Dialectical behavioral therapy
ï»¿Dialectical behavioral therapy (DBT) is a psychological method, based on Buddhist teachings, developed by Marsha M. Linehan to treat persons with borderline personality disorder (BPD). Research indicates its application to also be effective in treating patients who represent varied symptoms and behaviors associated with spectrum mood disorders, including self-injury. Key elements DBT practitioners emphasize, behaviorist theory, dialectics, cognitive therapy, and, DBT's central component, mindfulness.
There are two essential parts of the treatment, and without either of these parts the therapy is not considered "DBT adherent."
- 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.
- 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.
The four modules
The essential part of all skills taught in skills group are the core mindfulness skills. Mindfulness is derived from teachings of the Buddha, the Zen tradition being perhaps one of its most well-known proponents; it can be studied in Zen literature.
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 personâ€™s goals in a specific situation will be met, while at the same time not damaging either the relationship or the personâ€™s self-respect.
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
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 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.
- Linehan, M. M. & Dimeff, L. (2001). Dialectical Behavior Therapy in a nutshell, The California Psychologist, 34, 10-13.
- Brody, J. E. (2008, May 6). The growing wave of teenage self-injury. New York Times. Retrieved July 1, 2008.
- Stone, M.H. (1987) In A. Tasman, R. E. Hales, & A. J. Frances (eds.), American Psychiatric Press review of psychiatry (Vol. 8, pp. 103-122). Washington DC: American Psychiatric Press.
- 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), 301-311.
- 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. 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.
- An Overview of Dialectical Behaviour Therapy - Psychiatry Online
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