DBT in Clinical Practice Chap. 1

Dialectical Behavior Therapy in Clinical Practice

Chapter 1: Overview of DBT

• Individuals with BPD represent 14-20% of inpatients and 8-11% of outpatients (Widiger & Frances, 1989, Wildiger & Weissman, 1991)
• Treatment progress can be slow and sporadic 
• Therapists can struggle with their own emotional reactions when a client is recurrently suicidal and both rejects the help that the therapist offers and demands help that therapist cannot give
• DBT considers suicidal behavior to be a form of maladaptive problem solving and uses well-researched cognitive-behavioral therapy techniques to help clients solve life problems in more adaptive ways.  

Biosocial Theory

• Pervasive biological emotional dysregulation is hypothesized to be developed and maintained by both biological and environmental factors
• Biology- individuals are thought to be more vulnerable to difficulties regulating their emotions due to differences in the central nervous system (due to genetics, events during fetal development, or early life trauma)  
• Invalidating environments communicate that the individual's characteristic responses to events (particularly emotional responses) are incorrect, inappropriate, pathological, or not to be taken seriously.  
• By punishing communication of negative experiences and only responding to negative emotional displays when they are escalated, the environment teaches the individuals to oscillate between emotional inhibition and extreme emotional communication. 
• I found this theory valuable and could think of multiple cases in which adolescents with a working diagnosis of personality disorder NOS or BPD were raised in  environments that were not conducive to emotional expression.  Their emotional expressions were shut down, not validated, and ignored by their families, only acknowledged during explosions or suicide attempts.  
• For clients, it is difficult to know whether to blame oneself or others: either one is able to control one's own behavior (as other believe and expect) but won't, and therefore is "manipulative", or one is unable to control one's emotions, as a lifetime of experiences shows, which means that life will always be a never ending nightmare of dyscontrol.  
• When the person tries to fulfill expectations that are out of line with true capabilities, he or she may fail, feel ashamed, and decide that being punished or even being dead is what is deserved.  
• Therapist must validate the uncontrollable, helpless experience of emotional arousal

Stages, Goals, and Targets of Treatment

• Pretreatment:  client and therapist explicitly and collaboratively agree to the essential goals and methods of treatment and obtain engagement in therapy
• Stage 1- Targets: 1. Suicidal/homicidal or other imminently life-threatening behavior 2. therapy -interfering behavior by the therapist or the client 3. behavior that severely compromises the client's quality of life (eg Axis 1 problems, serious problems with relationships, legal system, employment/school, illness, and housing) 4. Deficits in behavioral capabilities needed to make life changes 
• Training to target deficits- regulate emotions, tolerate distress, respond skillfully to interpersonal situations, observe, describe, and participate without judging, with awareness and focusing on effectiveness. and manage their own behavior with strategies other than self punishment
• These skills are intended to decrease identity confusion, emptiness, and cognitive dysregulation; interpersonal effectiveness addressing interpersonal chaos and fears of abandonment; emotion regulation skills reducing labile affect and excessive anger; and distress tolerance helping to reduce impulsive behaviors, suicidal threats, and intentional injury.  
• many clients who are not out of control still experience tremendous emotional pain due to either post traumatic stress or other painful experiences that leave them alienated or isolated from meaningful connections to other people or to a vocation.  
• Stage 2- Goal: to have nontruamatizing emotional experience and connection to the environment
• Stage 3- client synthesizes what has been learned, increases his or her self-respect and an abiding sense of connection and works toward resolving problems in living. 
• Stage 4:  focuses on the sense of incompleteness that many individuals experience.  In this stage goals typically fall outside the realm of typically therapy and into a spiritual practice 
• Progress of therapy is not linear and the stages typically overlap.  Therapists must commonly revisit past stages throughout sessions
• This section was fairly straightforward but also barely touched the surface of what these stages of treatment entailed.  I wonder how is stage 2 carried out?  Does the therapist use a form of behavioral activation model focused around engaging in meaningful relationships, or formulating behavioral goals to work towards discovering a client's vocation?  Also, how does a therapist structure and carry out stage 4?  Is this stage skipped if the client is uninterested in exploring a spiritual lifestyle?  

DBT as Problem Solving

• Whenever one of the targeted problem behaviors occurs, the therapist and the client conduct an in-depth analysis of events and situational factors before, during and after that particular instance of the targeted behavior.  
• The goal of this chain analysis is to provide an accurate and reasonably complete account of the behavioral and environmental events associated with the problem behavior.  
• As the therapist and the client discuss a chain of events the therapist highlights dysfunctional behavior, focusing on emotions, and helps the client gain insight by recognizing the patterns between this and other instances of problem behavior.  Alternative responses that would have lead to positive outcomes are discussed 

Skills Training

• DBT skills training is provided on a weekly basis for approximately 2 1/2 hours.  
• Four skills training modules are taught over the course of approximately 6 months, allowing for completion of all skills, twice within a standard DBT outpatient group.  Skills include:
• Emotion regulation training teaches a range of behavioral and cognitive strategies for reducing unwanted emotional responses as well as impulsive dysfunctional behaviors that occur in the context of intense emotions by teaching clients how to identify and describe emotions, how to stop avoiding negative emotions, how to increase positive emotions, and how to change unwanted negative emotions.  
• Distress Tolerance:  teaches a number of impulse control and self-soothing techniques aimed at surviving crises without using drugs, attempting suicide, or engaging in other dysfunctional behavior.  
• Interpersonal effectiveness: teaches a variety of assertiveness skills to achieve one's objective while maintaining relationships and one's self respect.  
• Mindfulness skills: focusing attention on observing oneself or one's immediate context, describing observations, participating, assuming a non judgemental stance, focusing awareness and developing effectiveness.  

Validation

• DBT stresses communicated validation in the client's emotions, thoughts and actions.  
• A DBT therapist must search for strengths, normality, or effectiveness inherent in the client's responses whenever possible and teach the client to self validate
• Example: Cutting one's arm in response to overwhelming emotional distress is valid, given that it often produces relief from unbearable emotions.  It is also invalid:  it is not normative, it prevents developing other means of emotion regulation, it causes scars, and alienates others* (thoughts in italics below)  
• Unless the client believes that the therapist truly understands his or her dilemma and exactly how painful it is, he or she will not trust that the therapist's solutions are appropriate or adequate
• I think this aspect of DBT is very important.  I appreciate that it emphasizes the importance of validating the client's emotions and helping them feel as though they aren't "crazy" as many people label those with BPD.  I just wonder: the point in which the text mentioned the negative consequences of cutting such as "not normal, causes scars, and alienates others", are these consequences a therapist would discuss with a pt who engages in self harm behavior?  Wouldn't these negative and critical consequences shame or cause the client to feel worse about themselves?  At my placement, many of our clients harm themselves and we allow the patients to discuss in group therapy the pros and cons of cutting but we never tell a client they should not cut or that they alienate others by their self harming actions, because we do not want to further shame the client.   I also know that targeting suicidality and self harm behaviors are the first issues covered in DBT after the engagement and contract stage, but has enough of a positive working relationship been built to discuss the negative consequences of cutting without the patient or client thinking the therapist is judging them?  What are your thoughts on this Mary?  

DBT as Dialectics

• Dialectics is both a method of persuasion and a worldview or set of assumptions about the nature of reality
• The whole dialogue of therapy constructs new positions where the quality of one's life doesn't give rise to wanting to die.  Suicide is one way out of an unbearable life. However building a life that is genuinely worth living is an equally valid positions.  The constant refrain in DBT is that  a better solution can be found.  
• GREAT EXAMPLE:  Therapist:  So what you're saying is that if you saw a person in a lot of emotional pain, say your little niece, and she was feeling as badly as you were that night you burned your arm, she was feeling as devastated by disappointment as you were that night, you'd burn her arm with a cigarette to help her feel better.  Client:  No I wouldn't.  Therapist: Why not?  Client: I just wouldn't.  Therapist: I believe you wouldn't but why not?  Client:  I'd comfort her or do something else to help her feel better.  Therapist:  But what if she was inconsolable, and nothing you did made her feel better?  Besides you wouldn't burn her that badly.  Client:  I just wouldn't do it.  Its not right.  Id do something but not that.  Therapist:  That's interesting, don't you think?  
• The existence of "yes" gives rise to "no" and "all" to "nothing"