Handbook of Personality Disorders
Chapter 29
Dialectical behaviour therapy

Introduction

Dialectial behaviour therapy (DBT) is developed to address the skills deficits of individuals with borderline personality disorder, as well as the issues that lead therapist frequently to get stuck.

DBT is rooted in the principles of behaviour therapy including 1) a strong emphasis on ongoing data collection during treatment 2) clearly defined target behaviours 3) a collaborative therapist-patient relationship 4) the use of standard cognitive and behavioural treatment strategies.

DBT has an emphasis on dialectics. The fundamental dialectic is the need for both acceptance and change. The therapist needs to fully accept the patient as (s)he is and at the same time persistently push for and help the patient to change. The therapist also tries to develop and strengthen an attitude of acceptance toward reality on the part of the patient, as well as the motivation and ability to change what can be changed.

The fundamental treatment dialectic of acceptance and change is expressed through validation and problem solving.

DBT involves a dialectic of communication style between reciprocal, warm interpersonal style and a more irreverent style.

There is a dialectic in case management between consultation to the patient to help manage his or her environment and direct environmental intervention by the therapist.

Scope and focus: Domains of psychopathology

DBT addresses problems associated with pervasive emotion dysregulation.

Treatment stages and targets

DBT consists of five stages: 1) Pretreatment 2) control 3) order 4) synthesis 5) transcendence.

Each session agenda is based on the patient’s behaviour since the last session. It is the therapist’s responsibility to remain mindful of treatment goals and to ensure that patient treatment activities are directed toward creating a life worth living.

Pretreatment

The objectives of this stage are 1) To orient patients to the philosophy and structure of treatment 2) for therapist and patient to reach agreement on the goals of treatment.

If patients are currently engaging in suicidal or other self-harming behaviours, they must agree that reducing or eliminating such behaviour is the first priority. Patients must agree not to kill themselves while they are on DBT. Explicit patient agreement is necessary prior to full participation in treatment.

With patients who express reluctance to commit to DBT goals, ongoing pretreament focuses on commitment-enhancing strategies.

Stage 1: from behavioural dyscontrol to stability and behavioural control

For patients who enter treatment with severe behavioural dyscontrol, DBT focuses initially on movement toward behavioural control. Life-threatening behaviours are primary targets addressed by increasing basic capacities necessary to function in treatment.

Goals include: 1) attaining a reasonable (immediate) life expectancy 2) control of behaviour 3) stability 4) tending to relationships with those who give help.

The primary targets of stage 1 are: 1) decreasing behaviours involving self-harm, suicide, or violence towards others 2) decreasing therapy-interfering behaviours 3) decreasing serious quality-of-life-interfering behaviours 4) increasing skills needed to make life changes.

Treatment occurs I several modes: individual therapy, group skills training, telephone consultation and team meetings.

Individual therapy

Weekly diary cards are used to collect ongoing information about target problems. Targets listed on the diary card are individually tailored. On the other side is a list of DBT skills for the patient to mark skills that (s)he has used.

At the beginning of each individual session, the dairy card is reviewed to identify priorities for that session’s agenda. The diary card provides temporal detail about the relationship between maladaptive behaviours and emotional state.

All direct self-harm, suicide crisis behaviour, intrusive or intense suicidal ideation, images of communications, and significant changes in ideation or urges to self-harm are addressed in individual therapy in the session that follows their occurrence.

Skills training

DBT assumes that many problems experienced by patients who are chronically suicidal, self-harm or engage in other behaviours characteristic of borderline personality disorder result from a combination of motivational problems and behavioural skill deficits. DBT emphasizes building skills to facilitate behaviour change and acceptance.

Four skills modules are taught sequentially in weekly skills training groups, namely: mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance.

Working in tandem, simultaneous group and individual components of treatment create dedicated time to learn skills and a separate context for coached individual application. This allows individual therapy to focus on priority target behaviours, as well as other crisis issues.

Groups skills training has advantages 1) members practice together and learn from each other 2) skills practice is coached by an expert skills trainer 3) group membership often decreases real isolation and increases a patient’s sense of feeling understood.

Socially phobic patients are moved to groups skills training as soon as possible.

Telephone consultation

Between-sessions contact serves three functions 1) to provide skills coaching in vivo to promote skills generalization 2) to promote crisis intervention in a contingent manner 3) to provide an opportunity to resolve misunderstandings and conflicts that arise during therapy sessions.

Inability to call is viewed as therapy-interfering behaviour and becomes a target.

This contact must occur prior to any direct self-harm. If the patient has already engaged in such behaviour, the therapist does not provide non-scheduled contact to the patient for 24 hours.

Consultation team

DBT is a treatment system in which the therapist applies DBT to patients while the consultation team applies DBT to the therapist.

Without supervision and consultation, clinicians working with this patient population can become extreme in their positions, blame the patient and themselves, and become less open to feedback from others about the conduct of their treatment. DBT requires that all therapists doing any part of this treatment must be part of a consultation team.

Consultation to the therapist has several purposes 1) to ensure that the clinician remain in the therapeutic relationship and remains effective 2) validations of the therapist’s reactions, feelings and experiences 3) improve treatment fidelity.

Stage 2: from quiet desperation to nontraumatic emotional experiencing

This stage is alleviating the patient’s unremitting emotional desperation. It addresses posttraumatic stress syndrome.

Patients preparedness is indicated once serious maladaptive behaviours have not occurred for two months, even in the face of relevant stressors.

Posstraumatic responses are targeted using a DBT prolonged exposure protocol.

Entry into stage two means patients no longer engage in direct self-harm, or making concrete plans for suicide.

Stage 3: from problems in living to ordinary happiness and unhappiness

Stage 3 treatment focuses on moving problems in living to the level of ‘ordinary’ happiness and unhappiness, thereby attaining a higher quality of life.

Targets include self-respect and achievement of personal goals.

Patients cultivate an ongoing sense of connection to self, others, and life, synthesizing prior learning into mastery, self-efficacy, and a sense of personal values.

Stage 4: From incompleteness to freedom for capacity for joy

Stage 4 addresses any lingering sense of incompleteness that continues after resolution of problems in living. Goals include; developing capacity for sustained joy and freedom from psychological imperatives by integrating past, present and future, self and others, and accepting reality.

Diagnosis, assessment, and formulation

It is important to know the specific patterns of behaviour that create difficulty for this particular individual, and what his or her maintaining variables are.

Assessment of DBT emphasizes day-to-day monitoring of target behaviours through the diary card and in-depth behavioural analysis of target behaviours. This is also essential throughout treatment. This also helps to better understand the social context. The therapeutic relationship often provides an opportunity to identify subtle aspects of interpersonal problems.

Case formulation is conducted through understanding the biosocial theory as it applies to the particular patient, delineating the problem behaviours within the hierarchical system, and identifying aspects of patient and therapist behaviour that need to be addressed in order for treatment to be successful.

Theoretical foundation of DBT

Two theoretical frameworks provide the foundation for DBT; 1) a biosocial theory of borderline personality disorder, which helps the therapist to understand the patient’s behaviours, and to know both how the patient needs to change and what (s)he needs to learn   2) To core treatment principles.

DBT includes assumptions that reflect the balance between acceptance and change.

Theory of disorder: a biosocial theory of borderline personality disorder

Biosocial theory proposes that borderline personality disorder results form a series of transactions over time between a personal factor and environmental factor.

Difficulties in emotion regulation may occur because of a combination of two factors 1) an inherent emotional vulnerability, this also entails a slow return to baseline levels 2) difficulty in modulation emotions.

An invalidating environment contributes to emotion dysregulation.

Fundamental theoretical constructs: core treatment principles

DBT draws most of its treatment principles form three areas: behaviour therapy, Zen and dialectical philosophy.

Behaviour therapy

DBT assumes that many maladaptive behaviours, both over and private are learned, and therefore can be replaced by new learning. Three primary ways through which individuals can learn are: modelling, operant conditioning and respondent conditioning.

DBT therapists are constantly looking for opportunities to use shaping deliberately and contingently to provide interpersonal and other positive consequences to the patient’s skilful behaviour.

Zen

There is a strong need for patients to develop an attitude of greater acceptance toward a reality that is often painful. The most essential Zen principles and practices include 1) the importance of being mindful of the current moment 2) seeing reality without delusion 3) accepting reality without judgment 4) letting go of attachments that cause suffering 5) finding the middle way.

Zen has a humanistic assumption that all individuals have an inherent capacity for enlightenment and intuitive truth, the wise mind.

Dialectics

Dialectics refers to a process of synthesis of opposing elements, ideas, or events. DBT therapist model dialectical strategies and directly teach more balanced, synthesized, and dialectical patterns of thinking and behaviour.

In dialectical philosophy, reality is viewed as being whole and interrelated and at the same time as bipolar and oppositional. Reality is in continuous change, as its components transact with one another.

Dialectics are used to balance treatment strategies that are heavily change-oriented with others that are heavily acceptance-oriented. This means firmly embracing both.

Patients need to learn accept as much as they need to learn to change.

DBT strategies

Change and acceptance strategies are woven together, integrated throughout the treatment.

Dialectical strategies

Dialectical strategies entail: 1) balancing all the other treatment strategies. 2) entering the paradox, the therapist highlights the constant paradoxes of life without attempting to explain them, modelling teaching ‘both this and that’. 3) Use of metaphor, making a point trough metaphor often can be more powerful 3) Dialectical assessment, the therapist continuously seeks to understand the patient in a situational context.

Core strategies: validation

Validation is one of the primary strategies employed by DBT therapists. It entails communicating to the patient that his or her responses make sense in the current context. Validation form the therapist serves an important function in facilitating problem solving. It may be used to decrease emotional arousal on affective and physiological levels. It may also function to strengthen patterns of self-validation and combat self-invalidation, as well as strengthen the therapeutic relationship.

Core strategies: problem solving

Problem-solving strategies are the primary strategies for changing target behaviours and include procedures such as: skills training, contingency management, observing limits, cognitive modification and exposure.

The elements of problem solving are divided into a series of steps: 1) the problem behaviour must be fully understood, this involves chain analysis. A number of instances of a particular behaviour are analysed and therapist and patient together arrive at some insights about what factors maintain the behaviour 2) Generating and evaluating various possible solutions (solution analysis) 3) Actively work toward the solution 4) Elicit and explicit verbal commitment form the patient to engage in the specific behaviours suggested by solution analysis.

Behavioural chain analysis

The goal of behavioural analysis is to understand the factors that lead to the problem behaviour. The focus is on defining and describing the target behaviour in an explicit and detailed manner, then attempting to understand the behaviour in its current context.

Behavioural ‘chain’ analysis identifies the problem, the internal and external events preceding and causing the problem and the consequences of engaging in the target behaviour.

The object is to delineate as many links as possible. The more links, the more places there are that something different occurs in the future.

Solution analysis

Once a chain is clarified, the task becomes ‘solution analysis’, identifying potential resources for solving the problem. Solution analysis include some combination of four sets of procedures; 1) skills training to address skill deficits 2) contingency management strategies 3) cognitive modification procedures to address beliefs, attitudes and assumptions that interfere with skilful behaviour 4) exposure-based strategies to allow reduction in strong emotional responses that interfere with adaptive problem solving attempts.

An effective chain analysis is thorough, but there needs to be enough time for conducting solution analysis.

Skills-training procedures

Procedures can teach new skills and facilitate use of learned but unused skills. Acquired skills need to be strengthened and generalized across situations.

The individual therapist and skill trainers help the patient acquire skills by direct instruction, modelling, self-disclosing own behaviour, and particularly through role-play and behaviour rehearsal. Fledgling skills need to be strengthened by further in-session behaviour rehearsals and imagine practice as well as in vivo.

Contingency management procedures

The therapist tries to arrange for target-relevant adaptive behaviours to be reinforced, and for target-relevant maladaptive behaviours to be extinguished through lack of reinforcement or punishment.

The primary reinforce used is the relationship to the patient. For this, it must be highly valued by the patient.

It is helpful to discuss with the patient how reinforcement works regardless of intent or awareness, and that even unintended consequences still influence behaviour.

Reinforcement and punishment must be determined for each particular patient.

Punishment is used with great care in DBT, because it can lead to strong emotional reactions that interfere with learning, strengthen a self-invalidating style, and fail to teach specific adaptive behaviour. But, sometimes is it necessary.

Observing limits procedures

Contingency management procedures are applied in DBT to behaviours that interfere with the patient’s life and to those interfering with the therapist’s life. The DBT therapist must observe his or her own limits to prevent burnout.

Cognitive modification procedures

In DBT, thoughts, beliefs, assumptions, and expectations are seen as a category of behaviours that influence, and are reciprocally influenced by, transactions with emotional processes, overt behaviour and environmental factors.

In DBT, standard cognitive therapy procedures are paired with an emphasis on first validating the wisdom in the patient’s cognitions.  

The therapist stays alert for distortions of cognitive content and style. The therapist tries to help patients change these problems by 1) teaching self-observation through mindfulness practice and written assignments 2) identifying maladaptive cognitions and pointing to non-dialectical thinking 3) generating alternative, more adaptive cognitive content and style in session and for homework assignments 4) developing guidelines for when patients should trust their own interpretations 5) The patient should understand the contingencies that currently operate in life and how they influence behaviour.

Exposure procedures

The core of these treatments involves repeated exposure to anxiety-provoking stimuli or situations, while ensuring that the normal avoidance response does not occur. Most change strategies in DBT may be viewed as involving emotional exposure.

Stylistic strategies: reciprocal and irreverent communication

Reciprocal communication is the model stylistic strategy in DBT, used to convey acceptance and validation and to reduce the power differential. It requires the therapist to take the patient’s agenda and wishes seriously and respond directly to the content of communications. Therapists are enoucraged to use self-involving self-disclosures.

Case management strategies

Case management strategies include consultation to the patient, environmental intervention and consultation to the therapist.

Consultation to the patient

Therapists consult with patients about how to manage their social or professional networks. Consultation to the patient strategies begin by orienting the patient and the patient’s social network to the approach, advising and coaching the patient about how to manage other professionals and other members of their interpersonal networks.

Environmental intervention

Environmental intervention strategies include providing information to others independent of the patient, patient advocacy, and entering the patient’s environment to provide assistance. Direct environmental intervention by the therapist is approved only under conditions in which the short-term gain is worth the long-term loss in learning.

The therapeutic relationship in DBT

Problematic interactions in the therapeutic relationship are directly targeted for change In DBT.