Dialectical behavior therapy (DBT) is an evidence-based treatment therapy designed by Dr. Marsha Linehan to help people suffering from Borderline Personality Disorder. It has also been used to treat mood disorders as well as those who need to change patterns of behavior that are not helpful, such as self-harm, suicidal ideation, and substance abuse. This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions. DBT assumes that people are doing their best but lack the skills needed to succeed, or are influenced by positive reinforcement or negative reinforcement that interferes with their ability to function appropriately.
A modified form of cognitive behavioral therapy (CBT), DBT was developed in the late 1980s by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT is now used in a variety of psychological treatments including treatment for depression, substance use disorders, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates that DBT might have some effect on patients who present varied symptoms and behaviors associated with spectrum mood disorders, including self-injury. Recent work also suggests its effectiveness with sexual abuse survivors and chemical dependency.
DBT combines standard cognitive behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is based upon the biosocial theory and is the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.
Maps, Directions, and Place Reviews
Overview
Linehan observed "burn-out" in therapists after coping with "non-motivated" patients who repudiated cooperation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments, and, therefore, required a climate of loving-kindness and somewhat unconditional acceptance (not Rogers' positive humanist approach, but Hanh's metaphysically neutral one), in which to develop a successful therapeutic alliance. Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction.
DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the client's feelings at any given time, while, nonetheless, informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives. DBT focuses on the client acquiring new skills and changing their behaviors, with the ultimate goal of achieving a "life worth living," as defined by the patient.
Linehan and others combined a commitment to the core conditions of acceptance and change through the principle of dialectics (in which thesis + antithesis -> synthesis) and assembled an array of skills for emotional self-regulation drawn from Western psychological traditions, such as cognitive behavioral therapy and an interpersonal variant, "assertiveness training", and Eastern meditative traditions, such as Buddhist mindfulness meditation. One of her contributions was to alter the adversarial nature of the therapist-client relationship in favor of an alliance based on intersubjective tough love.
All DBT can be said to involve 4 components:
- Individual - The therapist and patient discuss issues that come up during the week (recorded on diary cards) and follow a treatment target hierarchy. Self-injurious and suicidal behaviors, or life-threatening behaviors, take first priority. Second in priority are behaviors which, while not directly harmful to self or others, interfere with the course of treatment. These behaviors are known as therapy-interfering behaviors. Third in priority are quality of life issues and working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
- Group - A group ordinarily meets once weekly for two to two and a half hours and learns to use specific skills that are broken down into four skill modules: core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.
- Therapist Consultation Team - A therapist consultation team includes all therapists providing DBT. The meeting occurs weekly and serves to support the therapist in providing the treatment.
- Phone Coaching - Phone coaching is designed to help generalize skills into the patient's daily life. Phone coaching is brief and limited to a focus on skills.
No one component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context. DBT skills training alone is being used to address treatment goals in some clinical settings.
Self Harm Treatment Centers Video
Four modules
Mindfulness
Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one's emotions and senses fully, yet with perspective. The practice of mindfulness can also be intended to make people more aware of their environments through their 5 senses: touch, smell, sight, taste, and sound.
"What" skills
"How" skills
How to do Mindful Meditation. There are many "scripted" meditations available on YouTube; for example: The 3 Minute Meditation; or The Body Scan. How to do it (The Body Scan): You listen to the body scan and you allow your mind to focus on each aspect of your physical self, usually starting at your toes and ending at the top of your head. As you listen to the body scan and allow your mind to focus in on the body, you will notice your "busy mind" will come into consciousness. You will notice that thoughts and feelings will attempt to distract you from focusing on each part of your body. You will notice that some of the thoughts and feelings may be distressing to you. You may want to stop the meditation because it might be very painful emotionally or physically or because you are having negative or busy thoughts. Sometimes memories may surface and they may also be difficult emotionally to accept. How to do Mindful Meditation involves learning to acknowledge the thoughts, feelings and memories without needing to fight them or chase them away. The paradox: If we try to fight them, they seem to get bigger; but when we move into acceptance, they seem to get smaller. We enter the mindfulness meditation body scan, 3 minute meditation or other meditation sessions with no goals and with a non-striving stance. Again, if we enter with a goal to "fix my problems by meditating", that goal and pressure to fix something tends to make the problems bigger. To enter the meditation with a non-goal/non-striving attitude, so having no expectations, paradoxically, usually results in a reduction of stress, pain and other symptoms.
Distress tolerance
Many current approaches to mental health treatment focus on changing distressing events and circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.
Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Since this is a non-judgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.
Emotion regulation
Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:
- Identify and label emotions
- Identify obstacles to changing emotions
- Reduce vulnerability to emotion mind
- Increase positive emotional events
- Increase mindfulness to current emotions
- Take opposite action
- Apply distress tolerance techniques
Story of emotion
PLEASE
Build mastery
Opposite action
Problem solving
Letting go of emotional suffering
Interpersonal effectiveness
Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.
Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing their own situation.
The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person's goals in a specific situation will be met, while at the same time not damaging either the relationship or the person's self-respect.
This list does not include the "problem solving" module, the purpose of which is to practice being one's own therapist.
Tools
Diary cards
Specially formatted cards for tracking therapy interfering behaviors that distract or hinder a patient's progress. Diary cards can be filled out daily, 2-3 times a day, or once per week.
Chain analysis
Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining. A growing body of research supports the use of behavior chain analysis with multiple populations.
Milieu
The milieu, or the culture of the group involved, plays a key role in the effectiveness of DBT.
Efficacy
Borderline personality disorder
DBT is the therapy that has been studied the most for treatment of borderline personality disorder, and there have been enough studies done to conclude that DBT is helpful in treating borderline personality disorder. A 2009 Canadian study compared the treatment of borderline personality disorder with dialectical behavior therapy against general psychiatric management. A total of 180 adults, 90 in each group, were admitted to the study and treated for an average of 41 weeks. Statistically significant decreases in suicidal events and non-suicidal self-injurious events were seen overall (48% reduction, p=0.03; and 77% reduction, p=0.01; respectively). No statistically-significant difference between groups were seen for these episodes (p=.64). Emergency department visits decreased by 67% (p<0.0001) and emergency department visits for suicidal behavior by 65% (p<0.0001), but there was also no statistically significant difference between groups.
Depression
A Duke University study of compared treatment of depression by antidepressant medication to treatment by antidepressants and dialectical behavior therapy. A total of 34 chronically depressed individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically-significant differences were noted in remission rates between groups, with a greater percentage of patients treated with antidepressants and dialectical behavior therapy in remission.
Source of the article : Wikipedia
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