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

2. 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

3. 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 by Marsha M. Linehan

4. 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: )
Copyright by Marsha M. Linehan

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

6. 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 by Marsha M. Linehan

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

8. 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

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

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

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

12. 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

13. 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 % 51.1%
Social phobia % 16.3%
Panic disorder % 40.2%
OCD % 19.8%
Eating disorder 41.3% 23.9%
Linehan et al., 2004 APA presentation

14. 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

15. 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).

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

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

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

19. 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 by Marsha M. Linehan

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

21. Emotion Dysregulation
Emotional Vulnerability
Inability to Modulate Emotions

22. BPD results from transaction of biological vulnerability with invalidation over timeAi
BPD

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

24. 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 by Marsha M. Linehan

25. STEP 1
Treatment
STRUCTURE
the

26. 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 by Marsha M. Linehan

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

28. 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 by Marsha M. Linehan

29. 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

30. 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

31. 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

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

33. 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 by Marsha M. Linehan

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

35. STEP 2 Do
Behavior
Therapy

36. Basic Behavioral Paradigm
Cue
Problem Behavior
Consequences

37. Emotion Dysregulation
Basic DBT Paradigm
Cue
Emotion Dysregulation
Problem Behavior
Consequences

38. 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

39. 1st Figure out the problem: Conduct a Behavioral Analysis
Copyright by Marsha M. Linehan

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

41. 2nd Figure out what to do: Generate solutions and new behaviors
Copyright by Marsha M. Linehan

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

43. 3rd Address factors getting in the way of new behaviors:
Apply Contingencies
Teach New Skills
Break Maladaptive Associations
Modify Cognitions

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

45. 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 by Marsha M. Linehan

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

47. DBT as
...
Cue Exposure
Response Prevention
Opposite
Action

48. 4th Give needed information: Do Psychoeducation (DBT Didactic Strategies)
Copyright by Marsha M. Linehan

49. 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 by Marsha M. Linehan

50. 6th Get a commitment: Strengthen it, get it again, strengthen it, get it again….
Copyright by Marsha M. Linehan

51. Core Strategy
PROBLEM
SOLVING
Copyright by Marsha M. Linehan

52. STEP 3
add
Validation

53. 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 by Marsha M. Linehan

54. 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 by Marsha M. Linehan

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

56. STEP 4
Apply
Dialectics

57. 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 by Marsha M. Linehan

58. 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 by Marsha M. Linehan

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

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

61. 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

62. STEP 5
DBT as
Practice

63. 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 by Marsha M. Linehan

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