DBT for Emotional Distress, Suicidal and Self-Destructing Behavior

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
* 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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