Dialectical Behavior Therapy: Clinical Outcomes and Essential Characteristics Marsha M. Linehan University of Washington Linehan, et al., 2001 Copyright 2004 by Marsha M. Linehan

DBT is a cognitive-behavioral therapy designed for the severe and chronic multi-diagnostic, difficult-to-treat patient with both Axis I and Axis II disorders

Borderline Personality Disorder (Re-organized) Emotion Dysregulation Affective lability & Problems with anger Interpersonal Dysregulation Chaotic relationships & Fears of abandonment Self Dysregulation Identity disturbance/confused sense of self Sense of emptiness Behavioral Dysregulation Parasuicidal behavior & Impulsive behavior Cognitive Dysregulation Dissociative responses &/or paranoid ideation Copyright 2004 by Marsha M. Linehan

Randomized Clinical Trials (6 with BPD) DBT Superior to Comparison Treatments Reducing: Suicide attempts and self-injury Premature drop-out Inpatient/ER admissions and days Drug abuse Depression, hopelessness, anger Impulsiveness Increasing: Global adjustment Social adjustment (See Lieb, K., Zanarini, M., Linehan, M.M. and Bohus, M. Seminar Section: Borderline Personality Disorder. The Lancet 2004;364:453-61.) Copyright 2004 by Marsha M. Linehan

DBT grew out of an iterative attempt (1971- ) to apply behavioral principles and standard cognitive behavior therapy to highly suicidal patients with Borderline Personality Disorder Copyright 2004 by Marsha M. Linehan

Workshop goals Learn the essential characteristics of DBT Assess whether DBT (in whole or in part) may be useful in your practice Decide if you are interested in further training in DBT In leaving you will probably have more questions than answers—and may want to get further training. In 6 hours—we will not have time to get through much of what DBT is at all. However—I do want to teach you the basic features, help you evaluate if DBT might be useful for you, and decide if you are interested in reading the entire book and or getting further training. BEFORE NEXT SLIDE— Now a unique feature of DBT is that in large part—it treats the therapist. A central idea is that the therapist shifts his/her way of thinking in order to shift the patient’s frame. So, the therapist practices DBT skills as well. So—one way we typically start our DBT supervision meetings (consultation) is to do a brief practice of mindfulness skills. Copyright 2004 by Marsha M. Linehan

Attempt to Reduce or Avoid Model Attempt to Reduce or Avoid the Painful Emotion PROBLEM BEHAVIOR EMOTION DYSREGULATION CUE OR TRIGGER TEMPORARY RELIEF

Impaired Cognitive Processing Intense Effort to Control Problem 1 !!AROUSAL!! SENSE OF OUT-OF-CONTROL FOCUS ON CHANGE Impaired Cognitive Processing + Intense Effort to Control

Shut Down, Withdrew, Quit or The Client Shut Down, Withdrew, Quit or ATTACKED

The Problem Further !!AROUSAL!! FOCUS ON ACCEPTANCE INVALIDATION SENSE OF OUT-OF-CONTROL INVALIDATION OF SUFFERING

Solution Was to Apply A Dialectical Approach Balancing Acceptance Strategies Change Strategies

Attempt to Reduce or Avoid Problem 2: Attempt to Reduce or Avoid the Painful Emotion Problem Behavior 1 EMOTION DYSREGULATION CUE OR TRIGGER Problem Behavior 2 Problem Behavior i TEMPORARY RELIEF

Percent Axis I Diagnoses: BPD Chronically Suicidal Patients Diagnosis Lifetime Current Major depression 96.7% 75.0% Dysthymic disorder N/A 14.3% Substance abuse 15.2% 5.4% Substance dependence 56.5% 26.1% PTSD 56.5% 51.1% Social phobia 21.7% 16.3% Panic disorder 52.2% 40.2% OCD 23.9% 19.8% Eating disorder 41.3% 23.9% Linehan et al., 2004 APA presentation

LOW Distress Tolerance Problem 2: Problem Behaviors 4,5…. LOW Distress Tolerance Problem Behavior 2 Problem Behavior 1 EMOTION DYSREGULATION Problem Behavior 2 CUE OR TRIGGER Problem Behavior 2 Problem Behavior i TEMPORARY RELIEF

Female Inner City Residential Treatment Correlation between a measure of distress tolerance (PASAT) and BPD (BSL) Female Inner City Residential Treatment Seeking Drug Users < ½ SD below BPD patient mean Lejuez, Daughters, Wolf, Kosson, & Lynch.(under review).

Solution Was to Teach Two Sets of New Behaviors Acceptance Skills Change Skills

Solution Was to Apply A Dialectical Approach Balancing Acceptance Validation Change Problem Solving Dialectics

Definition of Dialectics: “worldview… “debate…establishing truths on both sides rather than disproving one argument” Encarta World, English Dictionary, North American Edition

Dialectical World View Holistic, connected, and in relationship Complex, oppositional, and in polarity Change is continual Change is transactional Identity is relational and in continuous change Copyright 2004 by Marsha M. Linehan

BPD is a Systemic Emotion Regulation Disorder BPD criterion behaviors function to regulate emotions or are a natural consequence of emotion dysregulation

Emotion Dysregulation Emotional Vulnerability Inability to Modulate Emotions

BPD results from transaction of biological vulnerability with invalidation over time Ai BPD

Invalidating Environment Invalidates (punishes, ignores) behavior independent of the actual validity of the behavior Copyright 2004 by Marsha M. Linehan

Characteristics of an Invalidating Environment 1. INDISCRIMINATELY REJECTS communication of private experiences and self-generated behaviors 2. PUNISHES emotional displays and INTERMITTENTLY REINFORCES emotional escalation 3. OVER-SIMPLIFIES ease of problem solving and meeting goals Invalidating Environment Teaches Individual to: 1. Actively self invalidate and search social environment cues on how to respond 2. Oscillate between emotional inhibition and extreme emotional styles 3. Form unrealistic goals and expectations Copyright 2004 by Marsha M. Linehan

STEP 1 Treatment STRUCTURE the

FLEXIBLE COMPREHENSIVE PRINCIPLE-DRIVEN STANDARD DBT is.. FLEXIBLE COMPREHENSIVE PRINCIPLE-DRIVEN Make teaching points on rule-governed treatment v. principle driven treatments. Protocols v. Principles. DBT having protocols and principles. Copyright 2004 by Marsha M. Linehan

Standard DBT Modes Outpatient Individual Psychotherapy Outpatient Group Skills Training Telephone Consultation Therapists’ Consultation Meeting Uncontrolled Ancillary Treatments Pharmacotherapy Acute-Inpatient Psychiatric Copyright 2004 by Marsha M. Linehan

5 Functions of All Comprehensive Treatments 1. Enhance capabilities 2. Improve motivational factors 3. Assure generalization to natural environment Structure the environment Enhance therapist capabilities and motivation to treat effectively Copyright 2004 by Marsha M. Linehan

Commitment and Agreement Stages of Treatment Commitment and Agreement Pre-Treatment: Stage 1: Severe Behavioral Dyscontrol Behavioral Control Stage 2: Quiet Desperation Emotional Experiencing Stage 3: Problems in Living Ordinary Happiness /Unhappiness Stage 4: Incompleteness Capacity for Joy and Freedom

Stage 1 Primary Targets Dialectical Synthesis Commitment & Agreement Pre-Treatment: Decrease Life-threatening behaviors Therapy-interfering behaviors Quality-of-life interfering behaviors Increase behavioral skills Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion Regulation

Dialectical Synthesis - the “middle path” - Dialectical Analyses Truth is sought through efforts to discover what is left out of current ways of ordering events Dialectical Lifestyle: Balanced Behavior Patterns Balanced actions Balanced emotions Balanced cognition

DBT Targets for Skills Training Decrease behaviors likely to destroy therapy Increase skill acquisition/ strengthen skills Decrease treatment interfering behaviors Copyright 2004 by Marsha M. Linehan

DBT Targets for Phone Calls For the Individual Therapist DECREASE suicide crises behaviors INCREASE generalization of DBT behavioral skills DECREASE sense of conflict, alienation, distance with therapist Copyright 2004 by Marsha M. Linehan

DBT Therapists OBSERVE Their Own Limits Don't Panic !!!!!!!

STEP 2 Do Behavior Therapy

Basic Behavioral Paradigm Cue Problem Behavior Consequences

Emotion Dysregulation Basic DBT Paradigm Cue Emotion Dysregulation Problem Behavior Consequences

COGNITIVE MODIFICATION DBT Problem Solving S T A N D R C B Behavioral Analysis Insight Solution Analysis Didactic Orienting Commitment SKILLS TRAINING CONTINGENCIES EXPOSURE COGNITIVE MODIFICATION

1st Figure out the problem: Conduct a Behavioral Analysis Copyright 2004 by Marsha M. Linehan

Analyze the chain of events moment-to-moment overtime VULNERABILITY PROBLEM BEHAVIOR PROMPTING EVENT LINKS CONSEQUENCES

2nd Figure out what to do: Generate solutions and new behaviors Copyright 2004 by Marsha M. Linehan

Possible Solutions Solve the problem Change emotional reaction to the problem Radically Accept and Tolerate the problem Stay miserable

3rd Address factors getting in the way of new behaviors: Apply Contingencies Teach New Skills Break Maladaptive Associations Modify Cognitions

Contingency Management Goal Strengthen Behavior Weaken Suppress Consequence -Add Reinforcer -Remove Aversive -Withhold Reinforcer -Maintain Aversive -Add Aversive -Remove Positive

Contingency Management Changes the Hierarchy of Behavior Maladaptive Behavior Punish/ Extinguish Adaptive Behavior 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 high REINFORCE low STRENGTH OF BEHAVIOR Copyright 2004 by Marsha M. Linehan

Distress Tolerance Interpersonal Effectiveness SKILLS TRAINING Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion Regulation

DBT as ... Cue Exposure Response Prevention Opposite Action

4th Give needed information: Do Psychoeducation (DBT Didactic Strategies) Copyright 2004 by Marsha M. Linehan

5th Explain the rationale: Orienting to Treatment Describe the general task Link to C’s goals (rationale) Link to specific expectations and behaviors Rehearse new expectations Copyright 2004 by Marsha M. Linehan

6th Get a commitment: Strengthen it, get it again, strengthen it, get it again…. Copyright 2004 by Marsha M. Linehan

Core Strategy PROBLEM SOLVING Copyright 2004 by Marsha M. Linehan

STEP 3 add Validation

Validation Defined Synonyms "The action of validating or making valid…a strengthening, reinforcement, confirming; an establishing or ratifying" as valid Synonyms To Confirm To Authenticate To Corroborate To Substantiate To Verify Copyright 2004 by Marsha M. Linehan

Levels of Validation 1. Staying Awake: Unbiased listening and observing 2. Accurate reflection 3. Articulating the unverbalized emotions, thoughts, or behavior patterns 4. Validation in terms of past learning or biological dysfunction 5. Validation in terms of present context or normative functioning 6. Radical Genuineness Copyright 2004 by Marsha M. Linehan

Acceptance Validation Core Strategy Acceptance Validation Copyright 2004 by Marsha M. Linehan

STEP 4 Apply Dialectics

Dialectics: Step by Step Step 1: Adopt and model a dialectical world view Step 2: Balance treatment strategies and therapeutic positions. Step 3: When polarization occurs, work for a synthesis. Step 4: When one dialectical strategy doesn’t work, try another Copyright 2004 by Marsha M. Linehan

1. Model a Dialectical World View Teach biosocial theory of etiology. Development and maintenance of disorder is transactional. Disorder is systemic. Search for “what is left out.” Disorder occurs when focus is on part without reference to whole. Allow natural change. Copyright 2004 by Marsha M. Linehan

2. Balance Treatment Strategies Change Acceptance Core Problem Solving Irreverence Validation Team Consultation Reciprocity Environmental Intervention Consultation- to-the-Patient Copyright 2004 by Marsha M. Linehan

3. When Polarization Occurs Search for The Synthesis Invoke “WISE MIND”

4. When one dialectical strategy doesn’t work, try another Magnify the tension between opposites Devil’s Advocate Extending Enter the paradox And versus But Making Lemonade out of lemons Develop Metaphors Stories Analogies

STEP 5 DBT as Practice

In DBT, The Therapist Acting from Wise Mind... practices Observing (Just Notices) Describing (Puts Words On) Participating (Acts Intuitively from Wise Mind) and is Non-Judgmental (Neither Good nor Bad) One-Mindful (In-the-Moment) Effective (Focus on What Works) 50.20 Copyright 2004 by Marsha M. Linehan

Don't Panic !!!!!!! You can do this!