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DIALECTICAL BEHAVIOUR THERAPY

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INTRODUCTION

BPD is a disorder that is severe, chronic, and

persistent

individuals meeting criteria for the disorder is

aprox 11%

BPD individuals describe chronic feelings of

anger, emptiness, depressions and anxiety.

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DIALECTICAL BEHAVIORAL THERAPY

Marsha Linehan (1991) pioneered this treatment

Treatment goals were reducing Para suicidal

(self-injuring) and life-threatening behaviors.

reducing behaviors that interfered the

therapy/treatment process

finally reducing behaviors that reduced the

client's quality of life.

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THE TOP TARGETS AND GOALS OF TREATMENT IN

DBT

DBT organizes treatment into four stages

Stage I: Moving from Being Out of Control of

Ones Behavior to Being in Control

Target 1: Reduce and then eliminate life-

threatening behaviors

Target 2: Reduce and then eliminate behaviors

that interfere with treatment

Target 3: Decreasing behaviors that destroy the

quality of life

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CONTD..

Target 4: Learn skills that help people do the

following

Control their attention

Start new relationships, improve current

relationships, or end bad relationships

Tolerate emotional pain without resorting to self-

harm or self-destructive behaviors

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Stage II. Moving from Being Emotionally Shut

Down to Experiencing Emotions Fully

Stage III. Building an Ordinary Life, Solving

Ordinary Life Problems

Stage IV. Moving from Incompleteness to

Completeness/Connection

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PHILOSOPHICAL UNDERPINNINGS

Biosocial theory

BPD is seen as a biological disorder of emotional

regulation.

Characteristic behaviors and emotional

experiences associated with BPD theoretically

result from the expression of this biological

dysfunction in a social environment experienced

as invalidating by the borderline patient."

http://en.wikipedia.org/wiki/Biosocial_theoryhttp://en.wikipedia.org/wiki/Biosocial_theory

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INVALIDATING ENVIRONMENT

The invalidating environment is broadly

characterized by pervasive, criticizing,

minimizing, punishing or or irratically reinforcing

communication of internal experiences and oversimplifying the ease of problem solving.

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EMOTIONAL VULNERABILITY

The is characterized by heightened sensitivity to

emotion, increased emotional intensity and a

slow return to emotional baseline.

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EMOTIONAL DYSREGULATION

Emotional dysregulation

Environmental

invalidationEmotional

vulnerability

Emotional

dysregulation

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THE DIALECTIC

The word dialectic is the Greek dialegein, which means to argue or converse."As a

world view... dialectics anchors the treatment within other perspectives that

emphasize:

1. the holistic, systemic and interrelated nature of human functioning and reality

as a whole (asking always "what is being left out of our understanding here?");

2. searching for synthesis and balance, (to replace the rigid, often extreme, and

dichotomous responses characteristic of severely dysfunctional individuals);

3. enhancing comfort with ambiguity and change which are viewed as inevitable

aspects of life.

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GROUP SKILLS TRAINING

BPD lack many of the fundamental skills

Groups have a didactic orientation and the entire

sequence of weekly skills training takes

approximately six months to complete. Patients

typically go through the skills training at least

twice.

It includes four modules.

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THE FOUR MODULES

Mindfulness

Interpersonal effectiveness

Distress tolerance

Emotion regulation

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HOW IT WORKS

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cue

Emotional

dysregulation

DBT teaches

to tolerate

distress

Problem

behavior

Teaches to

stop this

behaviour

Temporary relief

Avoidance or escape

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INDIVIDUAL THERAPY

Individual therapy involves weekly (or daily if inpatient) sessions

in which problem behaviors (e.g., self-mutilation, therapy

interfering behaviors, bingeing / purging, abuse of alcohol / drugs,

etc.) are analyzed in great depth for both precipitants and

consequences which elicit, lead to, maintain, or reinforce thebehavior. Solutions are developed that address what gets in the

way of skillful behavior by changing reinforcement patterns,

overcoming inhibitions through exposure, cognitive modification,

and directly teaching skills.

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CONTD

Diary cards

Behavior analysis

Skill enhancement

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VALIDATION

Validation in DBT involves five different levels This first two are

similar to other psychotherapies

The third step of validation is to articulate for the patient

unverbalized emotions, thoughts, or behavior patterns.

The fourth step is for the therapist to validate the person's

present behavior based on their past learning history.

Fifth, the therapist looks for and articulates the part of the

patient's response that is valid and / or wise.

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DIALECTICAL STRATEGIES

Acceptance & change focused interventions

Nurturing the patient & demanding that he or

she helps himself

highlight patients strength & deficits

being stable & persistent, as well as flexible

point out paradoxes when present use metaphors

help patient activate wise mindetc

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TELEPHONE CONSULTATION

To enhance the generalization of skills, patients in DBT can

contact their therapist for telephone consultation between

sessions. However personal limits should be maintained making

the calls to be brief & lasting approximately 10 minutes. It uses

24- hour rule which states that patient will not receive skills helpfrom their individual therapists until 24 hours after any self

injurious behavior. in all these calls the DBT therapist assesses for

immediate danger & provide appropriate assistance.

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CONSULTATION TEAM

Because working with borderline individuals can be very difficult

and distressing, effective DBT treatment requires the formation of

a consultation team. The goal of the consultation team is to

provide feedback to therapists so that they keep the treatment

balanced, to strategies treatment approaches which may behelpful to the patient, to look for what may be missing in any

analysis or hypothesis, to help the therapists observe their own

limits and values, to strive for phenomenological empathy, and to

cheerlead when a therapist becomes demoralized.

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EMPERICAL EVIDENCES

Less parasucidal behavior Decrease psychiatric hospitalization

Decrease anger

Decrease psychotropic medication use

Increase social adjustment

Retention in therapy

Can also be applied in depression, PDs, affective

dysregulation problem, substance use & eating

disorder.

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