acronym, and it stands for the following:

Fair: Be fair to both yourself and the other person.

Apologies (few): Don’t apologize more than once for what you have done ineffectively, or apologize for something which was not ineffective.

Stick to Your Values: Stay true to what you believe in and stand by it. Don’t allow others to get you to do things against your values.

Truthful: Don’t lie. Lying can only pile up and damage relationships and your self-respect.

Tools

Diary Cards

Specially formatted cards for tracking Therapy interfering behaviors that distract or hinder a patient's progress.

Chain Analysis

Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining. Growing body of research supports the use of behavior chain analysis with multiple populations.

Milieu

The milieu or the culture of the group involved plays a key role in the effectiveness of DBT.

See also

• Mindfulness (psychology)
• Cognitive behavioral therapy
• Rational emotive behavior therapy
• Nonviolent Communication
• Emotional dysregulation
• Social skill
• Behavioral psychotherapy

References

• http://www.namimc.org/PDF/Ed%20Mtg/NAMI%20Ed%20Mtg%20-%20Wake%20Feb%202008%20Presentation.pdf
• Linehan,M.M., Armstrong,H.E., Suarez,A., Allmon,D., Heard,H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.
• Linehan,M.M., Heard,H.L. (1993) "Impact of treatment accessibility on clinical course of parasuicidal patients": Reply. Archives of General-Psychiatry, 50(2): 157-158.
• Linehan,M.M., Heard,H.L., Armstrong,H.E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971-974.
• Linehan,M.M., Tutek,D.A., Heard,H.L., Armstrong,H.E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151, 1771-1776.
• Linehan,M.M., Schmidt,H., Dimeff,L.A., Craft,J.C., Kanter,J., Comtois,K.A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addiction, 8(4), 279-292.
• Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13-26.
• Koons, C.R., Robins, C.J., Tweed, J.L., Lynch, T.R., Gonzalez, A.M., Morse, J.Q., Bishop, G.K., Butterfield, M.I., Bastian, L.A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371-390.
• van den Bosch, L.M.C., Verheul, R., Schippers, G.M., van den Brink, W. (2002). Dialectical Behavior Therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27(6), 911-923.
• Verheul, R., van den Bosch, L.M.C., Koeter, M.W.J., de Ridder, M.A.J., Stijnen, T., van den Brink, W. (2003). Dialectical behaviour therapy for women with borderline persoality disorder: 12-month, randomised clinical trial in the Netherlands. British Journal of Psychiatry, 182, 135-140.
• Linehan et al (2006) NIMH 3 Two-Year Randomized Control Trial and Follow up of DBT

Further reading

• 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. 1993. ISBN 0-89862-034-1.
• Cognitive Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan. 1993. ISBN 0898621836.
• Fatal Flaws: Navigating Destructive Relationships with People with Disorders of Personality and Character by Stuart C. Yudovsky. ISBN 1585622141.
• The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation by Alan E. Fruzzetti. ISBN 157224450X.
• Dialectical Behavior Therapy with Suicidal Adolescents by Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan. Foreword by Charles R. Swenson. ISBN 978-1593853839.
• Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (New Harbinger Self-Help Workbook) by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley. ISBN 978-1572245136.
• Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control (New Harbinger Self-Help Workbook) by Scott E. Spradlin. ISBN 978-1572243095.
• Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression & Anxiety by Thomas Marra. ISBN 978-1572243637.

External links

• An Overview of Dialectical Behaviour Therapy - Psychiatry Online
• An Emotional Hair Trigger, Often Misread - New York Times
• Introduction to DBT skills / application for addiction -

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