05 - 28.5 Dialectical Behavior Therapy

28.5 Dialectical Behavior Therapy

Snyder DK, Whisman MA, eds. Treating Difficult Couples. New York: Guilford; 2003. Spitz HI, Spitz S. Family and couple therapy. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:2845. Walker MD. When clients want your help to “pray away the gay”: Implications for couple and family therapists. J Fem Fam Ther. 2013;25(2):112–134. 28.5 Dialectical Behavior Therapy Dialectical behavior therapy (DBT) is the psychosocial treatment that has received the most empirical support for patients with borderline personality disorder. Put simply, the overarching goal of DBT is to help create a life worth living for patients who often suffer tremendously from chronic and pervasive problems across many areas of their lives. DBT is a type of psychotherapy that was originally developed for chronically selfinjurious patients with borderline personality disorder and parasuicidal behavior. In recent years, its use has extended to other forms of mental illness. The method is eclectic, drawing on concepts derived from supportive, cognitive, and behavioral therapies. Some elements can be traced to Franz Alexander’s view of therapy as a corrective emotional experience and other elements from certain Eastern philosophical schools (e.g., Zen). Patients are seen weekly, with the goal of improving interpersonal skills and decreasing self-destructive behavior using techniques involving advice, metaphor, storytelling, and confrontation, among others. Patients with borderline personality disorder especially are helped to deal with the ambivalent feelings that are characteristic of the disorder. Marsha Linehan, Ph.D., developed the treatment method, based on her theory that such patients cannot identify emotional experiences and cannot tolerate frustration or rejection. As with other behavioral approaches, DBT assumes all behavior (including thoughts and feelings) is learned and that patients with borderline personality disorder behave in ways that reinforce or even reward their behavior, regardless of how maladaptive it is. FUNCTIONS OF DBT As described by its originator, there are five essential “functions” in treatment: (1) to enhance and expand the patient’s repertoire of skillful behavioral patterns; (2) to improve patient motivation to change by reducing reinforcement of maladaptive behavior, including dysfunctional cognition and emotion; (3) to ensure that new behavioral patterns generalize from the therapeutic to the natural environment; (4) to structure the environment so that effective behaviors, rather than dysfunctional behaviors, are reinforced; and (5) to enhance the motivation and capabilities of the therapist so that effective treatment is rendered. Figure 28.5-1 illustrates how DBT breaks the cycle of problem behavior being used to avoid emotional distress.

FIGURE 28.5-1 How dialectical behavior therapy (DBT) works. The four modes of treatment in DBT are as follows: (1) group skills training, (2) individual therapy, (3) phone consultations, and (4) consultation team. These are described below. Other ancillary treatments used are pharmacotherapy and hospitalization, when needed. Group Skills Training In group format, patients learn specific behavioral, emotional, cognitive, and interpersonal skills. Unlike traditional group therapy, observations about others in the group are discouraged. Rather, a didactic approach, using specific exercises taken from a skills training manual, is used, many of which are geared toward control emotional dysregulation and impulsive behavior. Individual Therapy Sessions in DBT are held weekly, generally for 50 to 60 minutes, in which skills learned during group training are reviewed and life events from the previous week are examined. Particular attention is paid to episodes of pathological behavioral patterns that could have been corrected if learned skills had been put into effect. Patients are

encouraged to record their thoughts, feelings, and behaviors on diary cards, which are analyzed in the session. Telephone Consultation Therapists are available for phone consultation 24 hours per day. Patients are encouraged to call when they feel themselves heading toward some crisis that might lead to injurious behavior to themselves or others. Calls are intended to be brief and usually last about 10 minutes. Consultation Team Therapists meet in weekly meetings to review their work with their patients. By doing so, they provide support for one another and maintain motivation in their work. The meetings enable them to compare techniques used and to validate those that are most effective (Table 28.5-1). Table 28.5-1 Consultation Team Agreements in Dialectical Behavior Therapy RESULTS Several studies evaluating the effect of DBT for patients with borderline personality disorder found that such therapy was positive. Patients had a low dropout rate from treatment; the incidence of parasuicidal behaviors declined; self-report of angry affect decreased; and social adjustment and work performance improved. The method is now being applied to other disorders, including substance abuse, eating disorders, schizophrenia, and posttraumatic stress disorder. REFERENCES Bedics JD, Korslund KE, Sayrs JH, McFarr LM. The observation of essential clinical strategies during an individual session of dialectical behavior therapy. Psychotherapy. 2013;50(3):454–457. Brown MZ, Comtois KA, Linehan MM. Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. J Abnorm Psychol. 2002;111:198. Hadjiosif M. From strategy to process: Validation in dialectical behaviour therapy. Counsel Psychol Rev. 2013;28(1):72–80.