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Marsha Linehan had a wonderful half-day training on dialectical behavior therapy (DBT) “Where We Were, Where We Are, and Where We Are Going.”

Below are some key take-aways:

DBT skills training presented in a way you can understand them! - for all clincians! By popular demand, you can now learn “just the skills”. You don’t have to be a Dialectical Behavior (DBT) therapist for your clients to benefit from the DBT skills. Learn 85 DBT skills in this recording. Dialectical behavioral therapy uses a wide variety of techniques to help people change behaviors and build a “tool box” of skills.

* Dialectical Behavior Therapy (DBT) is a treatment that was developed by Marsha Linehan in order to help people with high suicide risk and multiple suicide attempts and/or self-harming behaviors.

• • The combination of an invalidating environment during childhood plus biological factors are common contributing factors.
    

* She developed the dialectical approach balancing both change and radical acceptance strategiesto address the fact that the patients with high risk of suicide all exhibited:

• Extreme sensitivity to rejection and invalidation
  • making a change-focused treatment unbearable
• Extreme suffering (all clients had suffered extreme traumas in their childhoods)
  • making an acceptance based approach also inappropriate

* DBT treatment requires a team; the function of a team is to keep the therapist on track with the DBT protocol.

*Radical acceptance on the therapist’s part entails acceptance of the client’s tragic past, slower rate of improvement vs. other disorders and high risk of suicide/self-harm.

Acceptance is change! Change only happens in the context of acceptance.

*Radical acceptance on the client’s side includes accepting:

• a focus on one set of problems at a time
• the past (what’s past is past)
• the present (some things in the present can also not be changed)
• limitations of the future

* The client is taught radical acceptance skills that include both radical acceptance and distress tolerance skills (to enable the radical acceptance).

* The BPD criterion behaviors (such as the suicidal and self-harm activities) serve as a regulatory function for people with BPD (regulating their emotions) and/or are a natural result of their emotion dysregulation.

DBT structures treatment goals and targets by level of disorder:

Pre-Treatment: Commitment and Agreement (when treatment first begins)

Decreasing life-threatening behaviors, therapy-interfering behaviors (such as missing sessions or coming late), and quality-of-life interfering behaviors

Increasing behavioral skills: mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation

Stage I: Severe Behavioral Dyscontrol
Stability and behavioral control (goal)

Stage II: Quiet Desperation
Non-anguished emotional experiencing (goal)

Stage III: Problems in Living/Simple Disorders
Ordinary happiness/unhappiness (goal)

Stage IV: Incompleteness
Freedom and capacity for joy (goal)

DBT added to standard Cognitive Behavioral Therapy (CBT) :

• Model of suicidal behavior
• Acceptance with change
• Integration of evidence-based trainings
• Suicide risk and assessment protocol
• Skills-based on evidence-based trainings and mindfulness skills
• Definition of team as part of therapy

* In general, she stated that the mental health field is moving toward a model in which emotion dysregulation is being considered a core component underlying most disorders. As a result, she thought that it was possible to think that DBT could one day be considered a potential treatment in addressing many mental health disorders (aside from BPD).

* While DBT tends to be viewed as a treatment for people with BPD only, the data indicate that it is already useful for other disorders such as eating disorders and recurrent major depressive disorder.

Where are we going?

• DBT for high risk for suicidal adolescents
• Models for integrating other evidence-based interventions into DBT (Melanie Harned, PhD)
• DBT effects on parenting effects on adolescent suicidality
• Friends and family DBT skills training
• DBT skills as prevention in school systems (Mazza and Mazza)

For the evidence-based training and/or books on DBT, please seeBehavioral Tech, LLC.

Finally, below is an excellent video created by the Borderline Personality Disorder Resource Center at NewYork-Presbyterian called “Back From the Edge” which offers guidance on treating Borderline Personality Disorder.

Please note that an interview providing an introduction to dialectical behavior therapy will be coming shortly…

What are your thoughts about dialectical behavior therapy? What are your thoughts about where Marsha Linehan is thinking of taking DBT?

Reference:

Linehan, M., Marsha Linehan on DBT: Where we were, where we are, and where we are going training, May 3, 2012.

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Dialectical Behavior Therapy (DBT): a highly specialized form of Cognitive Behavioral Therapy (CBT) designed to help people with difficulty with emotion regulation. They may struggle in five areas of dysregulation:

• Emotional dysregulation: emotions may feel overwhelming, moods may change rapidly and feel out of control, and a person may feel very angry, sad or fearful and have emotional outbursts.
• Behavioral dysregulation: as a response to emotional suffering, a person may have strong urges to self-harm. They may engage in various impulsive behaviours such as drugs, alcohol, spending, gambling, eating binges, unsafe driving or unsafe sex.
• Interpersonal dysregulation: a person may go back and forth between love and hate in close relationships. Relationships may be stormy. There may be deep fear of abandonment and frantic efforts to avoid losing connection.
• Cognitive dysregulation: in stressful situations, a person may become hyper-vigilant or dissociate. They may feel that others are deliberately mean to them or out to hurt them them. At other times they may feel spaced out or emotionally numb as if watching things from a distance.
• Dysregulation or fragmentation in one’s sense of self: a person may feel empty inside, unsure of who they are, or questioning if they even have an identity. They may feel that they change all the time according to the people they are with. They may feel like they don’t even exist.

Many therapists incorporate DBT into their treatment, however, only a handful in the area are intensively trained and provide DBT effectively. DBT skills is a small portion of the treatment, which incorporates very specific techniques to help our clients build a life they embrace.

We pride ourselves on adherence and fidelity to the model. Adherence is the accuracy of the therapists’ delivery of DBT which includes factors such as movement, speed and flow; balancing acceptance and change. Fidelity is the extent to which different components (modes) of treatment are being delivered in a manner consistent with the principles of the treatment.

DBT asserts that pervasive difficulties in managing emotions arise in part from skills deficits. Accordingly, part of DBT is a weekly skills training group designed to remedy those deficits. In group, clients learn skills for better management of emotions, relationships, distress and focusing on the present moment. In conjunction with the group, clients in DBT attend once weekly individual therapy that is focused on applying the skills to their particular problems and goals. If a client has an existing individual therapist, the client would continue with their existing therapist, and we would collaborate on the skills.

Dialectical Behavioral Therapy Training

CBT and DBT therapists believe that some clients can not be helped by insightful discussions alone. Although insight can be helpful at times, learning new behaviors is critical in DBT. “Behavior” refers to anything a person thinks, feels, or does. Dialectical behavioral therapy uses a wide variety of techniques to help people change behaviors and build a “tool box” of skills.

Acceptance (Validation)

In DBT a combination of validation and collaboration leads to change. Clients will also focus on acceptance of those things in their lives that cannot be changed. DBT teaches skills enabling clients to walk through instead of reacting or running away from difficult situations.

Dialectics

Dialectics are one of the important unifying concepts that reflect how the mind fundamentally understands and perceives most core concepts and ideas. The field of psychology contains an abundance of such concepts, including self esteem, trust, courage, honesty, rage, passivity, withdrawal, impulsivity, inhibition, blame, worthiness, guilt, risk taking, and on and on. Dialectics are based in part on the fact that we cannot fully understand any of these abstract concepts without appreciating that they consist of bipolar opposites with a higher level of integration somewhere in between them.

Often individuals may see a different “truth” to the same problem, and therefore become polarized taking opposite positions on the subject. In DBT we learn to understand the various truths that are possible, and that it is likely that the real “truth” is not a pure polarized position, but rather some shade of grey between the two viewpoints.

Dialectical Behavioral Therapy Pdf

“Dialectics” is a complex concept with roots in philosophy and science.
It involves several assumptions about the nature of reality. Everything is connected to everything else; Change is constant and inevitable; and opposites can be integrated to form a closer approximation to the truth (which is always evolving).

DBT Theory and Background

Dr. Marsha Linehan, the creator of DBT, studied a group of chronically depressed patients struggling with suicidal ideation who were unresponsive to existing cognitive behavior therapies (CBT) were frequently emotionally dysregulated. By this she meant that they became intensely emotional and had great difficulty returning to baseline.

She reviewed the existing Behavior Therapy (BT) literature to see what techniques had already been proven to effectively modulate intense emotional states like anger, anxiety, depression, and fear. CBT techniques that worked for those emotional issues were a good starting point to test on the emotionally dysregulated population she wanted to help. She also identified how mindfulness skills developed by practices such as meditation, often seen in religious or spiritual practices, may benefit these clients. Applying these skills in the context of DBT is not dependent on any particular religious or spiritual belief. Mindfulness skills are utilized for many reasons. These DBT Skills enable group members to become more proficient at slowing down and observing, describing, and labeling their emotional experiences, thoughts, and other internal experiences. With practice those skills also help them to participate more in the present moment and become more effective in decision making and problem solving, precluding impulsive actions that might make situations worse, and exacerbate or prolong emotional distress.

Although she imported a variety of tools, she was able to group them in a well organized treatment package. And given that many of the skills are effective on their own for treating particular problems, it makes sense that group members learning how to utilize many of them together increase the probability they can address many different kinds of intrapersonal and interpersonal challenges.

Training Courses Dialectical Behavior Therapy

The Counseling Center of Maryland^TM offers an adherent DBT Program which includes the four components of DBT: skills training group, individual treatment, DBT phone coaching, and consultation team.

• DBT skills training group is focused on enhancing clients’ capabilities by teaching skills.
• DBT individual therapy is focused on helping clients to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for as long as the client is in therapy and runs concurrently with skills groups.
• DBT phone coaching is focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most.
• DBT therapist consultation team is intended to be therapy for the therapists and to support DBT providers in their work so they can provide the best treatment possible.

As its name suggests, DBT emphasizes dialectics — the reconciliation of opposites in a continual process of synthesis. DBT emphasizes the dialectic of acceptance and change in improving the quality of participants’ lives.

Dialectical Behavior Therapy (DBT) is a highly specialized form of CBT designed to help people with pervasive difficulties managing their emotions. These difficulties may be apparent in a variety of ways including self-destructive or self injurious behavior, anger management problems, binge eating, ongoing relationship conflicts, and self-hatred. DBT is a mindfulness-based therapy that balances the use of change strategies from cognitive behavioral therapy along with acceptance strategies.

“Participate more in the present moment and become more effective in decision making.”

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