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| Dialectical Behavior Therapy at a Glance |
| In
the late 1970s, Marsha M. Linehan (1993) attempted
to apply standard Cognitive Behavior Therapy (CBT) to the
problems of adult women with histories of chronic suicide
attempts, suicidal ideation, urges to self-harm, and
self-mutilation. Trained as a behaviorist, she was
interested in treating discrete behaviors; however,
through consultation with colleagues, she concluded
that she was treating women who met criteria for Borderline
Personality Disorder (BPD). In the late 1970s, CBT
had gained prominence as an effective psychotherapy
for a range of serious problems. Linehan was keenly
interested in investigating whether or not it would
prove helpful for individuals whose suicidality was
in response to extremely painful problems. As she and
her research team applied standard CBT, they encountered
numerous problems with its use. Three were particularly
troublesome: |
| 1. |
Clients receiving CBT found
the unrelenting focus on change inherent to CBT invalidating.
Clients responded by withdrawing from treatment, by
becoming angry, or by vacillating between the two.
This resulted in a high drop out rate. And, obviously,
if clients do not attend treatment, they cannot benefit
from treatment. |
| 2. |
Clients unintentionally
positively reinforced their therapists for ineffective
treatment while punishing their therapists for effective
therapy. In other words, therapists were unwittingly
under the control of consequences outside their awareness,
just as all humans are. For example, the research team
noticed through its review of audio taped sessions
that therapists would “back off” pushing
for change of behavior when the client’s response
was one of anger, or emotional withdrawal, or shame,
or threatened self-harm. Similarly, clients would reward
the therapist with interpersonal warmth or engagement
if the therapist allowed them to change the topic of
the session from one they didn’t want to discuss
to one they did want to discuss. |
| 3. |
The sheer volume and severity
of problems presented by clients made it impossible
to use the standard CBT format. Individual therapists
simply did not have time to both address the problems
presented by clients – suicide attempts, urges
to self-harm, urges to quit treatment, noncompliance
with homework assignments, untreated depression, anxiety
disorders, etc, -- AND have session time devoted to
helping the client learn and apply more adaptive skills. |
| Adding
Validation and Dialectics to CBT. In response to these key problems
with standard CBT, Linehan and her research team made
significant modifications to standard CBT. They added
in new types of strategies and reformulated the structure
of the treatment (see below, next section). In the
case of new strategies, Acceptance-based interventions,
frequently referred to as validation strategies, were
added. Adding these communicated to the clients that
they were both acceptable as they were and that their
behaviors, including those that were self-harming,
made real sense in some way. Further, therapists learned
to highlight for clients when their thoughts, feelings,
and behaviors were “perfectly normal”,
helping clients discover that they had sound judgment
and that they were capable of learning how and when
to trust themselves. The new emphasis on acceptance
did not occur to the exclusion of the emphasis on change:
Clients also must change if they want to build a life
worth living. Thus, the focus on acceptance did not
occur to the exclusion of change based strategies;
rather, the two enhanced the use of one another. In
the course of weaving in acceptance with change, Linehan
noticed that a third set of strategies –Dialectics
--came into play. Dialectical strategies gave the therapist
a means to balance acceptance and change in each session
and served to prevent both therapist and client from
becoming stuck in the rigid thoughts, feelings, and
behaviors that can occur when emotions run high, as
they often do in the treatment of clients diagnosed
with BPD. Dialectical strategies and a dialectical
world view, with its emphasis on holism and synthesis,
enable the therapist to blend acceptance and change
in a manner that results in movement, speed, and flow
in individual sessions and across the entire treatment.
This counters the tendency, found in treatment with
clients diagnosed with BPD, to become mired in arguments,
polarizing positions, and extreme positions. Thus,
these three sets of strategies and the theories on
which they are based from are the three foundations
of DBT. |
| Restructuring
the Treatment. As noted above, very significant changes
were also made to the structure of treatment in order
to solve the problems encountered in the application
of standard CBT. Below we discuss how DBT treatment
is organized by Functions and Modes and by Stages and
Targets. The treatment we are describing is the treatment
that is considered to be Standard and Comprehensive
DBT. It is the form of DBT that has been subject to
the most rigorous research in terms of randomized controlled
trials (RCTs). The variations of DBT that differ from
the structure described below is being researched but
has not yet been subjected to as rigorous a test as
standard DBT. Thus, the reader should keep in mind
that this is how comprehensive DBT is defined and that
variations from this structure are not considered comprehensive
or standard. |
| Functions
and Modes. Briefly, Linehan (1993) hypothesizes that any
comprehensive psychotherapy must meet five critical
functions. The therapy must: a) enhance and maintain
the client’s motivation to change; b) enhance
the client’s capabilities; c) ensure that the
client’s new capabilities are generalized to
all relevant environments; d) enhance the therapist’s
motivation to treat clients while also enhancing the
therapist’s capabilities; and, e) structure the
environment so that treatment can take place. Due to
space considerations, we will not review every possible
mode (method) that can meet these functions. Rather,
we offer the most common examples of how these functions
are met in standard outpatient DBT. It is typically
the individual therapist who maintains the client’s
motivation for treatment, since the individual therapist
is the most salient individual for the client. Skills
are acquired, strengthened, and generalized through
the combination of skills groups, phone coaching (clients
are instructed to call therapists for coaching prior
to engaging in self harm), in vivo coaching, and homework
assignments. Therapists’ capabilities are enhanced
and burnout prevented through weekly consultation team
meetings. The consultation team helps the therapist
stay balanced in his or her approach to the client,
while supporting and cheerleading the therapist in
applying effective interventions. (In DBT, a therapist
is not considered to be meeting the requirements of
the treatment unless he or she meets weekly in a DBT
consultation team). Finally, the environment can be
structured in a variety of ways, say by the client
and therapist meeting with family members to ensure
that the client is not being reinforced for maladaptive
behaviors or punished for effective behaviors in the
home. |
| Stages
and Targets. DBT also organizes treatment into stages and
targets and, with very few exceptions, adheres strictly
to the order in which problems are addressed. The organization
of the treatment into stages and targets prevents DBT
being a treatment that, week after week, addresses
the crisis of the moment. Further, it has a logical
progression that first addresses behaviors that could
lead to the client’s death, then behaviors that
could lead to premature termination, to behaviors that
destroy the quality of life, to the need for alternative
skills. In other words, the first goal is to insure
the client stays alive, so that the second goal (staying
in therapy), results in meeting the third goal (building
a better quality of life), partly through the acquisition
of new behaviors (skills). In short, we have just described
the targets found in Stage I. To repeat, the first
stage of treatment focuses, in order, on decreasing
life threatening behaviors, behaviors that interfere
with therapy, quality of life threatening behaviors
and increasing skills that will replace ineffective
coping behaviors. The goal of Stage I DBT is for the
client to move from behavioral dyscontrol to behavioral
control so that there is a normal life expectancy.
In Stage II, DBT addresses the client’s inhibited
emotional experiencing. It is thought that the client’s
behavior is now under control but the client is suffering “in
silence”. The goal of Stage II is to help the
client move from a state of quiet desperation to one
of full emotional experiencing. This is the stage in
which post-traumatic stress disorder (PTSD) would be
treated. Stage III DBT focuses on problems in living,
with the goal being that the client has a life of ordinary
happiness and unhappiness. Linehan has posited a Stage
IV specifically for those clients for whom a life of
ordinary happiness and unhappiness fails to meet a
further goal of spiritual fulfillment or a sense of
connectedness of a greater whole. In this stage, the
goal of treatment is for the client to move from a
sense of incompleteness towards a life that involves
an ongoing capacity for experiences of joy and freedom. |
| Research on
DBT |
| Two randomized
controlled trials (RCTs) of DBT, supported by grants
from the National Institute of Mental Health and the
National Institute of Drug Abuse, have indicated that
DBT is more effective than Treatment-As-Usual (TAU)
in treatment of BPD and treatment of BPD and co-morbid
diagnosis of substance abuse (Linehan, Armstrong, Suarez,
Allmon & Heard, 1991; Linehan, Schmidt, Dimeff,
Craft, Kanter & Comtois, 1999). Clients receiving
DBT, compared to TAU, were significantly less likely
to drop out of therapy, were significantly less likely
to engage in parasuicide, reported significantly fewer
parasuicial behaviors and, when engaging in parasuicidal
behaviors, had less medically severe behaviors. Further,
clients receiving DBT were less likely to be hospitalized,
had fewer days in hospital, and had higher scores on
global and social adjustment. Likewise, in the RCT
conducted on DBT for women with co-morbid substance
abuse, in addition to similar findings to the original
study regarding improvement in BPD criterion behaviors,
DBT was more effective than TAU at reducing drug abuse.
Follow up indicated that subjects who had received
DBT also had greater gains in global and social adjustment.
DBT has also been the subject of RCTs conducted independently
of Linehan’s research clinic at the University
of Washington. Koons, Robins, Tweed & Lynch (2001)
randomly assigned 20 women veterans diagnosed with
BPD to either DBT or TAU. Unlike Linehan’s, et
al. (1991, 1993) original studies, subjects were not
required to have a recent history of parasuicide. However,
subjects enrolled in DBT showed statistically significant
reductions in suicidal ideation, depression, hopelessness,
and anger compared to subjects enrolled in TAU. Verheul,
Van Den Bosch, Koeter, De Ridder, Stijnen & Van
Den Brink (2003) conducted an RCT in the Netherlands,
again comparing DBT to TAU. Their findings are consistent
with the earlier studies: Subjects enrolled in DBT
had greater treatment retention, reduced suicidality,
reduced episodes of self harm and self-mutilation.
DBT continues to be the subject of randomized controlled
trials. At present, Linehan (personal communication,
2003) is completing a randomized controlled trial of
DBT v. Treatment- By-Community-Expert (TBCE). Other studies are
ongoing regarding the use of DBT with eating disorders,
DBT with BPD and co-morbid substance abuse, as well
as the utility of DBT in other than outpatient settings. |
| References |
| Allmon, D.,
Armstrong, H. E., Heard, H. L., Linehan, M. M., &.Suarez,
A. (1991). Cognitive-Behavioral Treatment of Chronically
Parasuicidal Borderline Patients. Archives of General
Psychiatry, 48, 1060-1064. |
| Koons, C. R.,
Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez,
A. M., Morse, J. Q., Bishop, G. K., Butterfield, M.
I., & Bastian, L. A. (2001). Efficacy of Dialectical
Behavior Therapy in Women Veterans with Borderline
Personality Disorder. Behavior Therapy, 32, 371-390. |
| Linehan, M.
M. (1993). Cognitive Behavioral Treatment of Borderline
Personality Disorder. New York: Guilford Press. |
| Linehan, M.
M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft,
J. C., Comtois, K. A., & Recknor, K. L. (1999).
Dialectical Behavior Therapy for Patients with Borderline
Personality Disorder and Drug-Dependence. American
Journal on Addiction, 8, 279-292. |
| Verheul, R.,
Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder,
M. A. J. , Stijnen, T., & Van Den Brink, W. (2003).
Dialectical Behaviour Therapy for Women with Borderline
Personality Disorder, 12-month, Randomised Clinical
Trial in The Netherlands. British Journal of Psychiatry,
182, 135-140. |
|
