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Dialectical behaviour therapy
Treatment approaches
Dialectical behaviour therapy
What’s new? • Dialectical behaviour therapy (DBT) was originally developed for the treatment of women with borderline personality disorder (BPD) in the community
Janet Feigenbaum
• DBT has been modified and evaluated for use with women with BPD and comorbid substance abuse (DBT-S) • DBT has been evaluated across a range of settings, including secure settings, patient units, and crisis services
Abstract Dialectical Behaviour therapy (DBT) was originally developed for the treatment of women diagnosed with borderline personality disorder (BPD) in the community. Since then DBT has been modified and evaluated for use with comorbid disorders, across the lifespan and across a range of clinical settings. The DBT model assumes that individuals with BPD lack key interpersonal, self-regulation, and distress tolerance skills, and that personal and environmental factors may frequently block and/or inhibit the use of behavioural skills or reinforce maladaptive actions. DBT is based on an assumption of a pervasive skills deficit; thus the therapy is designed to facilitate the learning of new skills, the embedding of these skills into the individual’s repertoire, and the generalization of these skills across contexts. DBT incorporates a range of change-enhancing strategies interwoven with acceptance-focused strategies. DBT was developed from the cognitive–behavioural model of treatment, and thus shares many of its key components. DBT incorporates the principles of dialectics, mindfulness, and validation with cognitive–behavioural principles and techniques.
• DBT has been modified and evaluated for use with other disorders, including binge eating disorder and older adults with chronic recurrent depression • DBT has been evaluated across the age range, including adolescents and older adults
a transaction between biological vulnerability and invalidating environments. It is hypothesized that individuals with BPD have emotional response systems that respond to stimuli with greater speed and strength than other individuals and a slower return to baseline. This emotional sensitivity and responsivity may be the result of inherited biological vulnerabilities or arise from early childhood experiences which may have led to changes in the development of neural structures underlying emotional regulation.7 Prefrontal and temporolimbic dysfunction may underlie the deficits that characterize BPD.8,9
Keywords binge eating disorder; borderline personality disorder; dialectical behaviour therapy; substance abuse
Areas of dysregulation in borderline personality disorder
Dialectical behavioural therapy (DBT) was originally developed for the treatment of women diagnosed with borderline personal ity disorder (BPD) in the community.1–3 Since then DBT has been adapted and evaluated for individuals with a range of comorbid disorders and service settings.4 DBT has been recommended as a treatment of choice for BPD by both the American Psychiatric Association5 and the UK Department of Health.6 Linehan biosocial model of borderline personality disorder Linehan’s biopsychosocial model2 suggests that BPD is primarily a dysfunction of the emotional regulation system, which is part of an interdependent set of systems involving cognition, beha viour, interpersonal communication, and self-identity (Table 1). Arousal in any one or more of these systems will result in dys regulation of the others. The model suggests BPD arises from
Affective instability due to marked reactivity of mood; inappropriate, intense anger and difficulties controlling anger
Behavioural dysregulation
Impulsivity in at least two areas that are potentially self-damaging; recurrent suicidal behaviour; recurrent gestures or threats or self-mutilating behaviour Frantic efforts to avoid real or imagined abandonment or rejection; a pattern of unstable and intense interpersonal relationships characterized by idealization and devaluation Identity disturbance; unstable self-image or sense of self; chronic feelings of emptiness Transient, stress-related paranoid ideation or severe dissociative symptoms
Interpersonal dysregulation
Self-dysregulation Cognitive dysregulation
Janet Feigenbaum DPhil is a Senior Lecturer in Clinical Psychology at University College London. She is also a Consultant Clinical psychologist, Head of the IMPART personality disorder service, and Clinical Lead for personality disorder for North East London Mental Health Trust. Conflicts of interest: Janet Feigenbaum is a member of the UK DBT training team.
PSYCHIATRY 7:3
Affective dysregulation
Source: Swales M, Heard HL, Williams JGM. Linehan’s dialectical behaviour therapy for borderline personality disorder: overview and adaptation. J Ment Health 2000; 9: 7–23.12
Table 1
112
© 2008 Elsevier Ltd. All rights reserved.
Treatment approaches
Emotional dysregulation reduces the effectiveness of cogni tive processing systems leading to difficulties with problem solv ing, poor access to memories for previous coping strategies, and limited capacity to consider the consequences of actions. The problematic (risk) behaviours displayed by individuals with BPD are both the consequences of and a means of coping with painful emotional states. Thus a primary focus of DBT is on recognizing, accepting, and moderating emotional responses.
The dialectical behavioural therapy programme DBT is a treatment that incorporates five functions (Table 2),2,3,12 which are delivered across a number of therapeutic modalities. Dialectical behavioural therapy modes Skills training group: developing new capabilities – the skills training group is designed to enhance the capabilities of the client. The format is psychoeducational, structured for the learning and rehearsal of new skills. The skills training group is divided into four modules: mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance. Individual therapy sessions: enhancing client capability and motivation – all clients in DBT receive 60–90 minutes a week of individual therapy. The function of individual therapy is to relate the skills learnt to the specific goals and targets of the client. The individual sessions have a clear structure and focus.
The role of invalidating environments Invalidating environments prevent children from developing an understanding of their emotional experiences, a means of com municating these experiences, and the means to manage or mod ify these experiences. The individual is left with a complex and intense emotional internal world, in which they have no skills to understand or manage their experiences. This may result in poor self-efficacy, dependency, or excessive help-seeking behaviour. The clearest example of an invalidating environment is child hood abuse, present in the histories of about 66–75% of patients with BPD,10 leading to beliefs of impending abandonment, vigi lance for rejection, and disillusionment. Expectation of abandon ment may lead to the testing of boundaries and relationships. Invalidating environments often lead to self-invalidation or avoid ance of one’s own emotional experiences, which further reduces one’s capacity to identify and modulate emotional experiences.
The five essential functions that must be provided by an adherent dialectical behaviour therapy programme Function one • To enhance the capabilities of the client, through the teaching of new skills or the activation of existing skills not used effectively
Principles of dialectical behavioural therapy DBT conceives of BPD as a combination of specific deficits of psy chological function and distorted motivations. The model assumes that: individuals with BPD lack key interpersonal, self-regulation (including emotional regulation), and distress tolerance skills; and personal and environmental factors may frequently block and/or inhibit the use of behavioural skills, and at other times reinforce maladaptive actions. DBT aims to offer a range of change-enhancing strategies combined with motivation-focused interventions. DBT incorporates both dialectical and Zen principles to enhance the capacity of the individual, and their therapist, to enact change.
Function two • To improve motivation to use these new skills in a range of settings. When emotionally aroused, newly learnt, or rarely used, skills may be forgotten while over-learnt (dysfunctional) patterns of behaviour are used Function three • To ensure that the new skills can be used in a range of settings and experiences. During therapy, skills are most often taught and learnt through discussion, modelling, role play, and rehearsal with a therapist or in a group. The skills are learnt in a particular setting when emotional arousal is likely to be controlled and the use of the skill feels ‘safe’ to the client. During learning of the new skill the therapist or group provide useful and supportive feedback on the use of the skill. However, the individual must be able to use the skill when highly emotionally aroused, when faced with a social context that may be resistant to the use of the skill, or in which a creative variation of the skill must be used to be effective
Dialectical principles: there are three main tenets of dialectics: the interconnectedness of the world; that truth can be found as a synthesis of differing views; and change is inevitable and constant. First, the concept of interconnectedness emphasizes the importance of taking a ‘whole systems’ approach. Second, individual reality comprises opposing forces, a thesis and antithesis, which are not static. The resolution of these tensions is found in synthesis, which in itself may create further dialectical tensions. The main dialectic in DBT is the synthesis between acceptance and change.
Function four • To provide a structure to the environment that supports both the client and the therapist in the development and use of new skills or capabilities
Mindfulness: derived from Zen spiritual practices, mindfulness is regarded as a core skill in DBT.11 Mindfulness involves increasing awareness of self and context. Mindfulness in DBT incorporates the ability to take a non-judgemental stance, to focus on one thing in the moment, and to identify what is effective – ‘doing what works’. Mindfulness facilitates ‘wise mind’ states, in which the individual is able to find a synthesis between emotional experience and logi cal thought. It is through the ability to mindfully attend to one’s current emotional state, identify the associated, often unhelpful, cognitions, and the actions and reactions of self and others, that solutions can be effectively generated and applied.
PSYCHIATRY 7:3
Function five • To provide a means of enhancing the therapist’s own skills and motivation to continue to work with the client effectively and safely through continued development of skills, monitoring of stress and burn-out, and identifying the client’s efforts to shape or modify the therapist’s behaviour Table 2
113
© 2008 Elsevier Ltd. All rights reserved.
Treatment approaches
Strategies to increase commitment to therapy – securing com mitment to treatment is critical. Strategies include: a collaborative assessment; treatment contracts; an emphasis on motivational strategies; dialectically informed commitment strategies (e.g. devil’s advocate); validation (acceptance); and the use of metaphors, which are less threatening and confrontational for the client. Problem-solving strategies (change strategies) – the main problem-solving strategy used in DBT is the behavioural chain analysis used to identify, in great detail, the affective, cognitive, behavioural, interpersonal and environmental triggers that led up to the target behaviour and the reinforcing consequences of the event. A solution analysis is generated, drawing upon existing functional skills and suggesting new skills, and skills rehearsed. Obstacles to implementing the solutions are resolved. Validation strategies (acceptance strategies) (Table 3) are used in DBT to: balance change strategies; help the client learn to validate themselves; and strengthen the therapeutic relationship. They are also used as a form of feedback.13 Dialectical strategies – in addition to identifying dialectical tensions as they arise and facilitating a synthesis, the DBT thera pist will use dialectical strategies to promote a shared view with the client. This includes creating a balance between acceptance and change, nurturance and challenge, flexibility and stability. The most commonly known dialectical strategies include: dev il’s advocate, ‘making lemonade out of lemons’, and use of metaphor.2
Behavioural chain analyses relating to the targets of the ses sion are conducted, and a solution analysis generated. Relevant skills identified in the solution analysis are rehearsed. Addition ally during the individual session, the therapist and client will identify and address commitment to therapy and motivation to change as problems arise. Telephone consultation: increasing generalization – in the original DBT programme,2 telephone consultation was used as an immediate and powerful means of generalization. The pur pose of these brief telephone consultations is to assist the client in identifying an appropriate skill and to overcome obstacles to using the skill effectively. There are a number of other means of generalization to the environment including: flashcards; audio/ video tapes; teaching the skills to family members or friends; or training out-of-hours staff to provide skills generalization. Case management: structuring the environment – structuring the environment can be provided through the care programme approach, meetings with family members, or in vivo coaching. The aim is to provide opportunities to use new skills and create an environment that recognizes, facilitates, and reinforces their effective use. Consultation meeting: enhancing therapists’ skills and motivation – the DBT team consultation meeting has two components: case discussion (supervision) and therapist skills development. Case discussion aims to ensure that a dialectical stance is taken, and that the therapist is adhering to the main strategies and tech niques of DBT. The therapist’s motivation is also addressed.
The evidence base The first randomized control trial compared DBT with treat ment as usual across a period of one year of treatment.1 DBT
Stages and targets: DBT is a staged psychological treatment.2,12 Pre-commitment – during the pre-commitment phase the therapist explains the treatment model, shares an understanding as derived from the assessment and the biopsychosocial model, and orients the client to the expectations of therapy. The client must commit to reducing self-harming behaviours, to work on interpersonal difficulties that may interfere with the process of therapy, and to developing new skills. The therapist adopts a ‘dialectical’ stance, highlighting both the need for and the dif ficulties with change. Stage one – the initial focus of therapy is on the development of new behavioural skills to reduce immediate life-threatening behaviours and difficulties that interfere with the client’s ability to attend therapy. When life-threatening and therapy-interfering behaviours have ceased, quality-of-life behaviours can then be addressed, including substance misuse and Axis I disorders. Stage two – the goal of stage two is to increase the individual’s ability to experience a full range of emotions and to reduce posttraumatic stress disorder symptoms. This will include exposure to traumatic memories and emotional processing of past, often abusive, experiences. The rationale is that the client will need the emotional and behavioural skills learnt in stage one to manage the emotional intensity of stage two and resolve the trauma effectively and safely.
The six levels of validation Description
Notes
1
Listening and observing Accurate reflection
Maintaining an attentive and interested stance Providing accurate summaries of expressed experiences Communicating what the client may be thinking or feeling but which has not been stated, thus indicating to the client that the therapist is actively involved in the client’s experiences Helping the client to make sense of their actions, or reactions, in terms of past experiences and biological predisposition Acknowledging that at ‘that moment in time’ the response of the client was understandable given their history, their existing skills, and the environmental context Treating the client as capable, effective, and reasonable, not fragile
2
Strategies in dialectical behavioural therapy: DBT uses the fundamental strategies of cognitive–behavioural therapy, includ ing behavioural analysis, exposure, contingency management, and cognitive restructuring. A number of additional and unique strategies are woven into the treatment to enhance the efficacy. DBT provides a framework in which the therapist selects thera peutic techniques based on the current target.
PSYCHIATRY 7:3
Level
3
Articulating the unverbalized
4
Validating in terms of past events
5
Validation in terms of current circumstances
6
Radical genuineness
Table 3
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© 2008 Elsevier Ltd. All rights reserved.
Treatment approaches
clients showed a reduction in frequency and medical sever ity of parasuicidal behaviours, a reduction in bed days, and increased retention in treatment; sustained at 6 and 12 months’ follow-up.14 In addition, reductions in anger and improvements in social functioning were shown.15 A replication trial16 com pared DBT with treatment as usual for women veterans with BPD (with low incidents of parasuicidal behaviour) and found a reduction in suicidal ideation, anger expression, hopelessness, and depression. A later replication, conducted in the Nether lands, compared women with BPD with and without substance abuse on DBT and treatment as usual. DBT was associated with greater treatment retention, reduced self-harm, and a reduction in impulsive behaviours17; all retained at a 6-month follow-up.18 Recently, Linehan and colleagues19 compared DBT with treat ment by experts, and found DBT to be associated with less fre quent and less severe suicide attempts, reduced use of crisis services, fewer inpatient admissions, and better retention in therapy. Linehan and colleagues recognized the high rates of comorbid substance abuse in this population and modified DBT (DBT-S) to increase efficacy for this population. The first trial20 compared DBT-S to treatment as usual and found a reduction in substance abuse and greater retention in therapy after 1 year. The second trial21 compared DBT-S with comprehensive validation therapy plus 12-step (CVT+12S) and found that both groups reduced their opioid use. The CVT+12S group showed greater retention in therapy but more relapse in the last 4 months of treatment compared with DBT-S. The authors suggested that validation is an important ingredient in treatment retention and success, but that this fosters dependence on the therapy, which may require more than 1 year of treatment to resolve. Further extensions to DBT have been evaluated, including therapy for inpatient settings22; binge eating disorder23; secure settings24; chronic depression in older adults25,26; and suicidal adolescents.27
5 American Psychiatric Association. Treating borderline personality disorder: a quick reference guide. Washington, DC: American Psychiatric Association, 2004. 6 National Institute for Mental Health for England 2003. Personality disorder: no longer a diagnosis of exclusion. London: National Institute for Mental Health for England, 2003. 7 Zanarini M. Childhood experiences associated with the development of borderline personality disorder. Psychiatr Clin North Am 2000; 23: 89–102. 8 Silk KR. Borderline personality disorder: overview of biologic factors. Psychiatr Clin North Am 2000; 23: 61–75. 9 Paris J. Childhood precursors of borderline personality disorder. Psychiatr Clin North Am 2000; 23: 77–88. 10 Zanarini MC, Frankenburg FR, Reich DB, et al. Biparental failure in the childhood experiences of borderline patients. J Personal Disord 2000; 14: 264–73. 11 Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clinical Psychology Science and Practice 2003; 10: 144–56. 12 Swales M, Heard HL, Williams JGM. Linehan’s dialectical behaviour therapy for borderline personality disorder: overview and adaptation. J Ment Health 2000; 9: 7–23. 13 Linehan MM. Validation and psychotherapy. In: Greenberg LS, Bohart AC, eds. Empathy reconsidered: new directions in psychotherapy, Washington, DC: American Psychological Association, 1997. 14 Linehan MM, Heard HL, Armstrong HE. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Arch Gen Psychiatry 1993; 50: 971–4. 15 Linehan MM, Tutek DA, Heard HL, Armstrong HE. Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. Am J Psychiatry 1994; 151: 1771–6. 16 Koons CR, Robins CJ, Tweed JL, et al. Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behav Ther 2001; 32: 371–90. 17 Verheul R, Van den Bosch LMC, Koeter MWJ, et al. Dialectical behaviour therapy for women with borderline personality disorder. Br J Psychiatry 2003; 182: 135–40. 18 Van den Bosch LMC, Koeter MWJ, Stijnen T, et al. Sustained efficacy of dialectical behaviour therapy for borderline personality disorder. Behav Res Ther 2005; 43: 1231–41. 19 Linehan M, Comtais K, Murray A, et al. Two-year randomised controlled trial and follow up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006; 63: 757–66. 20 Linehan MM, Schmidt H, Dimeff LA, Craft JC, Kanter J, Comtois KA. Dialectical behavioral therapy for patients with borderline personality disorder and drug-dependence. J Addict Dis 1999; 8: 279–92. 21 Linehan MM, Dimeff LA, Reynolds SK, et al. Dialectical behavioral therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend 2002; 67: 13–26. 22 Bohus M, Haaf B, Simms T, et al. Effectiveness of inpatient dialectical behavioural therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004; 42: 487–99. 23 Telch CF, Agras WS, Linehan MM. Dialectical behavioral therapy for binge eating disorder. J Consult Clin Psychol 2001; 69: 1061–5. 24 Low G, Jones D, Duggan C, et al. The treatment of deliberate selfharm in borderline personality disorder using dialectical behaviour
Conclusion As an integrative model of therapy DBT lends itself well to adap tations for different settings and populations, including adoles cents, older adults, and those with learning difficulties. This reduces the usual exclusion criteria applied by many therapeutic approaches. DBT is comprehensible to and can be applied by a range of professionals from different theoretical backgrounds. Despite limitations to the evidence base, DBT continues to gain support in clinical settings, to be investigated by evidence base practitioners, and is well supported by service users. ◆
References 1 Linehan MM, Armstrong HE, Suarez A, et al. Cognitive behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991; 48: 1060–4. 2 Linehan MM. Cognitive-behavioral treatment of borderline personality. New York: Guilford Press, 1993. 3 Linehan MM. Skills training manual for treating borderline personality disorder. New York: Guilford Press, 1993. 4 Feigenbaum J. DBT: an increasing evidence base. J Ment Health 2007; 16: 51–68.
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Treatment approaches
therapy: a pilot study in a high security hospital. Behav Cognit Psychother 2001; 29: 85–92. 25 Lynch T, Morse JQ, Mendelson T, Robins CJ. Dialectical behavior therapy for depressed older adults. Am J Geriatr Psychiatry 2003; 11: 33–45. 26 Lynch T, Cheavens J, Cukrowicz K, et al. Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach. Int J Geriat Psychiatry 2007; 22: 131–43. 27 Katz LY, Cox BJ, Gunasekara S, Miller AL. Feasibility of dialectical behavior therapy for suicidal adolescent inpatients. J Am Acad Child Adolesc Psychiatry 2004; 43: 276–82.
and invalidating childhood environments. The model presumes that BPD is primarily a disorder of emotional dysregulation • DBT is a team-based psychological therapy, delivering a range of functions across a number of modalities, including group and individual sessions, consultation to the client and their social network, and therapist supervision • DBT is a principle-driven therapeutic framework that incorporates the main principles of cognitive–behavioural therapy, adding principles from dialectics, mindfulness, and validation • DBT has been widely evaluated for both efficacy and effectiveness for individuals with BPD, and is a recommended treatment by both the American Psychiatric Association and the National Institute for Mental Health for England
Practice points • DBT is based on a biosocial theory that suggests that BPD arises from the transaction between biological vulnerability
PSYCHIATRY 7:3
116
© 2008 Elsevier Ltd. All rights reserved.
Dialectical behaviour therapy
What’s new? • Dialectical behaviour therapy (DBT) was originally developed for the treatment of women with borderline personality disorder (BPD) in the community
Janet Feigenbaum
• DBT has been modified and evaluated for use with women with BPD and comorbid substance abuse (DBT-S) • DBT has been evaluated across a range of settings, including secure settings, patient units, and crisis services
Abstract Dialectical Behaviour therapy (DBT) was originally developed for the treatment of women diagnosed with borderline personality disorder (BPD) in the community. Since then DBT has been modified and evaluated for use with comorbid disorders, across the lifespan and across a range of clinical settings. The DBT model assumes that individuals with BPD lack key interpersonal, self-regulation, and distress tolerance skills, and that personal and environmental factors may frequently block and/or inhibit the use of behavioural skills or reinforce maladaptive actions. DBT is based on an assumption of a pervasive skills deficit; thus the therapy is designed to facilitate the learning of new skills, the embedding of these skills into the individual’s repertoire, and the generalization of these skills across contexts. DBT incorporates a range of change-enhancing strategies interwoven with acceptance-focused strategies. DBT was developed from the cognitive–behavioural model of treatment, and thus shares many of its key components. DBT incorporates the principles of dialectics, mindfulness, and validation with cognitive–behavioural principles and techniques.
• DBT has been modified and evaluated for use with other disorders, including binge eating disorder and older adults with chronic recurrent depression • DBT has been evaluated across the age range, including adolescents and older adults
a transaction between biological vulnerability and invalidating environments. It is hypothesized that individuals with BPD have emotional response systems that respond to stimuli with greater speed and strength than other individuals and a slower return to baseline. This emotional sensitivity and responsivity may be the result of inherited biological vulnerabilities or arise from early childhood experiences which may have led to changes in the development of neural structures underlying emotional regulation.7 Prefrontal and temporolimbic dysfunction may underlie the deficits that characterize BPD.8,9
Keywords binge eating disorder; borderline personality disorder; dialectical behaviour therapy; substance abuse
Areas of dysregulation in borderline personality disorder
Dialectical behavioural therapy (DBT) was originally developed for the treatment of women diagnosed with borderline personal ity disorder (BPD) in the community.1–3 Since then DBT has been adapted and evaluated for individuals with a range of comorbid disorders and service settings.4 DBT has been recommended as a treatment of choice for BPD by both the American Psychiatric Association5 and the UK Department of Health.6 Linehan biosocial model of borderline personality disorder Linehan’s biopsychosocial model2 suggests that BPD is primarily a dysfunction of the emotional regulation system, which is part of an interdependent set of systems involving cognition, beha viour, interpersonal communication, and self-identity (Table 1). Arousal in any one or more of these systems will result in dys regulation of the others. The model suggests BPD arises from
Affective instability due to marked reactivity of mood; inappropriate, intense anger and difficulties controlling anger
Behavioural dysregulation
Impulsivity in at least two areas that are potentially self-damaging; recurrent suicidal behaviour; recurrent gestures or threats or self-mutilating behaviour Frantic efforts to avoid real or imagined abandonment or rejection; a pattern of unstable and intense interpersonal relationships characterized by idealization and devaluation Identity disturbance; unstable self-image or sense of self; chronic feelings of emptiness Transient, stress-related paranoid ideation or severe dissociative symptoms
Interpersonal dysregulation
Self-dysregulation Cognitive dysregulation
Janet Feigenbaum DPhil is a Senior Lecturer in Clinical Psychology at University College London. She is also a Consultant Clinical psychologist, Head of the IMPART personality disorder service, and Clinical Lead for personality disorder for North East London Mental Health Trust. Conflicts of interest: Janet Feigenbaum is a member of the UK DBT training team.
PSYCHIATRY 7:3
Affective dysregulation
Source: Swales M, Heard HL, Williams JGM. Linehan’s dialectical behaviour therapy for borderline personality disorder: overview and adaptation. J Ment Health 2000; 9: 7–23.12
Table 1
112
© 2008 Elsevier Ltd. All rights reserved.
Treatment approaches
Emotional dysregulation reduces the effectiveness of cogni tive processing systems leading to difficulties with problem solv ing, poor access to memories for previous coping strategies, and limited capacity to consider the consequences of actions. The problematic (risk) behaviours displayed by individuals with BPD are both the consequences of and a means of coping with painful emotional states. Thus a primary focus of DBT is on recognizing, accepting, and moderating emotional responses.
The dialectical behavioural therapy programme DBT is a treatment that incorporates five functions (Table 2),2,3,12 which are delivered across a number of therapeutic modalities. Dialectical behavioural therapy modes Skills training group: developing new capabilities – the skills training group is designed to enhance the capabilities of the client. The format is psychoeducational, structured for the learning and rehearsal of new skills. The skills training group is divided into four modules: mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance. Individual therapy sessions: enhancing client capability and motivation – all clients in DBT receive 60–90 minutes a week of individual therapy. The function of individual therapy is to relate the skills learnt to the specific goals and targets of the client. The individual sessions have a clear structure and focus.
The role of invalidating environments Invalidating environments prevent children from developing an understanding of their emotional experiences, a means of com municating these experiences, and the means to manage or mod ify these experiences. The individual is left with a complex and intense emotional internal world, in which they have no skills to understand or manage their experiences. This may result in poor self-efficacy, dependency, or excessive help-seeking behaviour. The clearest example of an invalidating environment is child hood abuse, present in the histories of about 66–75% of patients with BPD,10 leading to beliefs of impending abandonment, vigi lance for rejection, and disillusionment. Expectation of abandon ment may lead to the testing of boundaries and relationships. Invalidating environments often lead to self-invalidation or avoid ance of one’s own emotional experiences, which further reduces one’s capacity to identify and modulate emotional experiences.
The five essential functions that must be provided by an adherent dialectical behaviour therapy programme Function one • To enhance the capabilities of the client, through the teaching of new skills or the activation of existing skills not used effectively
Principles of dialectical behavioural therapy DBT conceives of BPD as a combination of specific deficits of psy chological function and distorted motivations. The model assumes that: individuals with BPD lack key interpersonal, self-regulation (including emotional regulation), and distress tolerance skills; and personal and environmental factors may frequently block and/or inhibit the use of behavioural skills, and at other times reinforce maladaptive actions. DBT aims to offer a range of change-enhancing strategies combined with motivation-focused interventions. DBT incorporates both dialectical and Zen principles to enhance the capacity of the individual, and their therapist, to enact change.
Function two • To improve motivation to use these new skills in a range of settings. When emotionally aroused, newly learnt, or rarely used, skills may be forgotten while over-learnt (dysfunctional) patterns of behaviour are used Function three • To ensure that the new skills can be used in a range of settings and experiences. During therapy, skills are most often taught and learnt through discussion, modelling, role play, and rehearsal with a therapist or in a group. The skills are learnt in a particular setting when emotional arousal is likely to be controlled and the use of the skill feels ‘safe’ to the client. During learning of the new skill the therapist or group provide useful and supportive feedback on the use of the skill. However, the individual must be able to use the skill when highly emotionally aroused, when faced with a social context that may be resistant to the use of the skill, or in which a creative variation of the skill must be used to be effective
Dialectical principles: there are three main tenets of dialectics: the interconnectedness of the world; that truth can be found as a synthesis of differing views; and change is inevitable and constant. First, the concept of interconnectedness emphasizes the importance of taking a ‘whole systems’ approach. Second, individual reality comprises opposing forces, a thesis and antithesis, which are not static. The resolution of these tensions is found in synthesis, which in itself may create further dialectical tensions. The main dialectic in DBT is the synthesis between acceptance and change.
Function four • To provide a structure to the environment that supports both the client and the therapist in the development and use of new skills or capabilities
Mindfulness: derived from Zen spiritual practices, mindfulness is regarded as a core skill in DBT.11 Mindfulness involves increasing awareness of self and context. Mindfulness in DBT incorporates the ability to take a non-judgemental stance, to focus on one thing in the moment, and to identify what is effective – ‘doing what works’. Mindfulness facilitates ‘wise mind’ states, in which the individual is able to find a synthesis between emotional experience and logi cal thought. It is through the ability to mindfully attend to one’s current emotional state, identify the associated, often unhelpful, cognitions, and the actions and reactions of self and others, that solutions can be effectively generated and applied.
PSYCHIATRY 7:3
Function five • To provide a means of enhancing the therapist’s own skills and motivation to continue to work with the client effectively and safely through continued development of skills, monitoring of stress and burn-out, and identifying the client’s efforts to shape or modify the therapist’s behaviour Table 2
113
© 2008 Elsevier Ltd. All rights reserved.
Treatment approaches
Strategies to increase commitment to therapy – securing com mitment to treatment is critical. Strategies include: a collaborative assessment; treatment contracts; an emphasis on motivational strategies; dialectically informed commitment strategies (e.g. devil’s advocate); validation (acceptance); and the use of metaphors, which are less threatening and confrontational for the client. Problem-solving strategies (change strategies) – the main problem-solving strategy used in DBT is the behavioural chain analysis used to identify, in great detail, the affective, cognitive, behavioural, interpersonal and environmental triggers that led up to the target behaviour and the reinforcing consequences of the event. A solution analysis is generated, drawing upon existing functional skills and suggesting new skills, and skills rehearsed. Obstacles to implementing the solutions are resolved. Validation strategies (acceptance strategies) (Table 3) are used in DBT to: balance change strategies; help the client learn to validate themselves; and strengthen the therapeutic relationship. They are also used as a form of feedback.13 Dialectical strategies – in addition to identifying dialectical tensions as they arise and facilitating a synthesis, the DBT thera pist will use dialectical strategies to promote a shared view with the client. This includes creating a balance between acceptance and change, nurturance and challenge, flexibility and stability. The most commonly known dialectical strategies include: dev il’s advocate, ‘making lemonade out of lemons’, and use of metaphor.2
Behavioural chain analyses relating to the targets of the ses sion are conducted, and a solution analysis generated. Relevant skills identified in the solution analysis are rehearsed. Addition ally during the individual session, the therapist and client will identify and address commitment to therapy and motivation to change as problems arise. Telephone consultation: increasing generalization – in the original DBT programme,2 telephone consultation was used as an immediate and powerful means of generalization. The pur pose of these brief telephone consultations is to assist the client in identifying an appropriate skill and to overcome obstacles to using the skill effectively. There are a number of other means of generalization to the environment including: flashcards; audio/ video tapes; teaching the skills to family members or friends; or training out-of-hours staff to provide skills generalization. Case management: structuring the environment – structuring the environment can be provided through the care programme approach, meetings with family members, or in vivo coaching. The aim is to provide opportunities to use new skills and create an environment that recognizes, facilitates, and reinforces their effective use. Consultation meeting: enhancing therapists’ skills and motivation – the DBT team consultation meeting has two components: case discussion (supervision) and therapist skills development. Case discussion aims to ensure that a dialectical stance is taken, and that the therapist is adhering to the main strategies and tech niques of DBT. The therapist’s motivation is also addressed.
The evidence base The first randomized control trial compared DBT with treat ment as usual across a period of one year of treatment.1 DBT
Stages and targets: DBT is a staged psychological treatment.2,12 Pre-commitment – during the pre-commitment phase the therapist explains the treatment model, shares an understanding as derived from the assessment and the biopsychosocial model, and orients the client to the expectations of therapy. The client must commit to reducing self-harming behaviours, to work on interpersonal difficulties that may interfere with the process of therapy, and to developing new skills. The therapist adopts a ‘dialectical’ stance, highlighting both the need for and the dif ficulties with change. Stage one – the initial focus of therapy is on the development of new behavioural skills to reduce immediate life-threatening behaviours and difficulties that interfere with the client’s ability to attend therapy. When life-threatening and therapy-interfering behaviours have ceased, quality-of-life behaviours can then be addressed, including substance misuse and Axis I disorders. Stage two – the goal of stage two is to increase the individual’s ability to experience a full range of emotions and to reduce posttraumatic stress disorder symptoms. This will include exposure to traumatic memories and emotional processing of past, often abusive, experiences. The rationale is that the client will need the emotional and behavioural skills learnt in stage one to manage the emotional intensity of stage two and resolve the trauma effectively and safely.
The six levels of validation Description
Notes
1
Listening and observing Accurate reflection
Maintaining an attentive and interested stance Providing accurate summaries of expressed experiences Communicating what the client may be thinking or feeling but which has not been stated, thus indicating to the client that the therapist is actively involved in the client’s experiences Helping the client to make sense of their actions, or reactions, in terms of past experiences and biological predisposition Acknowledging that at ‘that moment in time’ the response of the client was understandable given their history, their existing skills, and the environmental context Treating the client as capable, effective, and reasonable, not fragile
2
Strategies in dialectical behavioural therapy: DBT uses the fundamental strategies of cognitive–behavioural therapy, includ ing behavioural analysis, exposure, contingency management, and cognitive restructuring. A number of additional and unique strategies are woven into the treatment to enhance the efficacy. DBT provides a framework in which the therapist selects thera peutic techniques based on the current target.
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Level
3
Articulating the unverbalized
4
Validating in terms of past events
5
Validation in terms of current circumstances
6
Radical genuineness
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clients showed a reduction in frequency and medical sever ity of parasuicidal behaviours, a reduction in bed days, and increased retention in treatment; sustained at 6 and 12 months’ follow-up.14 In addition, reductions in anger and improvements in social functioning were shown.15 A replication trial16 com pared DBT with treatment as usual for women veterans with BPD (with low incidents of parasuicidal behaviour) and found a reduction in suicidal ideation, anger expression, hopelessness, and depression. A later replication, conducted in the Nether lands, compared women with BPD with and without substance abuse on DBT and treatment as usual. DBT was associated with greater treatment retention, reduced self-harm, and a reduction in impulsive behaviours17; all retained at a 6-month follow-up.18 Recently, Linehan and colleagues19 compared DBT with treat ment by experts, and found DBT to be associated with less fre quent and less severe suicide attempts, reduced use of crisis services, fewer inpatient admissions, and better retention in therapy. Linehan and colleagues recognized the high rates of comorbid substance abuse in this population and modified DBT (DBT-S) to increase efficacy for this population. The first trial20 compared DBT-S to treatment as usual and found a reduction in substance abuse and greater retention in therapy after 1 year. The second trial21 compared DBT-S with comprehensive validation therapy plus 12-step (CVT+12S) and found that both groups reduced their opioid use. The CVT+12S group showed greater retention in therapy but more relapse in the last 4 months of treatment compared with DBT-S. The authors suggested that validation is an important ingredient in treatment retention and success, but that this fosters dependence on the therapy, which may require more than 1 year of treatment to resolve. Further extensions to DBT have been evaluated, including therapy for inpatient settings22; binge eating disorder23; secure settings24; chronic depression in older adults25,26; and suicidal adolescents.27
5 American Psychiatric Association. Treating borderline personality disorder: a quick reference guide. Washington, DC: American Psychiatric Association, 2004. 6 National Institute for Mental Health for England 2003. Personality disorder: no longer a diagnosis of exclusion. London: National Institute for Mental Health for England, 2003. 7 Zanarini M. Childhood experiences associated with the development of borderline personality disorder. Psychiatr Clin North Am 2000; 23: 89–102. 8 Silk KR. Borderline personality disorder: overview of biologic factors. Psychiatr Clin North Am 2000; 23: 61–75. 9 Paris J. Childhood precursors of borderline personality disorder. Psychiatr Clin North Am 2000; 23: 77–88. 10 Zanarini MC, Frankenburg FR, Reich DB, et al. Biparental failure in the childhood experiences of borderline patients. J Personal Disord 2000; 14: 264–73. 11 Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clinical Psychology Science and Practice 2003; 10: 144–56. 12 Swales M, Heard HL, Williams JGM. Linehan’s dialectical behaviour therapy for borderline personality disorder: overview and adaptation. J Ment Health 2000; 9: 7–23. 13 Linehan MM. Validation and psychotherapy. In: Greenberg LS, Bohart AC, eds. Empathy reconsidered: new directions in psychotherapy, Washington, DC: American Psychological Association, 1997. 14 Linehan MM, Heard HL, Armstrong HE. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Arch Gen Psychiatry 1993; 50: 971–4. 15 Linehan MM, Tutek DA, Heard HL, Armstrong HE. Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. Am J Psychiatry 1994; 151: 1771–6. 16 Koons CR, Robins CJ, Tweed JL, et al. Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behav Ther 2001; 32: 371–90. 17 Verheul R, Van den Bosch LMC, Koeter MWJ, et al. Dialectical behaviour therapy for women with borderline personality disorder. Br J Psychiatry 2003; 182: 135–40. 18 Van den Bosch LMC, Koeter MWJ, Stijnen T, et al. Sustained efficacy of dialectical behaviour therapy for borderline personality disorder. Behav Res Ther 2005; 43: 1231–41. 19 Linehan M, Comtais K, Murray A, et al. Two-year randomised controlled trial and follow up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006; 63: 757–66. 20 Linehan MM, Schmidt H, Dimeff LA, Craft JC, Kanter J, Comtois KA. Dialectical behavioral therapy for patients with borderline personality disorder and drug-dependence. J Addict Dis 1999; 8: 279–92. 21 Linehan MM, Dimeff LA, Reynolds SK, et al. Dialectical behavioral therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend 2002; 67: 13–26. 22 Bohus M, Haaf B, Simms T, et al. Effectiveness of inpatient dialectical behavioural therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004; 42: 487–99. 23 Telch CF, Agras WS, Linehan MM. Dialectical behavioral therapy for binge eating disorder. J Consult Clin Psychol 2001; 69: 1061–5. 24 Low G, Jones D, Duggan C, et al. The treatment of deliberate selfharm in borderline personality disorder using dialectical behaviour
Conclusion As an integrative model of therapy DBT lends itself well to adap tations for different settings and populations, including adoles cents, older adults, and those with learning difficulties. This reduces the usual exclusion criteria applied by many therapeutic approaches. DBT is comprehensible to and can be applied by a range of professionals from different theoretical backgrounds. Despite limitations to the evidence base, DBT continues to gain support in clinical settings, to be investigated by evidence base practitioners, and is well supported by service users. ◆
References 1 Linehan MM, Armstrong HE, Suarez A, et al. Cognitive behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991; 48: 1060–4. 2 Linehan MM. Cognitive-behavioral treatment of borderline personality. New York: Guilford Press, 1993. 3 Linehan MM. Skills training manual for treating borderline personality disorder. New York: Guilford Press, 1993. 4 Feigenbaum J. DBT: an increasing evidence base. J Ment Health 2007; 16: 51–68.
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therapy: a pilot study in a high security hospital. Behav Cognit Psychother 2001; 29: 85–92. 25 Lynch T, Morse JQ, Mendelson T, Robins CJ. Dialectical behavior therapy for depressed older adults. Am J Geriatr Psychiatry 2003; 11: 33–45. 26 Lynch T, Cheavens J, Cukrowicz K, et al. Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach. Int J Geriat Psychiatry 2007; 22: 131–43. 27 Katz LY, Cox BJ, Gunasekara S, Miller AL. Feasibility of dialectical behavior therapy for suicidal adolescent inpatients. J Am Acad Child Adolesc Psychiatry 2004; 43: 276–82.
and invalidating childhood environments. The model presumes that BPD is primarily a disorder of emotional dysregulation • DBT is a team-based psychological therapy, delivering a range of functions across a number of modalities, including group and individual sessions, consultation to the client and their social network, and therapist supervision • DBT is a principle-driven therapeutic framework that incorporates the main principles of cognitive–behavioural therapy, adding principles from dialectics, mindfulness, and validation • DBT has been widely evaluated for both efficacy and effectiveness for individuals with BPD, and is a recommended treatment by both the American Psychiatric Association and the National Institute for Mental Health for England
Practice points • DBT is based on a biosocial theory that suggests that BPD arises from the transaction between biological vulnerability
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