Dialectical behavior therapy: a review and call to research.
Smith, Lisa D.
Peck, Patrick L.
|Publication:||Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2004 American Mental Health Counselors Association ISSN: 1040-2861|
|Issue:||Date: Jan, 2004 Source Volume: 26 Source Issue: 1|
Dialectical behavior therapy (DBT; Linehan, 1993a) is a systematic
and integrative orientation to treating borderline personality disorder
Borderline personality disorder, or BPD, may present a myriad of
challenges and difficulties for the beginning as well as the seasoned
mental health professional Although some empirical support exists for
DBT, more is needed. The current article is, in essence, a call for
research, but is also an effort at introducing DBT and its foundations
and stages of individual and group therapy. The goal is to give the
reader a clearer understanding of DBT through a review of the empirical
evidence, the therapeutic process, and the implications for mental
Very few client populations are as challenging for mental health professionals as people with borderline personality disorder (BPD; Linehan, Cochran, & Kehrer, 2001). BPD has a prevalence rate of approximately 2% in the general population, but makes up about 10% of clients in outpatient mental health clinics (American Psychiatric Association, 2000). People with BPD are generally very demanding, stretching the boundaries of most mental health clinicians. For example, clients with BPD tend to display suicidal ideation, inflict self-harm, and have frequent crises. Further, because very few treatments have been found to be effective for people with BPD, many clients may seesaw between the outpatient mental health clinic and the local psychiatric hospital. To compound matters, training may be inadequate, colleagues and institutions may offer little support, and supervisors may lack the experience to help deal with the interpersonal demands required of counseling someone with BPD (Koons, Sloan, & Bellizi, 2002).
Although several approaches such as psychodynamic or interpersonal therapies have met with limited success in the past (Linehan et al., 2001), few theoretical orientations have the empirical support to back up their claims of effectiveness for treatment of people with BPD. One approach to treating BPD has stood out among other theories due to its integrative approach to therapy and its successful, though limited, outcomes in empirical studies. Dialectical behavior therapy (DBT; Linehan, 1993a), developed primarily for dealing with parasuicidal behaviors in women, has now been extended for work with BPD and on inpatient units, with adolescents, and for drug dependence (Katz, Gunasekara, & Miller, 2002; Koons et al., 2001; Linehan et al., 1999; Telch, Agras, & Linehan, 2000). DBT combines a dialectical worldview with standard cognitive-behavioral therapy to produce a unique combination of interventions that balances acceptance and change.
EMPIRICAL SUPPORT FOR DBT
Several studies have examined DBT in conjunction with BPD symptomology with persons who self-harm. Much of the research has compared DBT with the standard practice by therapists in the institution or clinic within which the study was conducted. This standard practice in each institution will be referred to as treatment as usual. With women who inflict self-harm, DBT has significantly reduced hopelessness, depression, anger, suicidal acts, dissociation, and frequency of parasuicidal behavior (Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon, and Heard, 1991). Studies also found that women were less angry, had better self-reported social adjustment, had fewer inpatient days in the hospital at 4, 8, and 12 months post treatment (Linehan et al.; Linehan, Tutek, Heard, & Armstrong, 1994), and maintained higher global functioning (Linehan, Heard, and Armstrong, 1993) after undergoing DBT. In another study with clients who inflicted harm on themselves, DBT decreased self-harm, dissociative experiences, depressive symptoms, suicidal ideation, and impulsivity (Low, Jones, Duggan, Power, & MacLeod, 2001), while another study's suicidal adolescent participants showed fewer psychiatric symptoms, less suicidal ideation, and fewer symptoms of BPD after 12 weeks (Rathus & Miller, 2002). Miller, Wyman, Huppert, Glassman, and Rathus (2000) found that specific skills such as mindfulness and distress tolerance skills increased and were found to be helpful to suicidal adolescents involved in DBT treatment. In another study (Turner, 2000) comparing DBT to client-centered therapy in individuals with BPD, the DBT group had fewer self-harm incidents, suicide attempts, and inpatient days than did the client-centered group, and the therapeutic alliance had a significant influence on outcomes.
DBT has also been applied to other treatment groups. In a pilot study with depressed elderly adults, medication plus DBT skills training decreased self-reported depression (Lynch, Morse, Mendelson, & Robins, 2003). With eating disordered clients, DBT has been implemented with limited success. Studies have found that after undergoing group skills training, women with a binge eating disorder were not bingeing at the conclusion of the training (Safer, Telch, & Agras, 2001) or at follow-up (Telch et al., 2000). The two largest predictors of relapse were early age of onset of binge eating disorder and dietary restraint (Safer, Lively, Telch, & Agras, 2002). In examining people with dual diagnoses of BPD and drug dependence, DBT treatment has met with mixed results. In one study (Linehan et al., 1999), dropout rates were higher in the treatment as usual group than in the DBT group, and the DBT group had reduced drug use. In another study, Linehan et al. (2002) reported on the effectiveness of DBT or DBT plus a 12-step program with women diagnosed with BPD and heroin dependence. The two groups were not different in their opiate use at the conclusion of and 4 months past treatment, and the DBT-only group had a significantly higher dropout rate than the DBT with 12-step group. Similarly, a clinical trial compared the effectiveness of DBT with women who have BPD and women who have BPD and substance abuse and found that DBT was useful for treating BPD, but was not more effective than the treatment as usual group in reducing substance abuse problems (van den Bosch, Verheul, Schippers, & van den Brink, 2002). Finally, Dimeff, Rizvi, Brown, and Linehan (2000) report that DBT is effective in treating methamphetamine dependence in women with BPD. Overall, the empirical support for DBT indicates that it is an effective treatment, but additional research is warranted and findings should be evaluated with a conceptual understanding of the treatment.
CONCEPTUAL OVERVIEW OF DIALECTICAL BEHAVIOR THERAPY
Components of DBT
The dialectical worldview, the first component of DBT, has three primary principles: interrelatedness and wholeness, polarity, and continuous change (Linehan, 1993a). DBT is systemic in that it is based on the assumptions surrounding the construct of interrelatedness and wholeness. Essentially, all people are intimately connected with their environment. People both influence and are influenced by the people and experiences that comprise their environment. The second principle of the dialectical worldview is that of polarity. Everything in the world has its opposite. This construct suggests that a natural and inescapable tension exists between these polar, and thereby contradictory, forces. Examples of opposing forces include life and death, good and bad, or trust and mistrust. The third principle of a dialectical worldview is that of continuous change. Change is constant and produced by the tension between two extremes, or opposing forces (i.e., polarities). Individuals and larger systems move from one static state to another in response to internal and external pressures exerted by naturally existing opposites. One obvious example of this process at the systemic level is the tug-of-war between conservative and liberal ideologies that exist in many forms of government. Any new homeostatic state achieved is subjected to the same polarity and change pressures, and thus the cycle continues. Therefore, as a whole, these principles imply that there is no absolute truth; rather, truth is situational, subject to change, and continually constructed over time. In addition, Zen Buddhism is another interrelated force driving DBT's dialectical worldview (Linehan, 1993a; Robins, 2002). Zen principles often place a premium on balance and serenity. In conjunction with the previously discussed principles, DBT emphasizes balance in the client's life. Clients are encouraged to walk the middle path by using such principles as mindfulness. Mindfulness is the integration of a person's emotional mind with his or her logical mind, resulting in a "wise mind [which] adds intuitive knowing to emotional experiencing and logical analysis" (Linehan, 1993b, p. 63).
Cognitive behavioral therapy is the second component of DBT. During each of the stages of treatment, the mental health practitioner utilizes cognitive behavioral techniques--keeping a thought diary, behavioral analyses, exposure techniques, flooding, contingency management, and shaping--in order to meet the treatment target goals (Linehan, 1993a). In addition, clients in DBT are required to participate in a weekly, manualized skills training, complete with homework assignments and a structure for each session (Linehan, 1993b).
Dialectical Theory of Borderline Personality Disorder Development
In Linehan's (1993a) development of a theory about how BPD develops in women, invalidating environments are a primary factor. Such environments are characterized by a parent's inappropriate, unpredictable, or extreme responses when a child communicates his or her experience. The child is told that he or she is wrong in his or her assessment of this situation and is, consequently, wrong about his or her emotional response, or understanding (both positive or negative). The child then attributes his or her internal experiences to unacceptable personality traits. For example, Jean, age 4, shares her sadness with her caregiver, who rejectingly responds, "You shouldn't cry. Good girls don't cry." She may then say to herself, "There must be something wrong with me for feeling this way."
Although a person may be biologically predisposed to BPD, invalidating environments have devastating consequences for a young person. First, consistent with the inappropriate and unpredictable caregiver responses, the person is not able or does not learn to label and regulate emotions as the rest of society does. Also, the person becomes intolerant of stress, has developed unrealistic goals, is easily disappointed, has learned that extreme emotions are required to elicit help, and is unable or has learned not to trust his or her own judgment (Linehan, 1993a). Second, an invalidating environment may change the biology in a young person, similar to the way sexual abuse, found commonly in the history of someone with BPD, can create changes in physiological/biological responses. Thus, because of the environment, the person's physiology may be altered or swayed toward emotional dysregulation.
There are five areas of dysregulation that characterize BPD (Linehan, 1993a). First, emotional dysregulation consists of emotional instability (i.e., ups and downs) and problems with anger such as temper tantrums or domestic violence. Second, interpersonal dysregulation refers to a pattern of unstable relationships and efforts to avoid loss. For example, a woman may enter a relationship with the expectation of immediate emotional intimacy and when that is not forthcoming right away, she may accuse the other person of not letting her in and break off the relationship. Third, behavioral dysregulation encompasses suicide threats and self-damaging (e.g., cutting the self) and impulsive behaviors (such as alcohol and drug abuse). Fourth, cognitive dysregulation consists of cognitive disturbances such as ruminating thoughts or dichotomous thinking. Fifth, self-dysregulation refers to an unstable self-image and a feeling of chronic emptiness. Unstable self-image refers to feeling competent and confident in one area, such as academics, and insecure in another area, like sexual performance.
These areas of dysregulation are consistent with six identifiable behavioral patterns (Linehan, 1993a).
* Emotional vulnerability is one identifiable pattern in persons with BPD. The person demonstrates a high sensitivity to emotional stimuli, including extreme emotional reactions characterized by failing to return to his or her emotional baseline very quickly because of an activation of maladaptive cognitive processes. For example, Sally, in response to her therapist having to reschedule their appointment due to a family emergency, raged for 3 hours, prolonging the reaction by telling herself, "I don't deserve to be treated like this. My counselor has no regard for what is going on in my life. She is a horrible therapist."
* Self-invalidation is the tendency to invalidate one's own experiences and includes self-hate, shame, anger at the self, and unrealistic expectations for the self. For example, after receiving a well-deserved A on a term paper, Billy feels proud of himself, but immediately squashes the feeling, saying to himself, "The professor probably didn't even read the paper. Or he made a mistake and gave me the wrong grade."
* Unrelenting crises are a pattern of frequent, negative events that take precedence over everything else in the person's life.
* Inhibited grieving refers to the restriction of emotions, particularly negative emotions (e.g., sadness, anger, shame, anxiety, panic). One example might be a person who has a death in her family but is unable to feel any of the typical emotions that often accompany that type of loss (Linehan et al., 2001).
* Active passivity is essentially learned helplessness and, more specifically, looking to others to help solve one's problems, which interferes in the person's learning to rely on his or her own judgment. An example of this may be the BPD client who initially comes into therapy and wants the therapist to tell her what to do.
* Apparent competence refers to the person appearing to be more competent than he or she really is. (Linehan, 1993a). Competence is inhibited by the inability to transfer skills or knowledge across mood states.
APPLICATION OF DIALECTICAL BEHAVIOR THERAPY
In using DBT, the mental health counselor will be guided by seven assumptions and several tenants (Koons et al., 2002). In terms of assumptions: first, clients are doing the best they can; second, clients want to improve; and third, clients must learn their new behaviors in each and all relevant contexts. Fourth, clients cannot fail in DBT, meaning that any effort the client makes on behalf of bettering himself or herself is considered progress. Fifth, clients may not have caused all of their own problems, but they have to solve them anyway; and sixth, clients need to do better, try harder, or be more motivated to change. Although this assumption may seem inconsistent with the fourth assumption, it is consistent with the dialectical framework that is the foundation of DBT. This dialectical framework allows the therapist to both accept the client where he or she is (i.e., any effort is viewed as progress), while at the same time, challenging the client to do better and do more. The seventh assumption is that the lives of suicidal, borderline individuals are unbearable as they are currently being lived (Koons et al.). Other characteristics of DBT include a one-year treatment agreement, concurrent group skills training, and an agreement on attendance that involves calling if tardy or absent and arranging for missed appointments. Mental health professionals schedule telephone check-ups for clients and also allow phone calls only when the client has not reached a crisis state. If the client calls and has just attempted suicide or inflicted self-harm, the counselor establishes minimal safety (i.e., calls 911), and then refuses to talk to the client until the crisis has abated. In this way the therapist begins to shape the client toward non-crisis behavior. Thus, the therapeutic relationship is particularly important in the beginning of therapy in order to secure the client's commitment to the counseling process (Shearin & Linehan, 1989). Once established, the mental health practitioner uses the therapeutic relationship to, in essence, "blackmail" (Linehan, 1993a, p.134) the client into improving healthier behaviors.
Stages of Treatment
DBT consists of four stages of treatment. Prior to stage one, the client's commitment and agreement to the requirements of the DBT process are secured. Many clients with BPD are not accustomed to a yearlong commitment to treatment, nor to the 4 hours of individual, group, and consultation sessions each week. Nonetheless, this part of treatment is essential to DBT's success. The mental health counselor needs to spend as long as necessary convincing the client that it is critical to commit to therapy. If clients are not willing to commit to the year of therapy, mental health counselors should not use DBT as a treatment (Linehan, 1993a).
Stage one consists of the mental health counselor facilitating the client's attainment of basic capacities in three areas. One treatment task addressed by the mental health practitioner is decreasing life-threatening behaviors (e.g., threats, attempts, ideation, and communication about harming oneself). In DBT, suicidal behaviors are viewed as maladaptive problem solving--that is, the therapist acknowledges that an attempt was made at relying on oneself to solve one's problems. The solution (i.e., suicide), however, was not the most adaptive choice. The mental health counselor also focuses on therapy-interfering behaviors, for example a failure to establish a therapeutic relationship, pushing the therapist's limits (i.e., showing up at the therapist's home or staff splitting), and openly hostile attacks on other clients during group skills training. The mental health counselor's third targeted area is behaviors that interfere in the quality of life--substance abuse, risky sex, and mismanagement of survival tasks such as food, housing, employment, and finances. In stage one the mental health counselor also focuses on the additional tasks of increasing mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance, and self-management.
In stage two of DBT, the mental health professional focuses on reducing posttraumatic stress. Because almost 75% of the women diagnosed with BPD are victims of childhood sexual abuse (Linehan et al., 2001), and because most clients have symptoms consistent with post-traumatic stress, a specific focus on posttraumatic stress is a central feature of DBT. However, a person with BPD cannot adequately work through his or her trauma without successfully completing stage one of DBT. The skills gained in stage one enable the client to sustain the self when dealing with post-traumatic stress through interventions such as flooding or systematic desensitization (Becker & Zayfert, 2001).
For stage three, the mental health counselor shifts the therapeutic focus to increasing the client's self-respect and achieving individual goals. Again, a progression through the first two stages is deemed a necessary precursor to entering stage three. During stage three, the client with BPD is starting to transfer his or her newly learned skills to every area of life. Clients can actually look toward their future and plan for it. Clients in this third stage have learned to ask the therapist for help in an appropriate way, and they focus on reducing self-hate and shame. Any relapses to stage one or two are usually brief.
During stage four, which is designed to increase the capacity for sustained joy, the client continues to generalize his or her behaviors and skills, and works to integrate an identity as someone who has overcome BPD. In using DBT, the mental health practitioner recognizes that individuals usually feel incomplete, even after successful treatment; therefore, in stage four, the therapeutic focus shifts to the client's accepting reality as is and integrating the self with the past, the present, and the future (Koons et al., 2002; Linehan, 1993a). When accomplished, this work provides the client with a more integrated self, more adaptive coping mechanisms, and an acceptance for the self.
Concurrent Group Skills Training
As mentioned above, DBT consists of simultaneous individual and group sessions. The group skills training is organized into four modules: (a) core mindfulness skills, consisting of observing, describing, and participating in one's environment as well as adopting a nonjudgmental stance; (b) interpersonal effectiveness skills, which are getting one's own objectives or goals into the situation, keeping a good relationship while achieving one's objectives, or improving one's self-respect while achieving objectives; (c) emotion regulation skills, including understanding and identifying emotions, reducing emotional vulnerability, and decreasing emotional suffering, and; (d) distress tolerance skills, which are knowing how to get through a crisis without doing something that makes things worse, distracting oneself, self-soothing, improving the moment, and listing pros and cons (Linehan, 1993b). In terms of structure, each of the four modules is delivered in a similar 8-week format, resulting in approximately 32 weeks of skills training. Each session is structured, with handouts provided to participants each week. In session one, an orientation to the skills training is covered. In session two Core Mindfulness Skills are taught. In sessions three through seven, the skills specific to the module (i.e., Core Mindfulness, Interpersonal Effectiveness, Emotion Regulation, or Distress Tolerance) are taught, with session eight being a wrap-up session.
IMPLICATIONS FOR MENTAL HEALTH COUNSELORS
There are several advantages to implementing DBT in mental health counseling. In the current integrative culture of psychotherapy (Norcross & Goldfried, 1992), DBT is unique in integrating cognitive behavioral theory and a dialectical worldview (Becker & Zayfert, 2001; Robins, 2002). DBT can appeal to those mental health practitioners seeking a structural balance, which is enough structure to guide therapy, and enough freedom within the therapeutic relationship to allow for creativity. Because DBT's individual and group treatments are manualized and have specific tasks for the therapist, the approach is easy for the beginning practitioner to comprehend and utilize. On the other hand, given its complex and challenging dialectical framework and the integration of theoretical orientations, DBT appeals to the seasoned mental health practitioner as well. Another unique feature of DBT, its utilization of a consultation team in weekly meetings with clients, makes the model amenable to collaborative endeavors. The weekly consultation provides beginning mental health counselors with a support team that may be lacking in some community mental health settings. For even the seasoned mental health professional, DBT's regular consultation can serve to prevent therapist burnout and head off potentially problematic therapist and client behaviors. Moreover, mental health institutions could choose to undertake the implementation of DBT by using several different mental health counselors. Working with BPD clients can be challenging and maintaining appropriate boundaries could prove daunting (Kim & Goff, 2000). However, if several mental health counselors undertook a component part of the DBT process (i.e., individual therapy or group skills training), then collaboration and consultation would be necessary. DBT used in this manner could potentially promote a team approach, help maintain the mental health counselors well-being by reducing the overall strain of working with extremely difficult client populations (Swenson, Torrey, & Koerner, 2002), and enabling the mental health counselors to check-out aspects of the client's progress, story, and potential risk factors.
In addition to collaboration within institutions, mental health counselors from outside mental health institutions such as private practitioners could potentially partner with mental health institutions and both could benefit. For instance, many clients may be involved in a multi-layered system and receive services from several different mental health providers. If these mental health providers were to coordinate and provide differing aspects (i.e., concurrent group counseling and individual counseling) of the DBT model, continuity of therapeutic messages would increase, and the client would be less likely to fixate on only one helper's interventions (Linehan et al. 2001). Many BPD clients may move back and forth between outpatient clinics and psychiatric (or other) residential facilities. Clearly the client would benefit from the integration of treatment across institutions and mental health providers, as would mental health providers and agencies.
Conversely, DBT has several difficulties in implementation. First, DBT is seemingly simple, but in actual practice can be very complicated. Most DBT mental health practitioners recommend that agencies wishing to implement a DBT treatment program attend one of numerous available trainings (Koons et al., 2002). However, DBT trainers will not consider single mental health practitioners for the most intensive training available (Swenson et al., 2002). Therefore, mental health professionals who wish to implement DBT must have the backing of their agency or at least have enough people to form the consultation team in order to qualify for the training and the implementation of DBT. The consult team is another problematic point for implementation. Although this aspect can be very appealing to mental health practitioners, few mental health agencies or mental health professionals have the time to devote to weekly consultations for each BPD client.
A second difficulty related to utilizing DBT is the length of treatment, which is at minimum one year and which typically can last much longer (Linehan, 1993a). One issue related to length of treatment is the turnover rate of mental health professionals in mental health facilities. Mental health counselors are typically not in the same setting for the minimum one year requirement. Reimbursement for services is often a problem with DBT as well (Swenson et al., 2002). Individual psychotherapy may be covered for 10-20 sessions, but insurance companies typically will not reimburse for the group skills training, consultation meetings, or telephone interventions. Some mental health professionals have asked insurance companies to transfer funds from inpatient coverage to outpatient coverage enabling additional reimbursement for group and individual therapy, but this has met with limited success (Kim & Goff, 2000).
Overall, mental health counselors using DBT gain attractive perks, including a manualized approach to treatment, a support system in the consultation team, and an integrative approach to treatment. Nonetheless, there are also some disadvantages, mostly logistic, that could prevent successful implementation of DBT in mental health centers--namely, the cost of implementation due to training, the extra time devoted to treatment, and the problems with reimbursement, which could be prohibitive to a community agency already operating on meager funds. Despite these difficulties, the utilization and integration of DBT into a standard of practice for clients with BPD seems promising. Given the model's potential for benefiting the client, for collaborating within and among treatment institutions, and for ameliorating mental health practitioners' drain, DBT deserves greater attention from researchers.
SUGGESTIONS FOR RESEARCH
The empirical base for DBT, which was reviewed previously, is promising given its recent entry into the therapeutic literature. More research is needed, however, in particular research centered on its effectiveness within community mental health clinics. Because DBT would be considered relatively long-term therapy by today's standards, it is a therapy that could value from both base-line qualitative and longitudinal studies (McLeod, 1994; Patton, 2002). Perhaps the most useful research, initially, would be case-study methodology (Lundervold & Belwood, 2000) that examines the quality and effectiveness of the DBT model with a very limited group of subjects. Although the generalizability of such research is limited, it does have the potential for illuminating various aspects of DBT's therapeutic process. For instance, DBT is a multi-stage model that uses different interventions at each stage, and focusing on one intervention with one person at one stage could provide useful information to the mental health professional. The empirical evidence to date is promising but has focused solely on the initial stage of therapy. Clearly, the next logical step is to examine and validate stages 2-4. In addition, researchers could investigate the component aspects of DBT. To study aspects of DBT separately, although theoretically inconsistent with the model (i.e., principles of wholeness/interrelatedness), would provide useful information about the efficacy of DBT as it might be applied in real-world situations and institutions. Moreover, continuing research with DBT needs to focus on replicating the preliminary findings with regard to the efficacy of DBT. Validation of the model is incomplete without replication that utilizes different mental health practitioners, different institutional settings, and differing client populations. Then, ultimately, comparative analyses are also necessary. Comparing DBT with other models, techniques, and theoretical orientations may be necessary to determine the therapeutic factors involved that make DBT, or another model, more desirable when treating individuals with BPD, that is, identifying the necessary and sufficient elements for therapy with particular clients.
Finally, institutional and/or independent research on the efficacy of DBT may provide a basis for financial support for and allow for the possibility of integration and collaboration. Collaboration in the development and implementation of research projects could encourage greater levels of therapeutic continuity, consultation, and institutional cooperation, and might increase the chance of getting a grant to fund the research. Research results advance the therapeutic literature, may enhance empirical support of DBT treatment, and provide mental health counselors with a basis for implementing therapy that is advantageous for the client.
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Lisa D. Smith, is a doctoral student in Counseling Psychology, Department of Counseling, Educational Psychology, and Research, University of Memphis, TN. E-mail: email@example.com. Patrick L. Peck, Ed.D., is a professor in the Department of Psychology and Counseling, Arkansas State University, State University.
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