Motivation and emotion/Book/2019/Dialectical behaviour therapy

Dialectical behavior therapy:
What is DBT and how does it work?

[Replace this text with the URL Multimedia presentation (3 min)]

Overview

Dialectical Behaviour Therapy (DBT) is a modified version of Cognitive Behavioural Therapy (CBT). DBT was originally developed by Linehan (1993) for the treatment of Borderline Personality Disorder (BPD), it is considered the most-effective treatment for BPD (Kröger et al., 2006; Pasieczny & Connor, 2011; Khalid-Khan et al., 2016). In addition to treating BPD, DBT can also be useful with the treatment of eating disorders (Klein, Skinner & Hawley, 2012), substance abuse disorders (Courbasson, Nishikawa & Dixon, 2011), and self-harming behaviour (Feigenbaum, 2010; McCay et al., 2015). DBT is a multifaceted therapy aimed at improving the well-being of patients through teaching them new accepted-oriented skills and change-oriented skills.

Case Study Case study goes here

Focus Questions 1. How does DBT differ from CBT? 2. What are the four modules taught during DBT?

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is an extensively researched form of psychotherapy. This treatment approach focuses on developing the skills that allow a person to self-identify and challenge unhelpful thoughts. Reducing the number and strength of these negative thoughts has a positive influence on emotion and behaviour. CBT is the most researched method of psychotherapy, and therefore has the largest evidence base. As a result, it is commonly termed the gold standard of psychotherapy (David et al., 2018). CBT involves combining Cognitive Therapy (identifying and challenging negative thoughts) and Behavioural Therapy (teaching skills to alter behaviour).

CBT is effective for disorders such as:

• Anxiety
• Depression
• Anger
• Low self-esteem
• Substance abuse
• Eating disorders
• Problem gambling
• Insomnia

What is DBT?

Dialectical Behaviour Therapy was developed by Marsha Linehan in 1993 to treat Borderline Personality Disorder (BPD). DBT is based on a model that emphasises two things (Dimeff & Linehan, 2001):

1. That those who require DBT (usually BPD patients) lack important skills such as emotional regulation skills, interpersonal skills, and skills for distress tolerance
2. The patients' social environment reinforce dysfunctional behaviours.

Although DBT is a modified version of CBT, it is significantly different, instead trying to alter or remove negative thoughts (like CBT teaches), DBT focuses on helping the patient accept their thoughts and learn strategies to deal with negative emotions practically. DBT emphasises finding balance between accepting oneself and the need to change certain aspects of their experiences. It is composed of four main modules, with two being acceptance-oriented and two being change-oriented.

Figure 1. DBT skills

Acceptance-oriented skills

Acceptance-oriented skills consist of two practices:

• Mindfulness: mindfulness allows the patient to live in the present moment, it focuses on strengthening certain skills, namely, the "what and how" skills. The "what" skills allow the patient to observe, describe and be in the present moment, this allows the patient to avoid thinking about upsetting things that have happened to them in the past or anxieties about the future. Additionally, the"how" skills allow the patient to live with a non-judgemental mindset, which aims to target a patient's tendency to think in a 'black and white' manner as it is a common trait of BPD patients oscillate between devaluing someone/ themselves to idealising (May et al., 2016).
• Distress tolerance which allows the patient to be able to mitigate and deal with distressing situations. Distress tolerance skills allow the patient to accept that distressing situations are a part of life (and how not accepting it or avoiding it can lead to a greater amount of distress) and shows them how to accept and deal with distressing situations instead of avoiding them (May et al., 2016).

Change-oriented skills

Change-oriented skills also consist of two practices:

• Emotional regulation: involves learning skills to manage the emotional experience. Individuals who require DBT may present with extreme mood swings or labile mood which leads to ineffective coping strategies (such as self-harm). Emotional regulation skills often consist of teaching the individual to identify emotions and how to respond to them in a nondestructive, adaptive way (May, et al., 2016)
• Interpersonal effectiveness: consists of strategies to communicate with others in a way that maintains respect for one's self and others. As the name suggests, interpersonal effectiveness focuses on teaching the patient social skills to effectively communicate with others. Those who require DBT (such as BPD patients) often experience chaotic interpersonal relationships (May et al., 2016).

How is DBT theory applied?

Each aspect of DBT theory is applied in therapy by teaching the patient different skills and techniques, specific to each of the four modules. For an example of how DBT maybe be conducted see Figure 2.

Figure 2. An example of a DBT therapy schedule

DBT typically comprises three interacting therapeutic processes to develop a comprehensive treatment of multifaceted psychological issues (Chapman, 2006). These processes are:

1. Group sessions with a single therapist. The therapist trains the group in the necessary skills of DBT as well as promoting experience sharing amongst group members and group emotional support (1.5-2.5 hours, weekly)
2. One-on-one therapy sessions. These are focused on addressing the personal obstacles of an individual and incorporating skills to day-to-day life (1 hour, weekly)
3. Therapist consultation team meeting. This allows therapists to collectively problem-solve for an individual as well as provide support and recommendations amongst colleagues (1-2 hours, weekly)

Mindfulness

McKay and colleagues (2007) define mindfulness as "... the ability to be aware of your thoughts, emotions, physical sensations, and actions—in the present moment—without judging or criticizing yourself or your experience (pp. 64)."

Mindfulness has been practised in many cultures for decades, but in the 1980s mindfulness emerged as a useful therapy option for patients with chronic pain, due to these promising results, clinicians began integrating mindfulness into psychotherapies (Kabat-Zinn et al., 1985; McKay, et al., 2007). Research has shown that mindfulness is effective at reducing anxiety symptoms, reducing depressive disorders (Teasdale et al., 2000), and reducing chronic pain amongst many other applications (Kabat-Zinn et al., 1985). As mentioned above, patients are taught "what" and "how" skills to avoid thinking about negative events in the past or anxieties about the future (May et al., 2018). This enables the patient to be able to identify and evaluate their own emotions without judgement or criticism.

Case-study Joanna's boyfriend said he can't hang out with her today, and she feels horrible about it, she begins to think that her boyfriend doesn't love her anymore, and he doesn't want to be with her. She has been practising mindfulness with her therapist, so she decides to take a step back and notice how her bodily sensations- she notices that her stomach feels like it's in knots and her heart feels like it's dropped to her stomach. Joanna decides to label her emotion as "disappointment" and "sadness" but thanks to being mindful, she is able to remind herself this does not mean her boyfriend doesn't love her.

Distress tolerance

Relevant skills/methods. Examples/case studies

Case Study Case study goes here

Emotional regulation

Relevant skills/methods. Examples/case studies

Case Study Case study goes here

Interpersonal Effectiveness

Relevant skills/methods. Examples/case studies

Case Study Case study goes here

How DBT can be applied to relevant conditions?

DBT is useful as you can maintain the basic techniques that are standard to DBT while adjusting and changing the specifics to be more applicable to the patients needs.

Condition	How it can be tailored
Suicidal Tendencies and Self Harm	Focus on developing skills to resolve behavioral issues focusing on those that are life threatening and therapy interfering
Substance Abuse	Reducing therapy interfering behaviours are important to reduce chance of relapses, focus directed at change oriented skills development
Post Traumatic Stress Disorder	Heavy focus on distress tolerance and emotional regulation
Depression	Mindfulness specialisation and focus around limiting therapy interfering behaviours
Eating disorders	Disordered eating specialised recordkeeping, group discussions focused around eating habits.

Evidence Base of DBT

Chapman A. L. (2006). Dialectical behavior therapy: current indications and unique elements. Psychiatry (Edgmont (Pa. : Township)), 3, 62–68.

Valentine, S., Bankoff, S., Poulin, R., Reidler, E., & Pantalone, D. (2014). The Use of Dialectical Behavior Therapy Skills Training as Stand-Alone Treatment: A Systematic Review of the Treatment Outcome Literature. Journal Of Clinical Psychology, 71, 1-20. doi: 10.1002/jclp.22114

Conclusion

1. Implications for further research, such as applicability to other disorders
2. Summarise keys points
3. Take home messages

See also

• Motivation and emotion/Book/2014/Suicide prevention (Book chapter, 2014)

References

Chapman A. L. (2006). Dialectical behavior therapy: current indications and unique elements. Psychiatry (Edgmont (Pa. : Township)), 3(9), 62–68.

Courbasson, C., Nishikawa, Y., & Dixon, L. (2011). Outcome of Dialectical Behaviour Therapy for Concurrent Eating and Substance Use Disorders. Clinical Psychology & Psychotherapy, 19, 434-449. doi: 10.1002/cpp.748

David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Frontiers in psychiatry, 9, 4. https://doi.org/10.3389/fpsyt.2018.00004

Dimeff, L., & Linehan, M. M. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34(3), 10-13.

Feigenbaum, J. (2010). Self-harm – The solution not the problem: The Dialectical Behaviour Therapy Model. Psychoanalytic Psychotherapy, 24, 115-134. doi: 10.1080/02668731003707873

Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8, 163–190. https://doi.org/10.1007/BF00845519

Khalid-Khan, S., Segal, S., Jopling, E., Southmayd, K., & Marchand, P. (2016). Effectiveness of a modified dialectical behaviour therapy for adolescents within a stepped-care model. International Journal Of Adolescent Medicine And Health, 30, 449-476. doi: 10.1515/ijamh-2016-0030

Klein, A., Skinner, J., & Hawley, K. (2012). Adapted Group-Based Dialectical Behaviour Therapy for Binge Eating in a Practicing Clinic: Clinical Outcomes and Attrition. European Eating Disorders Review, 20, e148-e153. doi: 10.1002/erv.2165

Kröger, C., Schweiger, U., Sipos, V., Arnold, R., Kahl, K., & Schunert, T. et al. (2006). Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting. Behaviour Research And Therapy, 44, 1211-1217. doi: 10.1016/j.brat.2005.08.012

Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.

May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The mental health clinician, 6(2), 62–67. https://doi.org/10.9740/mhc.2016.03.62

McCay, E., Carter, C., Aiello, A., Quesnel, S., Langley, J., & Hwang, S. et al. (2015). Dialectical Behavior Therapy as a catalyst for change in street-involved youth: A mixed methods study. Children And Youth Services Review, 58, 187-199. doi: 10.1016/j.childyouth.2015.09.021

McKay, M., Wood, J.C. & Brantley, J. (2007). The Dialectical Behaviour Therapy Skills Workbook. New Harbinger.

Pasieczny, N., & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial. Behaviour Research And Therapy, 49, 4-10. doi: 10.1016/j.brat.2010.09.006

Shearin, E., & Linehan, M. (1994). Dialectical behavior therapy for borderline personality disorder: theoretical and empirical foundations. Acta Psychiatrica Scandinavica, 89, 61-68. doi: 10.1111/j.1600-0447.1994.tb05820.x

Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615–623. https://doi.org/10.1037//0022-006x.68.4.615

Valentine, S., Bankoff, S., Poulin, R., Reidler, E., & Pantalone, D. (2014). The Use of Dialectical Behavior Therapy Skills Training as Stand-Alone Treatment: A Systematic Review of the Treatment Outcome Literature. Journal Of Clinical Psychology, 71, 1-20. doi: 10.1002/jclp.22114

External links

https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/cognitive-behaviour-therapy

https://www.sane.org/information-stories/facts-and-guides/dialectical-behaviour-therapy-dbt