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Dialectical Behavior Therapy (DBT)HistoryMarsha Lineham pioneered dialectical Behavior Therapy. Based on the idea that psychosocial treatment of those with Borderline Personality Disorder is just as important in controlling the condition as the traditional methods of psycho- and pharmacotherapy. Included, as part of this belief was a hierarchical structure of treatment goals with the most important one being to reduce parasuicidal and life threatening behaviors. The next goal of the therapy was to reduce behaviors that interfered with the therapy and treatment process, and lastly, to reduce behaviors that reduced the client’s quality of life. The TheoryDialectical Behavior Therapy maintains the premise that some people react abnormally to emotional stimulation as a result of invalidating environments during upbringing and due to unknown biological factors. Additionally, their level of arousal increases quicker, peaks at a high level, and requires more time to return to baseline. This provides the insight into why borderlines tend to have crisis-strewn lives and extreme emotional shifts. Their past invalidation prevents them from having any methods for coping with these sudden, intense surges of emotion. DBT is a method that will teach the skills necessary to provide help in that task. Stages of Therapy and Treatment Targets Patients with Borderline Personality Disorder have multiple problems that can pose problems for the therapists in developing a proper course of treatment. In Dialectical Behavior Therapy, this problem is directly addressed. The continuation of therapy is organized into a number of stages and structured in terms of hierarchies of target goals at each stage. In the PRE-TREATMENT stage, focus is on assessment, commitment and orientation into the process of therapy. STAGE 1 focuses on suicidal behaviors and behaviors that interfere with therapy and the quality of life. STAGE 2 focuses on post-traumatic stress issues and related problems. STAGE 3 focuses on issues of self0esteem and individual treatment goals. Before moving on to the next phase, the targeted behaviors of each stage are brought under control. Post-traumatic stress related problems such as those related to childhood sexual abuse are only dealt with directly after Stage 1 has been successfully completed. Doing this would create a potential risk of an increase in serious self-injury. Any problems of this type such as flashbacks that emerge while the patient is still in stages 1 or 2 are dealt with using techniques known as “distress tolerance.” In Stage 2, the treatment of PTSD involves exposure to memories of the past trauma. At each stage of therapy, focus is placed on the specific targets for stages that are arranged in a definite hierarchy based on relative importance. These targets vary between the different modes of therapy but it is essential for therapists working in each mode to have a clear understanding what those targets are. In every mode, the overall goal is to increase dialectical thinking. The patient is required to record instances of targeted behaviours on the weekly diary cards. Failure to do so is regarded as therapy interfering behaviour. How It WorksDialectical Behavior Therapy is comprised of the following two parts: Weekly psychotherapy sessions are held in which a particular problematic behavior or event from the past is explored in detail. This begins with the chain of events that lead up to it, going through other possible solutions that might have been used, and examining reasons the client did not use for adaptive solutions to the problem. During and between sessions, the therapist will actively teach and reinforce adaptive behaviors, especially when they occur within the therapeutic relationship. Emphasis is placed on teaching patients how to manage emotional trauma instead of reducing or taking them out of crises. Telephone contact with the individual therapist in between sessions is another part of Dialectical Behavior Therapy procedures. Dialectical Behavior Therapy targets behaviors in a descending hierarchy as follows: Decreasing behaviors that may place the patient in the high-risk suicidal category Decreasing responses or behaviors that are interfering with the patient’s therapy Decreasing behaviors that interfere with or reduce the quality of life for the patient. Decreasing and learning to deal with any post-traumatic stress responses that are occurring. Enhancing the patient’s respect for himself/herself Acquisition of the behavior skills that are taught in-group sessions Additional goals are to be set by patient 2.Patient will attend weekly 2-1/2 hour group therapy sessions in which interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills are taught. Group therapists are not available over the phone between sessions, but will refer patients in crisis to the individual therapist. Follow Up Studies Since Linehan’s 1991 paper, she has been involved in several replication studies and has written a book and a skills training manual about Dialectical Behavior Therapy. Her results have consistently shown that Dialectical Behavior Therapy does seem to reduce the incidents of self-injury and crisis among clients. Although Linehan’s group works out of the University of Washington in Seattle, Washington, trained Dialectical Behavior Therapy therapists can be found in other parts of the United States. A skills discussion list for Dialectical Behavior Therapy is also available at the University of Washington. To subscribe to this list, send an email to busserv@u.washington.edu explaining your background and why you would like to join the list whose function is to allow subscribers to share experiences and get support while using Dialectical Behavior Therapy skills. |
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