Dialectical Behavior Therapy: (DBT) Philosophy and Applications
DBT Clientele Attributes • Unbalanced interpersonal relationships • Unstable self-image • Impulsivity • Recurring suicidal or self-harming behavior • Mood instability • Perfectionism • Attachment / abandonment issues • Borderline traits
DBT Incorporates: • Dialectics • Zen tradition • Cognitive behavioral therapy
DBT PhilosophyDialectical Worldview • Interconnectedness • Opposing forces. • Thesis – Antithesis – Synthesis – Thesis – Etc. • Walking the middle path. • Change is constant. • Example: Cutting relieves emotional pain versus health implications and dangers= Finding healthy ways to relieve emotional pain.
Choose the Dialectical Statement • People hate me / everyone thinks I am the coolest / some people enjoy being around me and others do not. • I can’t do anything right / I have strengths and things I am learning / I have it all figured out • There are things I like and dislike about others/ I hate them / They are so perfect
DBT PhilosophyZen Tradition • Mindfulness • Wide mind • Non-judgmental stance • Observing • Acceptance as a balance to change • Irreverence versus warmth • Radical acceptance • Example: Clients may not have caused all of their own problems, AND they have to solve them anyway.
DBT FilosophyCognitive Behavioral Therapy • Thoughts, feelings, behaviors. • Eliminate negative secondary gains. • Example: Crisis call to therapist after self-harming, therapist will ensure 911 is called and call will end. • Behavior skills training. • Example of Dear Man
Mindfulness Activity What Skills: How Skills: Observe: Pay attention to what is Non-Judgmentally: See and do not going on around you. 5 senses. evaluate. Do not judge your judging. Describe: Use words to say what Stay Focused: Do one thing at a time, you are observing. let go of distraction, concentrate. Participate: Enter the experience Do What Works: Act skillfully, play by fully. the rules, let go of feelings that hurt you.
Biosocial Theory of BPD • Emotional vulnerability • Invalidating environments. • Biological issues. • One cannot ignore the 75% prevalence of sexual abuse among those diagnosed with BPD.
DBT Therapy Assumptions • Clients are doing the best they can. • Clients want to improve. • Clients need to do better, try harder, and be more motivated to change. • Clients must learn new behaviors in all relevant contexts. • Clients cannot fail in DBT. • Clients may not have caused all their problems, and they have to solve them anyway. • The lives of suicidal BPD clients are unbearable as they are currently being lived.
Modes of DBTIndividual Therapy • Individual therapist is main contact. • Commitment to program and safety • Eliminate life threatening and therapy-interfering behaviors. • Improve quality of life. • PTSD treatment, application of skills, and self concept development. • Processing is to take place in individual therapy.
Modes of DBTGroup Skills Training In parallel with individual therapy – skills focus. • Core mindfulness • Interpersonal effectiveness • Emotional regulation • Distress tolerance • Walking the middle path
Interpersonal Effectiveness Activity • Validation Exercise
Modes of DBTTelephone Consultation • Individual therapist contact. • Support and assistance with skills before crisis. • Clear limits and boundaries.
Distress Tolerance Activities • Radical Acceptance • Ice • Pros and Cons of unhealthy behavior
Modes of DBTTherapist Consultation Meeting • Weekly meetings • Team acquires skills • Provides support • Integrates DBT philosophy • Plans treatment for clients.
Emotional Regulation Activity • Rope Challenge
DBT at Children’s Outpatient • 16 weeks of skills group. No more than 2 client absences. • Open ended with entry dates every 4 weeks. • Mandatory guardian and client attendance. • Staff supervision one hour weekly. • YOQ monitoring. • 2 hours of group and family/individual session weekly. • Broadened client symptomology.
References • Linehan, M. (1993a). Cognitive- behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press • Linehan, M. (1993b). Skills training manual for treating borderline personality disorder. New York, NY: The Guilford Press