P: No, I don’t think I want to do another mindfulness exercise. But I can tell you that I feel really guilty, and mad, about what happened.
T: Your anger is related to your urge to scream about your mom. Can you be mindful of any urges you are having right now, coming from feeling guilty?
P: Yes. Like I said, I don’t want to talk about what happened.
T: So, as you stop and notice your urges, the urge is to avoid talking about cutting yourself ?
P: I guess.
T: Okay. Would it be skillful for you to act with the guilty urge or to act opposite to it by talking about what happened?
P: I guess we should talk about what happened.
T: Okay.
THEORETICAL AND TECHNICAL DISTINCTIONS FROM
In addition to the therapist consultation team, ad hoc telephone consultation be- tween client and therapist is a unique structural element of DBT. Although it is con- ventional for clients across many psychotherapies to call their therapist “in crisis,” in DBT telephone calls are explicitly encouraged. Because individuals with BPD frequently experience crises, there is a prescribed structure and function for these calls. After some time in DBT, the structure and consistent process that accompanies telephone consulta- tion calls frequently leads to clients calling with fewer crises, being more clearly targeted to a specifi c problem when they call, and shorter phone calls.
Another structural element unique to DBT is the use of a treatment hierarchy of targets. As described previously, this framework allows the therapist to make deci- sions about which of the many possible problems to target in any given moment of a session. By including “therapy-interfering behavior” as a class of possible targets for treatment, the therapist is able to fl exibly shift from helping the client troubleshoot such “quality of life” problems as depression or anxiety to, for example, the desire to stop going to the skills training group, or to an unwillingness to practice skills learned in group.
Whereas some cognitive behavioral therapies prescribe and some proscribe teach- ing skills to clients, another arguably unique element of DBT is the use of both di- rect skill training and experiential learning. Th e goal in DBT is to enhance learning of key life skills in order to promote a life that is worth living. As such, therapists in DBT are required to have the agility to shift from teaching skills (e.g., rehearsing, role playing, shaping, diff erentially reinforcing, etc.) to facilitating meaningful expe- riential learning (e.g., practicing mindfulness, using a behavioral experiment, etc.), sometimes within the same session. Although other treatments in the CBT family use both direct skill training and experiential learning (e.g., MBCT), in DBT there is perhaps more attention paid than in other treatments to balancing these diff erent methods of learning across time.
Diff erences Between DBT and Other CBT Treatments for BPD
Two other CBT approaches have supportive evidence. Cognitive therapy (CT) has shown effi cacy in reducing suicidal behaviors (Brown et al., 2005), and schema- focused therapy (SFT) has been found to improve several outcomes in patients with BPD (Giesen-Bloo et al., 2006). Like DBT, there is acknowledgment that environmental contexts, biological factors, behavioral skills defi cits, dysfunctional cognitive content and styles, and emotional responses all transact with each other and may need to be addressed in therapy. However, CT and schema therapy more strongly emphasize and focus on cognitions such as dysfunctional attitudes, beliefs, and information processing styles (and particularly in the case of SFT their ori- gins), whereas DBT more strongly emphasizes biological dysfunction of the emo- tion regulation system, behavioral skills defi cits, reinforcement contingencies, and other environmental infl uences. Conceptually, DBT does not include the construct
of schema, instead discussing patterns of cognitive behaviors (thoughts), and in general being a more behavioral and function process–oriented, and less cognitive and form/structure–oriented, model of treatment. Cognitive styles and patterns, though never ignored, are less a focus in Stage 1 than is typically true in cognitive therapy, in part because distorted cognition is viewed as often a result of intense emotions rather than their cause, so that it is more useful to focus on development of behavioral and other skills for regulating emotions. In addition, many BPD patients experience a focus on distorted cognition, particularly early in treatment, as invalidating, and therefore reject it and may reject treatment. By Stage 2, and particularly Stage 3, it is often far more useful to use standard CT approaches, none of which are necessarily incompatible with DBT if used in a context of dialectically balanced strategies.
Dialectical Philosophical Framework
As described above, the core change strategies in DBT are built around both behavior therapy and cognitive therapy. Indeed, it is this core that places DBT squarely in the family of cognitive behavioral therapies. Because dialectics are woven throughout all elements of the treatment, however, the application of standard behavior therapy and cognitive therapy interventions takes a diff erent form in DBT. We have outlined above how the fundamental dialectic underlying DBT is that of acceptance and change. With both acceptance and change having equal importance in the model, it is important to highlight how DBT may be compared to other acceptance-based models of psychother- apy. We contend that a primary way to distinguish DBT from other acceptance-based treatments is through the former’s use of dialectics.
When considering the key role that dialectics have in DBT, both the theoretical framework and the technical delivery of DBT can be contrasted against other contem- porary acceptance-based behavioral therapies, including acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) and mindfulness-based cognitive therapy (MBCT; Segal et al., 2002). With regard to theory, dialectics underlie both the ontological and epistemological perspective taken by the DBT therapist. Ontologically, the patient is seen holistically, more than the sum of his or her parts, with multilayered and interrelating infl uences on daily functioning. Epistemologically, the solution to any given problem is found through a dialectical process. For each position that is taken (i.e., thesis), a counter or diff erent position is taken (i.e., anti-thesis), and this natural tension between two alternative positions is used to fi nd a new position (i.e., synthesis).
Th e synthesis may or may not be the exact middle position between two extremes. Th e optimal place between polarities in DBT, for any given moment, is that which yields the most eff ective solution. In the same way that the best trajectory to throw a ball to another person is based on the strength and direction of the wind, the DBT therapist and patient must together decide what the most eff ective synthesis may be for any given problem, in any given context.
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Th is reliance on the dialectical process of change provides perhaps the clearest dis- tinction between DBT and both ACT and MBCT. Th is is not to say that either ACT or MBCT may, at times, include a dialectical process of change. However, these treatments neither prescribe nor proscribe dialectics. In contrast, dialectics are explicitly prescribed throughout all main components of the treatment. In DBT, the dialectical process of arriving at a working synthesis is found during individual therapy, group skills training, telephone consultation, and the therapist consultation team. Without the theoretical model prescribing a ubiquitous dialectical process of change, DBT is, quite literally, not DBT.
With regard to the technical delivery of treatment, dialectics also diff erentiate DBT from other acceptance-based treatments. On the one hand, similar to DBT, therapists in both ACT and MBCT use mindfulness exercises in session to facilitate experiential learning. As in DBT, both ACT and MBCT use mindfulness-based ex- periential exercises to help patients learn to change the context, not the content, of internal experiences. For example, rather than restructure the form or frequency of intrusive thoughts, as is done in more conventional cognitive therapy, therapists us- ing ACT or MBCT would help a patient learn through experiential exercises to let go of the literal truth of intrusive thoughts, thereby letting go of the struggle to fi nd suffi cient evidence to support or refute the truth of the intrusion. Instead, the patient is encouraged to respond with a chosen, intentional, and values-driven action, irre- spective of the content of internal experiences. Th is form and function of technical delivery of experiential learning in ACT and MBCT may, at times, be very similar in DBT.
On the other hand, the infl uence of a dialectical philosophy in DBT creates, at times, both a diff erent form and function of mindfulness during DBT sessions.
For example, the DBT therapist might direct the patient to use mindfulness skills for a variety of reasons, and in a variety of ways, including (but not restricted) to:
(a) beginning a session eff ectively, thereby reducing therapy-interfering behavior such as being easily distracted; (b) helping conduct in-session behavioral analyses more eff ectively; (c) blocking attempts to escape from negative emotions during the session; (d) reducing emotional arousal prior to rehearsing, role-playing, or conducting in vivo exposure exercises; or (e) ending a session, in order to increase the probability that the patient will not immediately leave the session and engage in unskillful behavior. Th e dialectical process of change allows the therapist the fl ex- ibility to use mindfulness for these and other functions at any point during session, even if done inconsistently or unpredictably. Moreover, it is not important that the patient does mindfulness in any specifi c form (i.e., sitting, breathing, walking, etc.), for any specifi c amount of time, or with any specifi c instructional content. What matters is that the dialectical process of change provides the context for mindfulness to be used in session, in an organic way that is contingent upon in-session behav- ior. Mindfulness is used as needed during DBT sessions, which means that it can be used spontaneously and unpredictably, planned and consistently, or anywhere
between these extremes. Dialectics allow the therapist to move swiftly with intention from helping the patient use mindfulness in one form or another, for one function or another, both within and across sessions.