Dr. Marsha Linehan developed the Dialectical Behavior Therapy model as a way of addressing the behavior patterns she identified in clients with Borderline Personality Disorder. DBT is a broad-based cognitive and behaviorist form of treatment. The term Dialectical refers to the fundamental nature of the interrelatedness and wholeness of reality, and also to the treatment approach used by the therapist to bring about change. 'The individual is stuck in polarities, unable to move to synthesis.' It is the therapist's task to facilitate the client in moving out of the extreme positions (the reconciliation of opposites) towards the middle ground.
In DBT, the therapist draws a balance between acceptance of the client's current experience and an acknowledgement that change is required. Problems need to be resolved and ways through difficulties sought. However this is not at the expense of the acceptance of the client as an individual. The highest priority of the program is to decrease behaviors that threaten life. Then comes focusing on behaviors that undermine treatment and reduce the client's quality of life. The goals are a reasonable immediate life expectancy, improved communications with those able to offer help, a degree of stability and control of her actions, and an increase in basic abilities, particularly those which will allow her to benefit from therapy. To achieve this, skills are taught through four modules.
The underpinning skill is Mindfulness. It is a psychological and behavioral version of the meditation practices from Eastern spiritual training and 'is drawn most heavily from the practice of Zen, but the skills are compatible with most Western contemplative and Eastern meditation practices'. Mindfulness is taught so as to enable the client to be aware of her thoughts and feelings and encourage her awareness that urges, ideas and feelings do not have to be acted upon. Mindfulness is an approach to life and 'being', which can assist the client in concentrating on what is happening 'now'.
Other skills taught are Distress Tolerance, Emotion Regulation and Interpersonal Effectiveness. Distress Tolerance is intended to assist people to tolerate painful events and emotions. Suggested crisis survival skills include involvement in activities, contributing to someone else's needs, comparing self to others less fortunate, and many other activities which can distract the client from intolerable feelings, particularly if these are done 'mindfully'. The Emotion Regulation module attempts to put over the view that no one can tell someone else how they feel or what emotion they are experiencing. All feelings and emotions are allowable and serve some purpose. This module assists the client to understand the emotions she experiences, identify them in a way that others can recognize, and understand the function any feeling may have. It addresses the client's vulnerability to negative feelings and encourages the use of other skills to decrease emotional suffering and increase positive feelings.
The Interpersonal Effectiveness module encourages the client to attend to relationships, anticipate problems and resolve potential conflicts before they become overwhelming. Difficulties are identified and solutions suggested, assisting the client to form reasonable relationships in all areas of life, being effective within them and keeping those relationships.
In addition to the twice-weekly group skills sessions, the client has weekly meetings with her individual therapist. Individual therapy provides a specific, individual relationship for the client, a person to whom the client may turn and hopefully grow to trust. The therapist remains available at moments of crisis when the main role is one of encouragement and assistance to use the skills, which have been taught. The therapist does not take on the patient's battles, but encourages the client to deal with her own problems. As in other psychotherapies, the exchanges between therapist and patient are confidential, with specific exclusions for situations where there is serious risk to life.
The clients that come into the DBT program (all women where I work) are people who have a diagnosis of BPD. In many cases they are people who have needed high levels of observation in their previous hospital setting in order to prevent them from harming or killing themselves.
Clients who commit themselves to the DBT program will have received verbal and written information about the program and have thought through what will be expected of them. They will not be taken into the program unless they have a strong desire to undertake DBT treatment and engage in treatment which will help them find a 'life worth living', a life that is meaningful, for themselves. It is made clear to potential clients that this is Stage 1 of the treatment, where the focus is to decrease suicidal and self-harming behaviors and then behaviors that interfere with therapy and the client's quality of life.
Initially clients make an agreement to stay for a year in inpatient treatment. This commitment includes agreeing to undertake weekly individual therapy sessions and twice-weekly group sessions. They also agree to undertake 'homework' such as writing daily entries about their urges and thoughts, completing behavior chain analyses when appropriate, examining in detail emotions they experience. All homework is done in their own time.
It is due to the fact that people with BPD have extraordinary difficulty in managing the underlying feelings aroused by therapy that Stage 1 of the treatment concentrates on the enhancement of the client's ability to control her actions. The intention is to bring about changes in behavior that allow the client to continue treatment. Stage 2 of the treatment is carried out on an outpatient basis and involves the client integrating what they have learnt and working on issues relating to their past, if that seems appropriate.
A client's experience
DBT therapy is not an easy option. Anna said, 'Applying the skills I learnt is one of the most difficult parts of the treatment.' She spent a number of years in the DBT treatment program and is at the stage where she has completed Stage 1 of the program and is ready to leave the inpatient setting.
Prior to engaging in DBT, Anna undertook a year of psychodynamic therapy followed a few years later by six months in cognitive-behavioral therapy. Her view is that neither of these therapeutic treatments proved helpful to her. She said, 'I feel that I was unable to respond in psychodynamic treatment because I could not recognize or express my emotions. The therapy was wasted. Similarly with CBT, it was not helpful because I was not able to recognize my emotions and thoughts. I felt that my own thoughts were not important to anyone. I could not identify them. DBT is a lot about looking after yourself. I did not get this from other therapies I experienced. I did not think that I was worthy of such things as self-soothing (feeling I could be kind to myself).'
Anna said that before she was admitted onto the DBT unit her life was chaotic. She attempted to kill herself on many occasions. 'I did not see a future for myself. I was mixed up and "disregulated". I didn't think that I would ever have a "life worth living". But gradually over time, things have been fitting into place. It is helpful working on my own problems and the problems of others. I don't have an idealistic picture of life now, but a realistic picture. I now take the rough with the smooth. I reward myself with something nice when things are/have been difficult. I accept the difficulties that I have, and everyone has to some extent. Life is precious. We only have one chance and have to make the best of it.'
Anna said that the most helpful part of DBT is individual therapy and skills training sessions. Homework is helpful: 'It allows you to comment on a situation "on the spot". Now if I feel stressed, I use my skills to release the tension. I was not able to cry before I came to the unit. Others ways I have found for releasing stress include listening to stimulating music, for example powerful loud rock music. At other times I might use mindfulness skills. It depends on the individual situation and what I think I need at the time.' She sums up by saying: 'DBT is a good treatment but you have to be willing to participate and work on it. You have got to want it to work. You have to work through and solve the problems that arise for you. It is bloody hard work. If you have that willingness, go for it!' Anna's responses are typical of other clients who have engaged in DBT.
DBT is an approach to working with clients who have BPD (both men and women). It has been used as a treatment since the early 1990s in America, and the late 1990s in the UK. It is a complex treatment that 'blends cognitive-behavioral interventions with Eastern meditation practices and shares elements in common with psychodynamic, client-centered, Gestalt, paradoxical, and strategic approaches'. It is a therapy that requires commitment and hard work from both clients and therapists. In my opinion it is an effective form of treatment, which has enabled many clients to make significant changes to their lives. Some of those who previously needed to be observed 24 hours a day are now living back in the community without -- or with far fewer -- self-harming and suicidal incidents. Clients who complete the treatment are usually no longer overwhelmed by situations. They no longer see taking their life or harming themselves as the only way to resolve problems they encounter in their lives. My concern about whether it would be possible for me to work as both an integrative psychotherapist and a DBT therapist without one model adversely affecting the other, was unfounded. My increased knowledge is a strength. I believe that it has broadened greatly and I have also increased my understanding and awareness that the therapeutic mode which works for one person may be very different from what works for another. Whichever therapy one is involved in, supervision is essential because it brings reflection and objectivity into the therapeutic work.
- Dobbin, Gloria; A life worth living; Therapy Today; May 2006; Vol. 17 Issue 4
Reflection Exercise #12
The preceding section contained information
about dialectical behavior therapy for BPD. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are four skills taught to clients in Dialectical Behavior Therapy? Record the letter of the correct answer