The Hope of Dialectical Behavior Therapy (DBT)
by Anne M. Gresham, RN, MS, CS
Published in March, 1997
Journal for Guardians and Conservators
Hope and Borderline Personality Disorder (BPD) are two terms that have rarely been used in the same sentence. Since the development of Dialectical Behavior Therapy or DBT by Dr. Marsha Linehan from the University of Washington in Seattle, mental health professionals all over the world have felt hope for the first time in years. DBT is the first treatment known that is well researched to prove it’s effectiveness in treating people with Borderline Personality Disorder. In addition, professionals have been so excited about it that many are researching application of the method in dealing with other difficult to treat disorders.
Dr. Linehan has re-theorized the causes and shape of Borderline Personality Disorder away from the more standard DSM IV description to a more bio-social model. She describes BPD as primarily a dysfunction of emotion regulation and a lack of knowledge. The person experiences their own emotions as intolerable and has no skill to cope that is life enhancing. In Dr. Linehan’s theories, the person was probably born with a genetic predisposition toward sensitivity to emotions. If, during childhood, this person is then subjected to a severely “invalidating environment”, BPD develops. This individual may also be weighted more heavily on one of these sides than the other and BPD can still develop. Linehan does emphasize, however, that these theories are not supported by empirical evidence, but the value of the treatment technique does not depend on the theory being correct.
The treatment technique relies on dialectical philosophy and behavioral therapy, as the name Dialectical Behavior Therapy implies. The term “dialectical” comes from classical philosophy and refers to an argument in which an assertion is first made about a particular issue (the thesis), the opposing position is then formulated (the antithesis), and finally a “synthesis” is sought between the two extremes. The resulting synthesis embodies the valuable features of each position and resolves any contradictions between the two. Then the synthesized idea becomes the thesis for the next cycle. Therefore truth, is an evolving entity and not absolute. The key ‘dialectic’ in the therapy process is the balance between the acceptance of the client’s current behavior and the expectation of change. Behavior change is then accomplished through firm yet flexible behavioral reinforcements and punishments set up by the individual therapist and agreed upon by the client.
There are four main modes of therapy utilized in DBT: Individual therapy, group skills training, telephone consultation, and therapist to therapist consultation. Other modes are also acceptable and encouraged in individual circumstances. Medication therapy, group therapy, in-home therapy, etc. are examples and are up to the individual therapist and the client. In DBT, the individual therapist is considered the case manager or primary therapist, and all other therapies are conducted in conjunction with that therapy process. The bulk of the process happens in individual therapy.
Linehan breaks up DBT into five stages. The ‘pretreatment stage’ focuses on assessment, commitment, and orientation to therapy. ‘Stage one’ focuses on suicidal behaviors, therapy interfering behaviors, quality of life interfering behaviors, and developing necessary skills. ‘Stage two’ focuses on post-traumatic stress related problems. ‘Stage four’ focuses on development of spirituality and connection with life. The therapist targets behaviors to change in each of these stages and that behavior must change before moving onto the next stage. Therapy targets are specific for each stage and each therapeutic mode and are arranged in hierarchy of relative importance.
The first mode of therapy mentioned and the most important in DBT is individual therapy. The primary behavioral reinforcement used in the entire therapy process is the relationship with the therapist, so a great deal of time is given to developing a strong, honest relationship. The therapist, using dialectical thinking, has the goal of finding the wisdom in all the client’s behavior and validating that wisdom and at the same time expecting and reinforcing change. The client is required to fill out a “diary card” daily which will list any behaviors which are problematic for a quality life. The therapist then requires that the client bring this to each session, and the discussion usually starts off with this information. If the card is “clean”, with no real problems since last session, the client is allowed to choose the topic of discussion. The most immediate target of individual therapy is reducing Parasuicidal behaviors. Parasuicide refers to any behavior that could be potentially life threatening. In most cases this refers to suicidal behaviors or to self injurious behaviors. Because death is contraindicated in therapy, it simply makes sense to always deal with this first. Therefore if a client comes in to see their therapist, and there has been a self-injurious behavior since the last session, that is what is talked about in that session. The therapist and client do an extensive behavioral analysis of the incident and work out a solution analysis as well. Then the therapist focuses on getting the client to commit to not doing it again. Once this has been accomplished, the client can then choose the topic of conversation. The second target of individual therapy is always therapy interfering behavior, such as not bringing the diary card, or showing up for session late, or behavior toward the therapist in some way that could potentially burn out the therapist. If any of these take place, that is the subject of the session until it is resolved in some way. In addition, if the therapist or client identify any behaviors that the therapist has committed that is therapy interfering, this is pointed out and is discussed in the same way as the client’s behavior. The next target is quality of life interfering behaviors, such as not sleeping, risky sexual behaviors, eating disorders, isolating behaviors, etc. Again, if these behaviors are evident on the client’s diary card, these are talked about before the client is allowed to choose topics. The final target of individual therapy is ‘Skills Acquisition’. The therapist helps the client to understand and use the skills which are taught in the skills training group (discussed below). These are the skills that will replace the self injurious skills the client has been using. Therapy continues with these targets in this order until the old behaviors are extinguished and are replaced with more functional, life enhancing behaviors and any post traumatic issues are resolved. Therapy can continue later onto more esoteric subjects if the client chooses.
The second mode of therapy always required is skills training which usually take place in a group setting. This mode is different from group therapy in that it is strictly educational. The client is required to attend the course twice through the curriculum which takes about one year. It is important to note that the skills training group is in addition to individual therapy. For DBT to be effective, the client must be active in both modes. The skills taught are ones that most people with BPD are not taught in childhood and are known to be life enhancing. The most important and all encompassing of the skills are the ‘Mindfulness’ skills. Mindfulness implies a skill that allows one to be in control of one’s mind. Therefore, a Zen approach of meditative practice is taught. When practiced, these skills can help to focus thought and emotion during a crisis in a way that allows appropriate judgment. ‘Interpersonal Effectiveness’ skills are also taught which help the participants to have satisfying relationships that are not focused on extremes of emotion. Assertiveness skills are emphasized. ‘Emotion Regulation’ and ‘Distress Tolerance’ skills are also taught. These skills focus on helping to prevent emotions from becoming intolerable and tolerance to them if they do get overly intense. It is important to note that another overall goal of DBT is not to prevent emotions but to help the participants to TOLERATE their emotions. Many people entering a DBT program hope to eliminate their emotions, as “they are the problem”. ‘Radical acceptance’ of life, as it is, is strongly emphasized at the same time changing behaviors which will help to change emotions.
The third mode of therapy, telephone contact, is the mode which usually causes the most controversy in the professional field. DBT requires that the therapist be on call for the client. In fact, the client is strongly encouraged and in some cases required to call their therapist. This availability is to help the client to use effective skills before resorting to self destructiveness that usually happens after a crisis is out of control. If the client can only use the new skills in the context of the therapy office, it will not be effective in the client’s real life. Generalization of the skills to outside life is the primary goal of telephone contact. This contact is seen as consultation to the client in a tough situation and not a therapy session. The client is cheered on to use their new skills. They may even be encouraged to call back and report how it went so that the therapist can give reinforcement. Telephone contact can also be used as a “punishment” for using parasuicidal skills. If a client uses a parasuicidal skill and later calls the therapist, the therapist refuses to talk to the client except to ensure medical safety, for twenty-four hours after the incident. Then at the next meeting, a behavioral analysis will be done in session, as previously explained in this article. When first hearing about this aspect of DBT, many therapists become quite concerned that clients will call them constantly. In the reality of this practice, once the client has been given the permission to call, and they have tested it to see if it is really true, the clients call less often than would be expected. In addition, the calls are usually less crisis oriented and are very short. Many are concerned that phone calling is a boundary violation of some sort. In DBT, therapists are encouraged to ‘observe their limits’ and be honest about them with clients. Each therapist may accomplish the telephone contact in a little different way, but it is required.
The fourth mode of therapy is one that has historically been very neglected. ‘Therapist Consultation’ is seen as a required aspect of the client’s therapy. Therapists must be involved in a DBT consultation team of other DBT therapists on a regular basis. The goal of this is to keep the therapist on track with DBT and to prevent demoralization of the therapist. As most people are aware, working with Borderline clients can be very difficult for the therapist, and if the therapist becomes “burned out”, the client loses. Therapists in such a group make commitments to each other similar to the commitments clients make in entering DBT. The DBT process is used with the therapists in the group. The same skills are encouraged, and reinforcements and punishments are used. In order for therapy to work it is critical that the therapist be healthy and have enough support.
A central idea of DBT is that the client is the driver of their own bus. “Splitting” is addressed using this concept. When a client is dealing with a professional or support person and complaining about another, the support person is encouraged to refer the client back to the skills to encourage the client to deal with the situation or person. The support person is not held responsible for the client’s troubles in this way. In addition, therapists and support people in the client’s life are reciprocally responsible for themselves as well. This means that support people do not “tattle” on the client, rather the client is encouraged to “tell on” themselves. The exception to this is within the consultation group, and clients are informed that they are talked about in the consultation meetings. Therefore what is told to one is told to the group. Even in this case, however, the client is held responsible. This overarching concept helps to address how support persons can help the therapy process along. Always redirecting the client back to the skills they are learning and encouraging them to use them to solve their own problems is not only therapeutic but very respectful. Doing for someone what they can do for themselves is disrespectful. Because the skills are so integral to DBT, anyone in the clients’ lives are also encouraged to study the skills. This can be done through a direct educational experience or by reading. Dr. Linehan has written both a text book and a skills training manual for this purpose. The textbook is entitled, Cognitive – Behavioral Treatment of Borderline Personality Disorder and is published by Guilford Press. The skills training manual which is a bit easier to understand and focuses entirely on the skills is entitled, Skills Training Manual for Treating Borderline Personality Disorder and is also published by Guilford Press.
Although Dialectical Behavior Therapy seems a complicated treatment method, it is well worth the effort to learn about. Before Dr. Linehan’s research, therapists like me felt that there had to be away of treating people with Borderline Personality Disorder but were frustrated by the current means. I have long felt that people with BPD were people deserving of help and not neglect, but because of our ignorance we could not be successful. Therefore many of us have rejected such clients and have referred to them in quite pejorative terms. DBT has given me a way not only treat people with BPD successfully but a way to forgive myself.