Th e most fundamental dialectic observed and attended to in DBT is that of acceptance and change. Treatment strategies in DBT for helping patients to change draw primarily on standard behavioral and cognitive therapy procedures and on principles and fi ndings from research on learning, emotions, social infl uence and persuasion, and other areas of psychology. Treatment strategies for helping the therapist to convey his or her accep- tance of the patient draw primarily on client-centered and emotion-focused therapies.
Treatment strategies to help the patient develop greater acceptance of self, of others, and of life in general draw primarily on Zen Buddhist principles and practice. A dialecti- cal stance informs and sustains the balance and integration of acceptance and change strategies.
Stages of Treatment and Treatment Targets
One of the challenges in working with patients with BPD is the sheer number of prob- lems they often present with and the fact that the problem viewed as most urgent by the patient and/or therapist often changes from session to session. A loss of focus and
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continuity can easily result. DBT is guided by a conceptual model of four stages of treat- ment and of the prioritizing of problems within a treatment session, particularly in stage 1.
Th e broad stages of treatment include:
1. From behavioral dyscontrol to control
2. From emotional inhibition toward experiencing
3. From problems in living to ordinary happiness and unhappiness 4. From a sense of incompleteness to a sense of freedom and joy
DBT individual therapy sessions are guided by establishing a clear list of therapy targets and arranging these in a hierarchical order of priority that depends on their se- verity and impact on long-term functioning, rather than only on a short-term sense of urgency. Specifi cally, in stage 1 treatment, which has been the primary focus of research to date, life-threatening and related behaviors as the highest priority targets, followed by therapy-interfering behaviors of patient or therapist, then quality-of-life interfering behaviors and circumstances, and fi nally skills development (most of which is addressed in separate skills training mode of the treatment). Prior to beginning treatment, DBT explicitly includes a pretreatment stage, in which therapist and patient reach agreements about the most important treatment targets and the treatment structure, among other things.
Treatment Modes
Comprehensive treatment for patients with BPD needs to address four functions:
1. Help the patient develop new skills 2. Address motivational obstacles to skills use
3. Help the patient generalize what he or she learns to daily life 4. Keep therapists motivated and skilled
In standard outpatient DBT, these four functions are addressed primarily through four modes of treatment: group skills training, individual psychotherapy, telephone coach- ing, and a therapist consultation team meeting, respectively.
Linehan found that it was extremely diffi cult for the therapist to focus on long-term skills acquisition in individual therapy because of the need to respond simultaneously to current crises, dysregulated emotions, and recent instances of behavioral dyscontrol.
Consequently, she separated these two treatment functions into distinct treatment modes. Skills are taught in four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal eff ectiveness. In individual therapy, the therapist helps the patient use whatever skills he or she has and is learning to navigate crises more eff ectively and to reduce problem behaviors. Problems with motivation to use skills are addressed primarily in individual therapy.
Patients are instructed to call their individual therapist for skills coaching (within agreed parameters) when they are in crisis or having diffi culty controlling urges to self-injure, drink alcohol, leave work, or other problem behavior. A consul- tation team that meets regularly is also a required component of DBT, and has the purpose of keeping therapists motivated and providing guidance in conducting the treatment.
Treatment Strategies
Th ere are four primary sets of DBT strategies, each set including both acceptance- oriented and change-oriented strategies. Core strategies in DBT are validation (accep- tance) and problem solving (change). Dialectical strategies present or highlight extreme positions that tend to elicit their antithesis. Communication style strategies include a reciprocal style (acceptance) and an irreverent one (change). Case management strategies include (a) environmental intervention for the patient (acceptance of the current limited capability of the patient), (b) being a consultant to the patient (change in the patient’s capability), and (c) making use of a consultation team (balancing both acceptance and change).
Commitment Strategies
Th e initial task in treatment is to determine whether there is, or can be, an agreement between patient and therapist on the goals and methods of treatment and the primary targets that will be initially addressed. For patients with suicidal and self-injurious behaviors in particular, there may or may not be strong commitment to work on the behaviors and situations that the therapist views as most problematic, or even to stay alive long enough for treatment to have a chance to be helpful. DBT therefore also includes a set of strategies for eliciting commitment, based on principles supported in research in social psychology, marketing, and motivational interviewing. Th ese include:
1. Evaluating the pros and cons of changing and of not changing
2. Foot-in-the-door strategies, in which eliciting agreement to a small request in- creases the probability of subsequent agreement to a larger one
3. Door-in-the-face approaches, in which refusal of a large request increases the probability of subsequent agreement to a smaller one
4. Devil’s advocate, in which the therapist tries to strengthen a weak commitment by noting the diffi culty of or obstacles to change
5. Connecting the present commitment to previous commitments the patient has made
6. Highlighting the patient’s freedom to choose whether or not to commit, while ac- knowledging the consequences of the choice (e.g., the patient may continue to be hospitalized, the therapist can choose not to treat the patient)
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Problem-Solving Strategies
Th e fi rst step in helping the patient to change a problem behavior is to conduct a behavioral analysis of a particular instance of it. Th e focus is typically on a recent oc- currence of the target behavior, and the analysis attempts to highlight the variables that maintain the behavior through principles of learning. Antecedent consequences are elucidated, and hypotheses are generated and tested about ways to disrupt chains leading to and following problem behavior. A helpful behavioral analysis will point to one or more solutions, and these solutions will be examined for their utility until an optimal solution is evident. To facilitate behavior changes, the therapist uses stan- dard cognitive behavior therapy procedures, which can be usefully classifi ed into four groups
1. Skills training, if the patient does not know how to behave more skillfully 2. Contingency management, if the patient’s maladaptive behavior is being reinforced,
or adaptive behavior is being punished or not reinforced
3. Exposure, if conditioned emotional reactions to particular stimuli interfere with adaptive behavior
4. Cognitive modifi cation, if the patient’s beliefs, attitudes, and thoughts interfere with adaptive behavior
Because contingency management and exposure are standard CBT procedures, we do not discuss them further here, except to say that in DBT, therapists particularly at- tend to the potential reinforcing, extinguishing, or punishing functions of their own be- haviors, and that in addition to formal exposures, DBT aff ords many opportunities for informal exposures (through elicitation of diffi cult emotions, by mindfulness practice, etc.). As described below, relative to some other CBT approaches, behavioral analyses tend to be conducted in greater detail in DBT.
Behavioral Analysis
Th e goal of a behavioral analysis in DBT is to understand the sequence of vulnerability factors, prompting events, thoughts, feelings, action urges, and observable behaviors that led to an instance of a particular problem behavior, as well as the personal, interper- sonal, and other consequences that followed it. Th e fi rst step is to describe the problem behavior objectively, specifi cally, and nonjudgmentally. An example might be “Friday evening, between 11 and 11.30 p.m., scratched ankles repeatedly with fi ngernails, enough to draw blood but not requiring stitches.” It is helpful next to identify a prompting en- vironmental event. Th e patient may initially be unable to identify one and, for example, respond with “I always feel suicidal.” One useful strategy is to identify the time at which the urge increased. Solutions directed at the prompting event include avoiding such events (stimulus control) or changing them. It is often helpful to identify vulnerability factors that made the prompting event more diffi cult for the patient to cope with, such
as other recent stressors, moods, lack of sleep, or inadequate nutrition. Solutions may then include attempts to reduce such vulnerability factors.
Th e therapist and patient also identify links in the chain from the prompting event to the problem behavior, which may include thoughts about the event, emo- tional reactions, subsequent behaviors, and reactions to those behaviors by the patient and others. Th e greater the number of links identifi ed, the greater the number of potential solutions. Patients may need repeated controlled exposure to the situation to allow their emotional responses to habituate, to change what they tell themselves about the situation, to use interpersonal skills, or to use distress tolerance skills to cope with urges to engage in the problem behavior. Th e therapist also inquires about consequences of the problem behavior, including changes in the patient’s emotions, responses of other people, and environmental changes. Th is may identify reinforcers that the therapist may be able to remove, and negative consequences that the therapist can highlight.
Validation Strategies
Validation, which is used in DBT to balance problem solving, simply means commu- nicating to the patient that his or her responses make sense, are understood, or are in a sense reasonable. It is important only to validate that which is, in fact, valid. Valida- tion does not mean saying positive things about the patient, certainly if they are not true. Some things always are valid and so always can be validated, such as emotional responses, which are by defi nition always understandable reactions to a perception or thought, even if the perception or thought itself is not valid. Other things clearly are invalid, such as a belief that all other drivers on the road intend to harm the patient.
Many things, however, can be valid in some way but not valid in another. For example, self-injury may regulate a patient’s emotions. Th e behavior, therefore, is valid in terms of a short-term consequence. It makes sense. On the other hand, the behavior probably has various negative consequences and is not eff ective in helping the patient reach his or her longer-term goals in life. Early in treatment, it may be helpful to validate self-injury in the sense of communicating that it is understandable. Th is may be unnecessary or undesirable later in treatment. Validation can occur at a number of levels. First, unbi- ased listening and observing communicates to the patient that he or she is important.
Second, accurate refl ection communicates to the patient that he or she has been under- stood. Th ird, articulating emotions, thoughts, and behavior patterns that the patient has not yet put into words, when accurate, may help the patient to feel deeply understood.
Fourth, validation in terms of past learning history or biological dysfunction communi- cates that, even if a behavior currently is maladaptive, its occurrence nonetheless makes sense. Fifth, validation in terms of the present context or normative functioning lets the patient know that that is how most people would respond in that situation. Finally, radical genuineness on the part of the therapist, who does not treat the patient as overly fragile, validates the patient’s capability.
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