Dialectical Behavior Therapy

DBT

The Challenge of Working With Personality Disorders

Ø Patients typically come for therapy with presenting problems other than personality problems

Ø They require more work within the session

Ø Longer duration of treatment

Ø Greater strain on the therapist’s skills and patience

Ø Greater difficulty in treatment compliance

Diagnostic Features of BPD

Ø Hypersensitivity to abandonment

Ø Pattern of unstable and intense interpersonal relationships

Ø Unstable self-image or sense of self

Ø Marked impulsivity

Ø Recurrent suicidal behavior

Ø Affective instability

Ø Chronic feelings of emptiness

Ø Inappropriate or intense anger or difficulty controlling anger

Ø Transient stress-related paranoid ideation or dissociative symptoms

Significance of BPD

Ø 2% of general population meet criteria for BPD

Ø 11% of outpatients and 19% of inpatients meet criteria for BPD (Widiger & Francis, 1989)

Ø Of those meeting for some personality disorder, 33% of outpatients and 63% of inpatients meet for BPD

Ø 70-75% of BPD patients have a history of self-injurious acts

Ø Estimates of suicide rates for BPD patients are approximately 10%

Ø 74% of BPD referred patients are women

Linehan Model

Components of Emotional Dysregulation

Ø Emotional vulnerability

l High sensitivity to emotional stimuli

l Intense response to emotional stimuli

l Slow return to emotional baseline once emotional arousal has occurred

Components of Emotional Dysregulation

Ø Deficits in emotion modulation strategies

l Ability to inhibit inappropriate behavior related to strong negative or positive emotions

l Ability to act in a way that is not mood-dependent

l Ability to self-soothe any physiological arousal that the strong emotion has induced

l Ability to refocus attention in the presence of strong emotion

Features of the Invalidating Environment

Ø During development, people respond to the communication of the child's preferences, thoughts, and emotions with either nonresponsiveness or more extreme negative consequences

Ø An invalidating environment emphasizes the inhibition of emotional expressiveness

Role of the Invalidating Environment

Ø Persistent discrepancies between a child’s private experience and what others in the environment respond to as her experience provide the fundamental learning environment for many of the behavioral problems associated with BPD

Consequences of the Invalidating Environment

Ø Child fails to learn how to label emotion or modulate emotional arousal

Ø Child fails to learn to tolerate distress or form realistic goals and expectations

Ø Child learns that extreme emotional reactions will sometimes provoke a helpful environmental response

Ø Child fails to learn to trust her own internal experiences and hence looks for external cues about how to think, act, and feel

Linkage of Emotional Dysregulation and BPD Behavioral Characteristics

Ø The behavioral characteristics of borderline individuals (i.e., self-mutilation, suicide attempts) can be conceptualized as the effects of emotional dysregulation and maladaptive emotional regulation strategies

Ø Emotional lability leads to unpredictable behavior and cognitive inconsistency, thus interfering with identity development

Ø The chaotic relationships seen with BDPs is understandable given the person’s difficulties in controlling impulsive behaviors and negative emotions

Areas of Divergence From Standard CBT

Ø Emphasis on acceptance and validation of behavior as it is in the moment

Ø DBT emphasizes the importance of balancing the technology of change with the technology of acceptance

Ø Emphasis on treating therapy-interfering behaviors of both client and therapist

Ø Emphasis on the therapeutic relationship as essential to treatment

Ø Emphasis on dialectic processes

Characteristics of the DBT Treatment

Ø Applies many standard CBT principles and techniques

Ø Attempts to reframe suicidal and other dysfunctional behaviors

Ø Adopts a problem-solving focus

Ø Encourages exposure to fear-eliciting stimuli

Ø Emphasizes strategies for validating client's thoughts, feelings, and actions

Characteristics of the DBT Treatment

Ø Emphasis on modifying current maladaptive behaviors before ameliorating long-standing interpersonal conflicts or the effects of early trauma and abuse

Ø Combines therapy into two conceptual components – psychosocial skills training and motivational issues

Aims of DBT

Ø DBT addresses four main areas or targets in the following order of importance:

l Reducing suicidal and self-harming behaviors.

l Reducing behaviors that interfere with the process of therapy such as not

l addressing problems, not showing up to appointments etc. This is known as

l "therapy interfering" behavior.

Aims of DBT

l Reducing behaviors that seriously interfere with quality of life such as

l frequent hospitalization, interpersonal problems, drug abuse, etc. This is

l known as "quality of life interfering" behavior.

l Increasing specific skills to cope more effectively.

l Commitment to working towards these targets is made before entering Stage I of DBT.

Major Modes of Treatment in DBT

Ø Group skills training

l Group behavioral skills training for 2.5 hours per week

Ø Individual psychotherapy

l to coach the client in applying the skills taught in the group and to problem-solve current difficulties the client is facing.

Ø Telephone Consultation

l Phone coaching for clients with their individual therapist and/or the after hours service.

Ø Case consultation for therapists

l DBT therapists also meet once per week to ensure good communication between group

Skills Training Rules

• Clients who drop out of therapy are out of therapy

• Each client has to be in ongoing individual therapy

• Clients can’t come to session on drugs/alcohol

• Clients are not to discuss parasuicidal behaviors with other clients outside of session

Skills Training Rules

5. Clients who call one another for help when feeling suicidal must be willing to accept help

6. Information obtained during session must remain confidential

7. Clients who are going to be late should call ahead

8. Clients may not form private relationships outside of training sessions

9. Sexual partner may not be in skills training together

Skills Training Modules

Ø Core Mindfulness

l Each session starts and finishes with a mindfulness exercise

Ø Interpersonal Effectiveness

Ø Emotional Regulation

Ø Distress Tolerance

Mindfulness

Ø This module is taught at the beginning of all the following modules.

Ø The focus of mindfulness is to increase one's awareness of events, emotions, and behaviors

Ø Learn how to do this in a focused and non-judgmental manner.

Ø Mindfulness skills are central to DBT

Mindfulness

Ø Mindfulness skills

l Paying attention to the ebb and flow of emotional experience

l Paying attention to thoughts in the moment

l Paying attention to action urges

l Practice labeling them correctly

l Practice accepting them w/o trying to suppress them

Interpersonal Effectiveness

Ø This module focuses on learning to communicate one’s needs effectively, and dealing with interpersonal conflict

Emotional Regulation

Ø This module is about understanding emotions, learning how to reduce emotional vulnerability and decreasing emotional suffering

Emotion Regulation

Ø Emotional regulation skills

l Understanding emotions and their reactions

l Observing emotions

l Experiencing emotions

l Reducing emotional vulnerability through exercise and reducing alcohol/drugs

Distress Tolerance

Ø This module increases one’s ability to tolerate and survive crises, and to accept life as it is in the moment

Distress Tolerance

Ø Distress tolerance skills

l Distraction techniques

l Self-soothing procedures

l Realistically evaluating the pros and cons of tolerating events

l Acceptance strategies

Skills Training Group

Ø Each group should last approx 8 sessions

Ø Clients will generally go through the group numerous times

Ø Ask clients to lead mindfulness exercises

Skills

Ø DEAR MAN

Ø WISE MIND

Ø GIVE

Ø PLEASE MASTERy

Ø Diary Cards

Ø Behavior Chains

Outcome

Ø Linehan et al (1991)

Ø Assigned 24 subjects to DBT and 23 to community control treatment!

Ø Low attrition rate: 17%

Ø Treatment: Indiv. and group therapy weekly for one year!

Ø Assessments at 4, 8, and 12 months

Ø Results: Significantly fewer parasuidal acts. 95.5% (Controls) versus 63.6% DBT (1.5 acts/yr versus 9 for controls)

Outcome

Ø During last 4 mos. of treatment 61.9% of controls engaged in parasuicidal acts compared to only 35% for DBT.

Ø Maintenance of treatment: DBT more likely to seek individual treatment (100% vs 73%)

Ø More inpatient days for controls.

Ø No differences in depression, or hopelessness

Ø Linehan et al (1993)

Ø 12 month follow-up revealed good maintenance of treatment gains