DIALECTICAL BEHAVIOR

THERAPY
-Dr. Charanteja Koganti
-C/P Dr. Aruna

Dialectical behavior therapy (DBT) :

It is :
a multicomponent,
cognitive-behavioral psychotherapy
intended for complex, difficult-to-treat
patients.
Originally developed to treat the seriously
and chronically suicidal patient .

Dialectic :
a method of examining and discussing
opposing ideas in order to find the truth.

DBT has evolved into a treatment for

suicidal patients who also meet criteria for
borderline personality disorder (BPD).
It has adapted for BPD patients with
presenting problems other than suicidal
behaviors and for other disorders of emotion
regulation.
Treatment is based on a unique blend of
behavioral psychology principles used to
promote change, and Eastern mindfulness
principles used to promote acceptance.

INTRODUCTION AND OVERVIEW

Marsha Linehan and her research team at

the University of Washington developed
DBT .
during the 1980s ,
as a treatment for the chronically suicidal
patient who had a pattern of both suicide
attempts and/or nonsuicidal self-injurious
behaviors (i.e., parasuicidal behavior).

DBT was soon extended to treat

individuals meeting criteria for borderline
personality disorder (BPD), a disorder
often characterized by parasuicidal
behaviors.
DBT has since been standardized in
Linehans 1993 treatment manuals, and
evaluated in randomized clinical trials.

The data suggest that it is more effective

than usual psychotherapies offered in the
community for treating women with BPD
with primary presenting problems of
suicidal behavior and substance abuse.

It is also adapted to the treatment of

A.eating disorders and
B.dissociative disorders, and to families
and adolescents.

DBT is rooted in standard cognitive and

behavioral protocols, and it remains, first
and foremost, a problem- solving,
behavior therapy approach.

Functions:
(1) enhance patient motivation;
(2) enhance patient capabilities;
(3) ensure that new capabilities generalize
to the patients natural environment;
(4) enhance therapist capabilities and
motivation to treat patients effectively; and
(5) structure the environment in a manner
that will promote and reinforce patient and
therapist capabilities.

DBT in its standard formatan outpatient

treatment program with four
components:
1. individual psychotherapy to address
motivational enhancement and skills
strengthening (most often weekly, onehour sessions);

2. highly structured group skills training to

enhance capabilities (weekly for 21/2
hours);
3. phone consultation with the individual
therapist to address application of new
capabilities;

4. a consultation meeting for DBT

treatment providers intended to keep
therapists motivated and to ensure that
they are providing effective treatment
consistent with the DBT approach (most
often once weekly for 60 to 90 minutes).

Function 1:

Pts commit to 12 months of psychoeducation skills

training.
Function 2:
Each pts has an individual therapist.
Function 3:
Generalization is promoted by telephone or in vivo sessions.
Function 4:
DBT therapists provide weekly supervision to other DBT
therapists.
Function 5:
Structure the environment via family, school and other
consultations.

DBT in its functions allows for flexibility in

how the treatment is delivered.
DBT can be applied in any mode as long
as the five treatment functions are
addressed.

Standard DBT Has a Dialectical

Worldview

DBT is based on dialectical philosophy.

Assumes opposing internal forces in
continuous flux
This entails multiple tensions and
motives
Pts are taught to accept this condition
Explores contradictory emotions,
cognitions, and behavior patterns.
Attempts to find middle ground.

Therapist uses dialectics in two ways:

1) Attempts to maintain a collaborative

therapeutic relationship by balancing:
change & acceptance
flexibility & stability
challenging & nurturing

2) Teaches and models dialectical

thinking and behavior by:
Highlighting contradictions in pts behavior
and thinking.

By offering opposite or alternative

positions.
By maintaining that truth is not absolute
but is constructed and evolves over time.
Attempts to find synthesis of oppositions .

Linehans Theory of the

Emotionally Vulnerableof
Person
Development
BPD

Based on a bio-social theory of BPD.

Parasuicidal behaviors are seen as:

Failures to self-regulate and
Dysfunctional attempts to regulate
The behaviors of others.
Painful affective states.

Valuable clinical features of this theory are:

1) It avoids blaming the victim
2) It facilitates psychoeducation by identifying
inadequate learning experiences.
3) It helps pts acquire skills
to modulate extreme emotions,
to reduce emotional vulnerability
to reduce maladaptive mood-dependent
behaviors
to validate their own thoughts, feelings, and
behaviors.

The Dialectical Dilemma of

Persons with BPD

Emotional vulnerability vs.self

invalidation

Inappropriate blame of other

vs. In appropriate blame of
self.

Inhibited grieving vs.

Unrelenting crisis.

Active passivity vs. Apparent

competence.

Dilemma
Emotional Vulnerability vs. SelfInvalidation
Treatment Target
Increasing emotional modulation.
Decreasing emotional reactivity.
Increasing self-validation.
Decreasing self-invalidation.

Dilemma
Active Passivity vs. Apparent Competence
Treatment Target
Increasing active problem solving.
Decreasing active passivity.
Increasing accurate communication.
Decreasing mood dependency of
behavior.

Dilemma
Unrelenting Crisis vs. Inhibited Grieving
Treatment Target
Increasing realistic decision making and
judgment.
Decreasing crisis generating behaviors.
Increasing emotional experiencing.
Decreasing inhibited grieving.

Therapists Working
Assumptions about the Client
1)

2)

3)

4)

The client wants to change, and despite

appearances, is trying his/her best as a particular
time.
His/Her behavior pattern is understandable given
his/her background and present circumstances.
In spite of this, he/she needs to try harder if
things are to improve.
Clients can not fail at DBT.

Clients and Therapists

Agreements

To work in therapy for a specified period of

time, and to attend the majority of therapy
session.

If suicidal or para-suicidal behaviors are

present, he/she must agree to work on
reducing these.

To work on therapy interfering behaviors.

To attend skills training.

Modes of Treatment
1.

Individual therapy,

2.

Group skills training.

3.

Telephone contact.

4.

Therapist consultation.

Skills Training
1.

Core mindfulness skills.

2.

Interpersonal effectiveness.

3.

Emotion modulation skills.

4.

Distress tolerance skills.

Individual Therapy

Stages of therapy.

Hierarchy of therapy targets.

Treatment strategies.

Hierarchy of Therapy Targets

Decreasing suicidal behaviors.

Decreasing therapy interfering behaviors.

Decreasing behaviors that interfere with quality of life.

Increasing behavioral skills.

Decreasing behaviors related to post-traumatic stress.

Improving self-esteem.

Individual targets negotiated with the client.

Treatment Strategies

Treatment strategies in DBT are divided

into four sets:
(1) Dialectical strategies,
(2) core strategies (problemsolving and
validation),

(3) communication strategies

(irreverence and reciprocal
communication), and
(4) case management strategies
(consultation to the patient,
environmental Intervention, and
supervision/consultation with therapists).

1. Dialectical Strategies
Dialectical strategies are woven
throughout all treatment interactions.
The most fundamental dialectical
strategy is the balanced therapeutic
stancethe constant attention to
combining acceptance with change.
The goal is to bring out the opposites,
both in therapy and the clients life, and
to provide conditions for synthesis.

Strategies include
-extensive use of stories, metaphor, and
paradox;
- the therapeutic use of ambiguity;
-viewing therapy,
-cognitive challenging ,
-restructuring techniques; and
- reinforcement for use of intuitive,
nonrational knowledge bases.

2. Core Strategies
Core strategies consist of the balanced
application of problem-solving and
validation strategies.
Included are a wide variety of behavioral
assessment and behavioral therapy
techniques that are used to directly
target maladaptive behaviors.

Problem solving is a two-stage process :

1. an analysis and acceptance of the
current problem, and
2. an attempt to generate, evaluate, and
implement alternative solutions that
might have been made or could be made
in the future in similar problematic
situations.

Analysis of the clients problem

behaviors, including
dysfunctional actions,
emotions,
physiological responses, and
thought processes,
requires careful scrutiny of the chains of
events leading up to the problematic
responses.

This analysis was described earlier and is

repeated for every instance of targeted
problem behaviors until both therapist
and client achieve an understanding of
the response patterns involved.

The second stage, which is actually

interwoven with the first, requires
-the generation of new, more skillful
responses,
- an analysis of the individuals
capabilities and motivation to actually
engage in the new behaviors.

This process leads into application of change

procedures---- drawn primarily from
cognitive-behavior therapy protocols and
anchor the change end of the primary dialectic
in DBT.
They include:
management of contingencies in the
therapeutic relationship,
training in behavioral skills,
exposure techniques with response
prevention, and
cognitive restructuring.

For hierarchy purposes, validation can be

conceptualized in six levels.
1, 2,3 :The first three levels are basic
therapeutic strategies for building and
maintaining rapport.
4,5,6: The second three focus on
communicating accurately the valid and
invalid nature of the patients behavior and
emotional responses.

Level 1 validation

It involves
1. listening to and observing what the client is
saying, feeling, and doing .
2.an active effort to understand and make
sense of what is being observed.

T he therapist is demonstrating interest in the

client and notices the nuances of both verbal
and nonverbal response in the interaction.

Level 2 validation

It is the accurate reflection, paraphrasing,

and summarizing of the clients thoughts,
feelings, and behaviors.

At Level 2, validating statements remain

relatively close to what the client said
rather than adding to the clients
communication.

Level 3 validation

It refers to articulating or mind-reading

that which is unstated, such as fears of
admitting emotions or thoughts, but
without pushing the interpretation on the
client.

The therapist conveys an intuitive

understanding of the client; sometimes
knowing clients better than they know
themselves.

Level 4 validation

The therapist validates the clients

experience in terms of past learning or in
terms of biological dysfunction .

Ex: during a first therapy session, a therapist

might validate the clients fears that the
therapist will be rejecting by saying, It
makes sense that you would have such
concerns, given that you have been rejected
by many important people in your life.

Level 5 validation

It involves validating the client in terms

of present and normal functioning.

Ex: In the above situation, a therapist

might respond, Of course you are
concerned about me rejecting you; after
all, this is our first therapy session and
you really dont know what to expect.

Level 6 validation

This calls for the therapist to show radical

genuineness with clients.
The therapist must treat the clienttherapist
relationship as authentic and real, wherein
the therapist behaves as his/her natural self
rather than acting in a role-prescribed
manner.
This involves not treating the client as fragile
or as unable to solve problems, but rather as
a person of equal status who is capable of
effective and reasonable behavior.

3. Communication Strategies

In DBT, the therapist balances two

communication strategies, which
represent different interpersonal styles.
Reciprocal strategy : includes
A. responsiveness to the clients agenda
and wishes, warmth, and
B. self-disclosure of personal information
that might be useful to the client as-well
as immediate reactions to the clients
behavior.

Reciprocity is balanced by an irreverent

communication style that is used to promote
change:
a matter-offact or
at times slightly outrageous or humorous
attitude
the therapist takes the clients underlying
assumptions or unnoticed implications of the
clients behavior ---- maximizes or minimizes
them---- in either an unemotional or
overemotional manner to make a point the
client might not have considered before.

Irreverence jumps track, so to speak,

from the clients current pattern of
response, thought, or emotion.
Ex: if a client says I am going to kill
myself!, the therapist might respond,
But I thought you agreed not to drop out
of therapy!

It is important that irreverence is

balanced with reciprocity.
Overuse of irreverence may alienate the
patient, while too much reciprocal
communication will result in minimal
change.

4. Case Management Strategies

There are three strategies designed to

guide each therapist during interactions
with individuals outside the therapy dyad.
1. The consultant-to-the-client strategy :
It is the application of the principle that
the DBT therapist teaches the client how
to interact effectively with the clients
environment rather than teaching the
environment how to interact with the
client.

2. The environmental intervention

strategy:
He or she actively intervenes in the
environment to protect the client or to
modify situations that the client does not
have the power to influence.

3.The consultation-to-the-therapist
strategy:
Each DBT therapist meet regularly with a
supervisor or consultation team.

The idea here is that complex, multidisordered clients should not be treated
alone.

Future research:

To address the following questions:

(1) Which components of DBT (e.g., specific
treatment strategies) contribute to outcomes?
(2) can we / how can we improve the efficacy
of DBT through additional treatment
development?
(3) To what different populations/settings can
DBT be successfully adapted?
4) Is DBT effective in public health settings?
(5) How long does DBT maintain its gains
after treatment is over?

Thank you