Adult Dialectical Behavior Therapy . . .
"There are two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle.."
- Albert Einstein
Dialectical Behavioral Therapy (as described at www.behavioraltech.org):
DBT is a therapeutic methodology developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat persons with borderline personality disorder (BPD). DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of mindful awareness, distress tolerance, and acceptance largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD. DBT is also effective in treating persons who represent varied symptoms and behaviors associated with spectrum mood disorders, including self-injury.
DBT involves two components:
An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards, and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
The group, which ordinarily meets once weekly for two to two-and-a-half hours, learns to use specific skills that are broken down into four modules: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.
Neither component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.
The first goal of DBT is to insure the client stays alive, so that the second goal (staying in therapy), results in meeting the third goal (building a better quality of life), partly through the acquisition of new behaviors (skills). In short, we have just described the targets found in Stage I. This stage of treatment focuses, in order, on decreasing life threatening behaviors, behaviors that interfere with therapy, quality of life threatening behaviors and increasing skills that will replace ineffective coping behaviors. The goal of Stage I DBT is for the client to move from behavioral dys-control to behavioral control so that there is a normal life expectancy.
In Stage II, DBT addresses the client’s inhibited emotional experiencing. It is thought that the client’s behavior is now under control but the client is suffering “in silence”. The goal of Stage II is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.
Stage III, DBT focuses on problems in living, with the goal being that the client has a life of ordinary happiness and unhappiness.
Marsha Linehan, the founder of DBT, has posited a Stage IV specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.
Clients in standard DBT receive three main modes of treatment – skills group, individual therapy, and phone coaching (in some instances, not all). In individual therapy, some clients receive once weekly or every other week individual sessions that are typically an hour to an hour-and-a half in length. Clients also must attend a weekly skills group for at least 8 months to one year. Unlike with regular group psychotherapy, these skills groups emerge as classes during which clients learn four sets of important skills – Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Clients are also asked to call their individual therapists for skills coaching prior to hurting themselves. The therapist then walks them through alternatives to self-harm or suicidal behaviors.
In collaboration with the client, the therapist keeps track of how the treatment is going, how things are going with everyone involved in the treatment, and whether or not the treatment is helping the client reach his or her goals.
It is important to know that the therapist who facilitates the skills group has a slightly different role when compared to traditional group therapy. The therapist role is more like a teacher or coach. He or she will be presenting and teaching skills and coaching participants through how to use and implement the skills. Deeper process and therapeutic intervention typically take place in individual sessions.