Dialectical Behavioural Therapy (DBT) is a comprehensive cognitive – behavioural treatment for complex difficult to treat mental disorders. It was developed in late 1970s by Mrsha Linehan and colleagues to treat chronically suicidal individuals, especially Borderline Personality Disorders (BPD). However, since it is not unusual for individuals diagnosed with BPD to also struggle with other problems like depression, dipolar disorder, and post-traumatic stress disorder (PTSD), anxiety, eating disorders, or alcohol and drug problems, Dialectical Behavioural Therapy has been adapted for other seemingly intractable behavioural disorders involving emotional deregulation; including substance dependence and binge eating. Other areas where Dialectical Behavioural Therapy has been suggested useful are the treatment of depression, bipolar disorder, anxiety and panic disorders, social phobias, trauma, PTSD among others. (see Katz, Gunasekara, & Miller, 2002; Koons, Robins, Tweed, Lynch, Gonzalez and Morse, 2001 et al.; Linehan et al, 1999; Telch, Agras &
Linehan, 2000).
Dialectical Behavioural Therapy was defined by Swenson, Torrey & Koerner (2002) as a cognitive – behavioural therapy for the treatment of borderline personality disorder in which an ongoing focus on behavioural change is balanced with acceptance, compassion and validation of the consumer. Dialectical Behaviour Therapy integrates proven techniques from cognitive and behavioural therapies within a philosophical and theoretical framework for understanding borderline pathology. Its theory and practice borrow from four different orientations: biological, social, cognitive – behavioural and spiritual (Linehan 1993).
“Dialectics” is a complex concept that has its roots in philosophy and science. It refers to a form of argument in which an assertion is first made about a particular issue (the „thesis‟), the opposing position is then formulated (the “antithesis”) and finally a “synthesis is sought between the two extremes, embodying the valuable features of each position and resolving the contradictions between the two”. This synthesis then acts as the thesis for the next cycle, truth is seen as a process which develops over time in transactions between people. From this perspective, there can be no statement representing absolute truth. Truth is approached as the middle way between extremes (Kiehn & Swale, 1995). In other words, “dialectics” involves several assumptions about the nature of reality: (1) everything is connected to
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everything else (2) change is constant and inevitable and (3) opposites can be integrated to form a closer approximation to the truth (which is always evolving). In conjunction with these principles, DBT emphasises balance in the client‟s life.
Clients are encouraged to walk the middle part by using such principles as mindfulness.
2.1.16.1 Theoretical Basis for DBT
DBT is based on biosocial theory of personality functioning in which Borderline Personality Disorder (the disorder for which Linehen developed DBT) is seen as a biological disorder of emotion regulation. The disorder is characterised by heightened sensitivity to emotion, increased emotional intensity and a slow return to emotional baseline. Characteristic behaviours and emotional experiences associated with BPD theoretically result from the expression of the biological dysfunction in a social environment experienced as invalidating by the patient (Murphy & Gunderson, 1999).
The biosocial theory suggests that BPD is a disorder of self-regulation and particularly of emotional regulation, which results from biological irregularities combined with certain dysfunctional environments, as well as from their interaction and transaction over time (Linehan 1999). Biosocial theory is a theory that explains the problems of people with BPD, the related disorders are therefore important because they offer information which becomes a tool of validation in itself, offering the client the option of seeing their problems as no fault of their own while also offering them the possibility of taking responsibility for future change.
In Linehan‟s (1993a) theory about how BPD develops, invalidating environments are a primary factor. Such environments are characterised by a parent‟s inappropriate, unpredictable, or extreme responses when a child communicates his or her experience. The child is told that he or she is wrong in his or her assessment of the situation and is consequently, wrong about his or her emotional response or understanding (both positive and negative). The child then attributes his or her internal experiences to unacceptable personality traits.
Although, a person may be biologically predisposed to BPD (and related disorders like anxiety disorder), invalidating environments have devastating consequences for a young person. First, consistent with the inappropriate and unpredictable caregiver responses, the person is not able or does not learn to label and
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regulate emotions as the rest of society does. Also, the person becomes intolerant of stress, has developed unrealistic goals, is easily disappointed, has learned that extreme emotions are required to elicit help and is unable or has learned not to trust his or her own judgement (Linehan, 1993a). Second, an invalidating environment may change the biology in a young person, because of the environment; the person‟s physiology may be altered or swayed toward emotional dysregulation (Smith & Peck 2004). The focus of DBT is therefore on helping the client learn and apply skills that will decrease emotion dysregulation and unhealthy attempts to cope with strong emotions.
2.1.16.2 Treatment Model of DBT
While using DBT, Koon, Sloan and Bellizi (2002) asserts that therapy should be guided by seven assumptions and several tenants. The first is assumption clients are doing the best they can; second, clients want to improve and third, clients must learn their new behaviours in each and all relevant contexts. Fourth, clients cannot fail in DBT, meaning that any effort the client makes to improve himself or herself is considered progress. Fifth, clients may not have caused all of their own problems, but they have to solve them anyway; and sixth, clients need to do better, try harder or be more motivated to change. Although this may seem inconsistent with the fourth assumption, Smith and Peck (2004) noted that it is consistent with the dialectical framework that is the foundation of DBT. This dialectical framework allows the therapist to both accept the client where he or she is (i.e. any effort is viewed as progress), while at the same time, challenging the client to do better and do more (Smith & Peck, 2004). The seventh assumption is that the lives of individuals with BPD (and its related disorders e.g. anxiety disorder) are unbearable as they are currently being lived (Koons et al., 2002).
The main focus of DBP is emotional dysregulation which may manifest in dysfunction interpersonal dysregulation, self-dysregulation, cognitive dysregulation and behavioural disregulation. DBT skill training therefore addresses these problems with four corresponding behavioural skills module which are discussed hereunder.
Mindfulness: The core skill module, “mindfulness”, addresses self-dysregulation and cognitive dysregulation. Mindfulness skills are psychological and behavioural versions of meditation skills usually taught in Eastern spiritual practices (Linehan, 1993a). Often, these patients find themselves making emotional choices. An
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important treatment goal is to help them move away from exclusive reliance on their
“emotional mind” to using both emotional and rational input to make balanced decisions, called “wise-mind decision”. These patients are taught to use mindfulness skills to facilitate observing their experiences in nonjudgmental ways and putting their observations into words-to help make a transition from emotional mind to wise mind.
Focused use of these skills ultimately increases their effectiveness in coping with difficult situations (Katz, Gunasekara & Miller, 2002).
Distress Tolerance: This skill module targets behavioural dysregulation and impulsivity and includes both crisis survival skills (i.e. distracting oneself, self-soothing using five senses, making a list of pros and cons) and radical acceptance skills (Katz et al. 2002). These skills help the patient tolerate seemingly intolerable, painful circumstances without engaging in impulsive behaviour like parasuicide, substance-related or other dangerous behaviour. Distress tolerant skills have to do with the ability to accept in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although, the stance advocated here is a nonjudgmental one, this does not mean that it is one of approvals because acceptance of reality is not approval of reality.
Emotional Regulation: Under the emotional regulation skill module, the individual is taught how to reduce emotional vulnerability, increase positive experience (resulting in positive emotions), and change current emotion by acting oppositely.
According to Stone, Hurt & Stone (1987) and Holmes, Georgescu and Liles (2005), dialectical behavioural therapy skills for emotion regulation include the following:
Identifying and labelling emotions;
Identifying obstacles to changing emotions;
Reducing vulnerability to emotion mind;
Increasing positive emotional events;
Increasing mindfulness to current emotions;
Taking opposite action and,
Applying distress tolerance techniques.
Interpersonal Effectiveness: Interpersonal response pattern taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal
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problem – solving classes. The skill addresses interpersonal problems and teaches individuals how to negotiate to get what they want while maintaining good relationships and self-respect (Linehan 1993b).
DBT comprises of a total of four stages of treatment, beginning with “pre-treatment”
stage. During pre-treatment (orientation and commitment), the targets on therapy are an orientation to treatment and the agreement on goals, during which the client makes a commitment to therapy. In the first stage of treatment (Attaining Basic Capacity), the targets are addressed in hierarchical order of importance. The most important target is decreasing self-destructive behaviour. After these behaviours have been addressed, the next target is decreasing behaviours that interfere with treatment. This includes problems that threaten the continuation of therapy and those that interfere with the process of treatment. Another target is decreasing quality of life-interfering behaviours. Behaviours causing immediate crises are targeted and easy-to-change behaviours are targeted over difficult-to-change behaviours. The final target is increasing behavioural skill. (i.e. core mindfulness, interpersonal effectiveness, emotional regulation and distress tolerance). The therapist addresses the highest priority target that is relevant at that time. The goal of stage 2 (Reducing post traumatic stress), is the direct treatment of post-traumatic stress. This is only done after the client has had the necessary skills and decides to resolve the trauma.
Increasing self-respect and achieving individual goals is the target of the third stage.