Dialectical Behavior Therapy (DBT) is becoming
increasingly popular among practitioners, and research continues to suggest
that it is an effective treatment for a broad range of problems. Therapists,
treatment providers and individuals continue to seek out DBT in order to
alleviate severe and debilitating emotional and behavioral problems. There is
promising research to indicate that as an adjunct to medication management it
is an effective treatment for depression.
What Is
Dialectical Behavior Therapy?
DBT grew out of the work of Marsha Linehan, Ph.D.
Linehan, a cognitive behavioral psychologist by training, developed the theory
while working primarily with women who were suicidal and engaged in
self-harming behaviors. Initially, she approached her treatment from a strict
cognitive behavioral perspective. However, over time and with careful scrutiny
of her work, she found that cognitive behavioral techniques were deficient.
Linehan noticed that although many people improved with cognitive behavioral
techniques, too many others responded to treatment with anger or withdrawal.
She began to adapt her work in order to create a treatment method that both
helped people change problem behaviors and provided the acceptance and
validation that would reduce anger and improve treatment retention. The result
was a blend of behavioral and crisis intervention strategies with an emphasis
on acceptance and tolerance.
Today DBT is a cognitive-behavioral and acceptance-based
therapy practiced as a comprehensive intervention package aimed at reducing
high-risk and treatment-interfering behaviors. The focus of the DBT model is on
teaching the individual to:
* Modulate extreme emotions and reduce negative behaviors
that result from those emotions, and
* Trust their own emotions, thoughts, and activities.
These two goals are accomplished through multiple
treatment modalities, including skills training, individual therapy, coaching
in crisis, structuring the environment and consultation teams for providers.
Fundamentals of Dialectical Behavior Therapy
There are three
major fundamentals for the DBT Approach:
1. Cognitive Behavioral Therapy
Learning new behaviors -- which can be anything a person
thinks, feels or does -- is a crucial part of DBT. There are four main
strategies that are used to change behavior: skills training, exposure therapy,
cognitive therapy, and contingency management.
* Skills Training - Attending
skills groups, doing homework assignments and role playing new ways of
interacting with people.
* Exposure Therapy - Exposing
oneself to feelings, thoughts or situations which were previously feared and
avoided.
* Cognitive Therapy -
Recognizing and reassessing patterns of negative thoughts and replacing them
with positive thoughts that more closely reflect reality.
* Contingency Management -
Identifying how maladaptive behavior is rewarded and how adaptive behavior is
punished and using this knowledge to modify behavior in a positive way.
2. Validation
For patients with borderline personality disorder, the
process of cognitive behavioral therapy can cause a great deal of distress. The
push for change feels to them as if it invalidates the emotional pain they are
feeling. Linehan and her team found that by offering validation along with the
push for change, patients were more likely to cooperate and less likely to
suffer distress at the idea of change. The therapist validates that the
person's actions "make sense" within the context of his personal
experiences without necessarily agreeing that they are the best approach to
solving the problem.
3. Dialectics
Dialectics makes three basic assumptions:
1. All things are interconnected.
2. Change is constant and inevitable and
3. Opposites can be integrated to form a closer
approximation of the truth.
In DBT, the patient and therapist are working to resolve
the seeming contradiction between self-acceptance and change in order to bring
about positive changes in the patient.
What Conditions
Does DBT Treat?
Dialectical behavioral therapy focuses on high-risk,
tough-to-treat patients. These patients often have multiple diagnoses.
DBT was initially designed to treat people with suicidal
behavior and borderline personality disorder. But it has been adapted for other
mental health problems that threaten a person's safety, relationships, work,
and emotional well-being.
DBT is particularly effective for patients who tend to
see situations as polarized (black or white, right or wrong).
Borderline personality disorder is a disorder that leads
to acute emotional distress. Patients may have intense bursts of anger and
aggression, moods that shift rapidly, and extreme sensitivity to rejection.
People with borderline personality disorder may have
difficulty regulating emotions. They experience instability in:
* moods
* behavior
* self-image
* thinking
* relationships
Impulsive behavior, such as substance abuse, risky sex,
self-injury, and repeated life crises such as legal troubles and homelessness,
are common.
The American Psychiatric Association has endorsed DBT as
effective in treating borderline personality disorder. Patients who undergo DBT
have seen improvements such as:
* less frequent and less severe suicidal behavior
* shorter hospitalizations
* less anger
* less likely to drop out of treatment
* improved social functioning
Substance abuse is common with borderline personality
disorder. DBT helps substance abusers
with borderline personality disorder but hasn't proven effective for addiction
alone.
Researchers are claiming that DBT is effective in
treating the following conditions as well:
* mood disorders
* binge eating
* ADHD
* post-traumatic stress disorder
Though DBT originally was developed to treat quite severe
issues, described earlier, the treatment has become a widely respected method
for treating clients who exhibit the following, much milder traits and issues:
* Difficulty with emotional regulation.
* A high level of reactivity, with a slow return to
baseline.
* Impulsiveness with a tendency toward self-destructive
behaviors.
* An inclination toward extreme thinking, unable to
perceive a middle ground.
* A lack of sense of self, tending to feel incomplete or
empty.
* A history of instability in relationships, and
difficulty with interpersonal interactions.
* Extreme sensitivity, accompanied by rapid mood swings,
anxiety, and depression.
* Fears of abandonment and trouble with intimate
relationships.
Dialectical behavior therapy has proven to be a very
effective tool to help people manage intense emotions, change negative thought
patterns, and decrease self-destructive behaviors. Individual therapy sessions
focus on current detrimental behaviors in the client’s life, while group
sessions involve learning skills from the four modules: mindfulness,
interpersonal effectiveness, distress tolerance, and emotion regulation.
How Does DBT Work?
Comprehensive DBT focuses on four ways to enhance life
skills:
* Distress tolerance: Feeling intense emotions like anger
without reacting impulsively or using self-injury or substance abuse to dampen
distress.
* Emotion regulation: Recognizing, labeling, and
adjusting emotions.
* Mindfulness: Becoming more aware of self and others and
attentive to the present moment.
* Interpersonal effectiveness: Navigating conflict and
interacting assertively.
DBT offers a commonsense, multistage approach:
Stage 1: Treats the most self-destructive behavior, such
as suicide attempts or self-injury.
Stage 2: Begins to address quality-of-life skills, such
as emotional regulation, distress tolerance, and interpersonal effectiveness.
Stage 3: Focuses on improved relationships and
self-esteem.
Stage 4: Promotes more joy and relationship connection.
Patients participating in DBT take part in both individual and group sessions:
* During individual sessions, the patient and therapist
meet to discuss issues that have arisen during the previous week. Issues
are prioritized. Self-injurious behaviors take top priority, followed by
behaviors that interfere with therapy, quality of life issues and finally, life
improvement goals. The goal of individual sessions is to improve specific life
skills.
* During group sessions, several DBT patients meet to
practice different life skills in a safe, controlled environment. These
skills include recognizing and controlling emotions, tolerating distress, or
staying mindful.
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