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Dialectical Behaviour Therapy: Distinctive Features
Dialectical Behaviour Therapy (DBT) is a psychotherapeutic approach designed particularly to treat the problems of chronically suicidal individuals with borderline personality disorder (BPD). The therapy articulates a series of principles that effectively guide clinicians in responding to suicidal and other behaviours that challenge them when treating this population. Dialectical Behaviour Therapy highlights 30 distinctive features of the treatment and uses extensive clinical examples to demonstrate how the theory translates into practice. In part I: The Distinctive Theoretical Features of DBT, the authors introduce us to the three foundations on which the treatment rests -- behaviourism, Zen and dialectics -- and how these integrate. In part II: The Distinctive Practical Features of DBT, Swales and Heard describe both how the therapy applies these principles to the treatment of clients with borderline personality disorder and elucidate the distinctive conceptual twists in the application of cognitive and behavioural procedures within the treatment. This book provides a clear and structured overview of a complex treatment. It is written for both practicing clinicians and students wishing to learn more about DBT and how it differs from the other cognitive behaviour therapies.
- GenresPsychology
184 pages, Hardcover
First published December 1, 2008
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June 13, 2021
This is a professional development read. Dialectical Behaviour Therapy is the current go to therapy for the treatment of Borderline Personality Disorder (BPD). I was reading to remind myself of the concepts that underlie it’s process. What follows is fundamentally notes to myself of points that sung to me.
It is a principle-driven treatment “These principles are designed to enhance therapist effectiveness in applying the treatment adherently while remaining maximally responsive to the client” (p 4). My take is who follow a general philosophy, not rules based. Probably because people with BPD are really good at pointing out problems and inconsistencies with rules, and then the rules themselves become problematic. A perceived weakness with Cognitive Behavioural Therapy is that it is a protocol-driven treatment and does not have the flexibility of a philosophy,
“While CBTs provide the technology of change, Zen practice provides the technology of acceptance” (p 19). This builds on the above point. DBT aim to take the best of CBT and meld it with ‘Zen’, but I would argue psychodynamic strategies. I was a lot of psychodynamic strategies through out the book that were not acknowledged.
“The therapist does not try to protect the client from natural change but instead tries to help the client learn to cope with such change” (p 20). The philosophy of coping with discomfort underlies a lot of DBT.
“The identification of reinforcing consequences are an important component of functional analysis that endeavours to establish the purpose or function that a behaviour serves in the life of an individual. Functional analysis requires the identification of reinforcing consequences that maintain the behaviour. DBT applies functional analysis to the suicidal, multi-diagnostic client and looks explicitly for commonality of function across apparently disparate problem behaviours” (p37). I think this is addressing what is described as secondary gains in the old parlance. What is even unconsciously is the behaviour aiming to achieve? This should be discussed with the person. A psychodynamic approach would gently try to bring what is happening subconsciously, to the conscious.
“Zen suggests that suffering results primarily from attachments to or insatiable desires for reality to be a certain way” (p 43). Or to quote Shakespeare ‘for there is nothing either good or bad, but thinking makes it so’. This idea around attachment is embedded in Stoic thought. Eastern traditions are not the only traditions to recognise this. We have a long tradition in the West comparable to ‘Eastern’ thought.
“Members must commit to applying DBT as adherently as possible with clients. Members also agree to use the skills taught in DBT for themselves and to apply the therapy to themselves to solve problems in their DBT roles” (p 60). A lot of therapy is applying this stuff to yourself. You cannot control another, but you can role model and practise what you preach. “The importance of the DBT therapist receiving DBT themselves” (p 86).
“Stage 1. This stage of treatment assists clients to achieve behavioural stability, by reducing threats to life and other severely destabilizing behaviours. After Stage 1, clients may progress through some or all of the remaining stages or decide to end treatment. Stage 2 focuses on emotionally processing the past and is especially relevant for clients with a past history of trauma. Stage 3 aims to assist clients to return to ordinary levels of happiness and unhappiness. Problems at this stage of treatment are of low to moderate severity and have only a moderate impact on clients' functioning, in comparison to Stage 1 and 2 problems. Stage 3 problems may include marital, education or employment difficulties. Stage 4 aims to enhance the capacity for joy and focuses on assisting individuals for whom ordinary happiness and unhappiness remains insufficient and who continue to experience a degree of meaninglessness or absence of connectedness. At this stage, long-term insight-oriented therapies may prove beneficial, as may spiritual or religious practices” (p 71). This is worth remembering if I ever interview for a job where DBT is the model of use.
“DBT therapists counterbalance this approach with an emphasis on withdrawing treatment at the end of the contracted period if the client has made insufficient progress. Making further or increased input contingent upon progress within DBT contradicts the approach of many mental-health interventions, which tend to provide more input in response to deterioration or absence of progress. Such stacking of the systemic contingencies to enhance clients' motivation, however, characterizes DBT. Also, continuing to provide an ineffective treatment could be considered unethical. (p 75). If DBT is not working it is withdrawn. The less it is working, the less support is provided. Again my sense is that this addresses secondary gains. If a person likes what is happening and enjoys the support and skills gained, it is important that emotional self-regulation begins to occur.
“DBT organizes the primary targets in order of priority as follows: decreasing life-threatening behaviours, therapy-interfering behaviour, and quality-of-life-interfering behaviours and increasing behavioural skills (p 83)”. This is the structure and I am sure that people can move forward and backwards along this continuum, but must be making progress over time.
DBT stresses the importance of “Diary Cards” (p 87). If these are not completed by the person, they cannot progress. The person has work to do as well.
“When Linehan was developing the treatment, she observed that the incessant focus on change presented a major challenge to clients, often leading to treatment drop-out. She hypothesized that a constant focus on change when there are so many problems both overwhelms the client and invalidates his or her belief that he or she is incapable of change” (p 92). One of the themes was constantly balancing change with acceptance. Acceptance of the present that things are as they are, but that change towards better is possible.
“Validation does not require the therapist to be positive, rather the therapist conveys which aspects of the client's responses are accurate, regardless of whether they are positive or negative” (p 92). I am not a Pollyanna and always struggled with seeing everything as positive as a clinician. Acknowledgment and acceptance are the keys, the person often provides the judgement themselves.
“Level 6 validation is termed radical genuineness. When using this strategy, the therapist conveys his or her genuine human response to the client; he or she does not treat the client as fragile but rather like a robust individual who can hear the truth” (p 94). I like this. Too often people are completed as fragile, rather than given the traumas they have often suffered, they are strong survivors who have developed maladaptive coping mechanisms that are understandable in their past, but do not work in their present.
“DBT therapists must disclose only information in the best long-term interests of the client” (p 131). When it comes to self disclousure. I must ask myself. Why am I doing this and what is my aim that will benefit the individual? How am I being a catalyst for the best version of themselves?
“DBT recommends modelling a coping rather than mastery model of skill use. Many clients may experience a mastery model as demotivating, believing that such a level of competence is beyond them” (p 132). Agreed – Life is about coping day to day and thinking about how to cope better.
“In using the strategy of ``plunging in where angels fear to tread'' the therapist simply says directly and clearly what many would consider unsayable, without ``beating about the bush'' or ``hedging bets' (p 136)”. Say what is obvious, but potentially impolite. This plays to accepting things as they are, not pretending they are better than they are. Be genuine and frank with people.
“Just as the DBT therapist does not intervene to solve problems with other professionals on behalf of the client, the DBT therapist does not intervene with clients on behalf of other professionals” (p 141). I like the non-interventionist underlying philosophy. You do not take the problem from the person or rescue.
“The therapist would begin to treat the behaviour by describing the behaviour, without judgement or inferring intent, to the client. For example, a therapist would say: ``You just threatened to harm yourself if I don't extend the session'', rather than, ``You're trying to manipulate me'', or: ``I've noticed that you seldom complete your homework'', rather than, ``I think that you're sabotaging the therapy'' (p 144). A clear description of what is happening is what is required, without embellishing, ignoring, or exaggerating. Describe the events without emotional ladened language.
“Just as therapists treat clients' therapy-interfering behaviours, so too must they treat their own behaviours that stop or reverse the progress of the treatment. Examples of such therapy interfering behaviours include invalidating the valid, failing to target properly, not engaging the client in active problem solving, treating the client as overly fragile or reinforcing suicidal behaviour. These behaviours may result from some combination of the therapist's personal issues, clinical skills deficits, strong emotions or cognitive distortions during the session, or contingencies imposed by the system” (p 147). The most important person for a therapist to manage is themselves. Supervision and therapy for self is an important part of therapy.
I liked this and this review will become an important resource should I interview for a position where DBT is the model of care. I was surprised at how much it borrowed from psychodynamic approaches. A useful reference material.
It is a principle-driven treatment “These principles are designed to enhance therapist effectiveness in applying the treatment adherently while remaining maximally responsive to the client” (p 4). My take is who follow a general philosophy, not rules based. Probably because people with BPD are really good at pointing out problems and inconsistencies with rules, and then the rules themselves become problematic. A perceived weakness with Cognitive Behavioural Therapy is that it is a protocol-driven treatment and does not have the flexibility of a philosophy,
“While CBTs provide the technology of change, Zen practice provides the technology of acceptance” (p 19). This builds on the above point. DBT aim to take the best of CBT and meld it with ‘Zen’, but I would argue psychodynamic strategies. I was a lot of psychodynamic strategies through out the book that were not acknowledged.
“The therapist does not try to protect the client from natural change but instead tries to help the client learn to cope with such change” (p 20). The philosophy of coping with discomfort underlies a lot of DBT.
“The identification of reinforcing consequences are an important component of functional analysis that endeavours to establish the purpose or function that a behaviour serves in the life of an individual. Functional analysis requires the identification of reinforcing consequences that maintain the behaviour. DBT applies functional analysis to the suicidal, multi-diagnostic client and looks explicitly for commonality of function across apparently disparate problem behaviours” (p37). I think this is addressing what is described as secondary gains in the old parlance. What is even unconsciously is the behaviour aiming to achieve? This should be discussed with the person. A psychodynamic approach would gently try to bring what is happening subconsciously, to the conscious.
“Zen suggests that suffering results primarily from attachments to or insatiable desires for reality to be a certain way” (p 43). Or to quote Shakespeare ‘for there is nothing either good or bad, but thinking makes it so’. This idea around attachment is embedded in Stoic thought. Eastern traditions are not the only traditions to recognise this. We have a long tradition in the West comparable to ‘Eastern’ thought.
“Members must commit to applying DBT as adherently as possible with clients. Members also agree to use the skills taught in DBT for themselves and to apply the therapy to themselves to solve problems in their DBT roles” (p 60). A lot of therapy is applying this stuff to yourself. You cannot control another, but you can role model and practise what you preach. “The importance of the DBT therapist receiving DBT themselves” (p 86).
“Stage 1. This stage of treatment assists clients to achieve behavioural stability, by reducing threats to life and other severely destabilizing behaviours. After Stage 1, clients may progress through some or all of the remaining stages or decide to end treatment. Stage 2 focuses on emotionally processing the past and is especially relevant for clients with a past history of trauma. Stage 3 aims to assist clients to return to ordinary levels of happiness and unhappiness. Problems at this stage of treatment are of low to moderate severity and have only a moderate impact on clients' functioning, in comparison to Stage 1 and 2 problems. Stage 3 problems may include marital, education or employment difficulties. Stage 4 aims to enhance the capacity for joy and focuses on assisting individuals for whom ordinary happiness and unhappiness remains insufficient and who continue to experience a degree of meaninglessness or absence of connectedness. At this stage, long-term insight-oriented therapies may prove beneficial, as may spiritual or religious practices” (p 71). This is worth remembering if I ever interview for a job where DBT is the model of use.
“DBT therapists counterbalance this approach with an emphasis on withdrawing treatment at the end of the contracted period if the client has made insufficient progress. Making further or increased input contingent upon progress within DBT contradicts the approach of many mental-health interventions, which tend to provide more input in response to deterioration or absence of progress. Such stacking of the systemic contingencies to enhance clients' motivation, however, characterizes DBT. Also, continuing to provide an ineffective treatment could be considered unethical. (p 75). If DBT is not working it is withdrawn. The less it is working, the less support is provided. Again my sense is that this addresses secondary gains. If a person likes what is happening and enjoys the support and skills gained, it is important that emotional self-regulation begins to occur.
“DBT organizes the primary targets in order of priority as follows: decreasing life-threatening behaviours, therapy-interfering behaviour, and quality-of-life-interfering behaviours and increasing behavioural skills (p 83)”. This is the structure and I am sure that people can move forward and backwards along this continuum, but must be making progress over time.
DBT stresses the importance of “Diary Cards” (p 87). If these are not completed by the person, they cannot progress. The person has work to do as well.
“When Linehan was developing the treatment, she observed that the incessant focus on change presented a major challenge to clients, often leading to treatment drop-out. She hypothesized that a constant focus on change when there are so many problems both overwhelms the client and invalidates his or her belief that he or she is incapable of change” (p 92). One of the themes was constantly balancing change with acceptance. Acceptance of the present that things are as they are, but that change towards better is possible.
“Validation does not require the therapist to be positive, rather the therapist conveys which aspects of the client's responses are accurate, regardless of whether they are positive or negative” (p 92). I am not a Pollyanna and always struggled with seeing everything as positive as a clinician. Acknowledgment and acceptance are the keys, the person often provides the judgement themselves.
“Level 6 validation is termed radical genuineness. When using this strategy, the therapist conveys his or her genuine human response to the client; he or she does not treat the client as fragile but rather like a robust individual who can hear the truth” (p 94). I like this. Too often people are completed as fragile, rather than given the traumas they have often suffered, they are strong survivors who have developed maladaptive coping mechanisms that are understandable in their past, but do not work in their present.
“DBT therapists must disclose only information in the best long-term interests of the client” (p 131). When it comes to self disclousure. I must ask myself. Why am I doing this and what is my aim that will benefit the individual? How am I being a catalyst for the best version of themselves?
“DBT recommends modelling a coping rather than mastery model of skill use. Many clients may experience a mastery model as demotivating, believing that such a level of competence is beyond them” (p 132). Agreed – Life is about coping day to day and thinking about how to cope better.
“In using the strategy of ``plunging in where angels fear to tread'' the therapist simply says directly and clearly what many would consider unsayable, without ``beating about the bush'' or ``hedging bets' (p 136)”. Say what is obvious, but potentially impolite. This plays to accepting things as they are, not pretending they are better than they are. Be genuine and frank with people.
“Just as the DBT therapist does not intervene to solve problems with other professionals on behalf of the client, the DBT therapist does not intervene with clients on behalf of other professionals” (p 141). I like the non-interventionist underlying philosophy. You do not take the problem from the person or rescue.
“The therapist would begin to treat the behaviour by describing the behaviour, without judgement or inferring intent, to the client. For example, a therapist would say: ``You just threatened to harm yourself if I don't extend the session'', rather than, ``You're trying to manipulate me'', or: ``I've noticed that you seldom complete your homework'', rather than, ``I think that you're sabotaging the therapy'' (p 144). A clear description of what is happening is what is required, without embellishing, ignoring, or exaggerating. Describe the events without emotional ladened language.
“Just as therapists treat clients' therapy-interfering behaviours, so too must they treat their own behaviours that stop or reverse the progress of the treatment. Examples of such therapy interfering behaviours include invalidating the valid, failing to target properly, not engaging the client in active problem solving, treating the client as overly fragile or reinforcing suicidal behaviour. These behaviours may result from some combination of the therapist's personal issues, clinical skills deficits, strong emotions or cognitive distortions during the session, or contingencies imposed by the system” (p 147). The most important person for a therapist to manage is themselves. Supervision and therapy for self is an important part of therapy.
I liked this and this review will become an important resource should I interview for a position where DBT is the model of care. I was surprised at how much it borrowed from psychodynamic approaches. A useful reference material.
March 6, 2015
a really handy book to dip into to remind myself of the dbt principles inbetween sessions or when finding myself stuck.
Displaying 1 - 2 of 2 reviews