Mindfulness Approaches
(ACT & DBT) Part 2
Overview
DBT was conceived by Marsha Linehan to treat a very specific client group: the highly suicidal. Many of the clients that displayed self-harming behaviors met the criteria for the diagnosis BPD in the DSM-5, so DBT has become known as an approach directed at this specific diagnostic category. These individuals are considered very difficult to help.
Linehan began her theoretical journey attempting to use CBT with these clients, but soon realised that she was adding elements of acceptance of feelings and emotions and, oddly, confrontational and somewhat paradoxical interventions that seemed more like those used in family systems therapy. She noticed a tension between validating the client (acceptance) and addressing the very real need for change in these clients, a phenomenon that evolved into the dialectical philosophy of DBT.
Central constructs
Dialectics
Refers to a philosophy and also to strategies
Similar to the philosophy of ACT; refers to a holistic perspective in which context is critical. In this view, reality is fluid and is composed of opposing forces (polarities), the synthesis of which creates a new set of opposing forces. The trick is to move back and forth and to view life as an ever-changing balancing act. The core DBT strategy is conceptualized as the tension between problem solving and validation of the client's perspective.
Emotion regulation
In traditional CT, emotion is conceptualized as largely resulting from thought. In contrast, in DBT, emotion stands on its own as a critical factor in psychological functioning. Emotion regulation refers to the ability to pay attention to emotional experience but not let it carry you away, self-soothe any accompanying physiological arousal, and the ability to act deliberately in the presence of strong emotion.
Advocates of DBT are more likely to discuss emotion dysregulation than regulation, but we can infer that healthy regulation leads to adaptive behavior instead of the extreme shifts seen in emotionally vulnerable individuals who don't have such skills.
Theory of the person and
development of the individual
Because DBT emerged in the context of helping individuals diagnosed with BPD, the conceptions of human development and personality are focused on understanding this presentation. Linehan proposed a biosocial theory of development that points to the failure of the emotional regulation system in combination with a dysfunctional environment as the primary cause of BPD.
The roots of DBT in the principles of behavioral and cognitive approaches lead to a basic assumption that the individual's behavior is strongly influenced by environmental contingencies (reinforcement and punishment). Yet at the same time, another important factor in development is the ability to regulate emotion. The ability to deal with emotion is thought to be biologically based (not necessarily genetic, although this can be one factor; can also be affected by intrauterine events and environmental events that affect nervous system development). Children are thus born with different sensitivities to emotion. When such a child is raised in an invalidating environment, emotional experience is not validated, and the child is not taught to modulate emotion. In healthy family environments, parents and others help children identify an emotional experience, express it, and take action, if appropriate.
Health and dysfunction
Healthy people, in the DBT model, do not have specific vulnerability to emotion and are able to regulate their emotions. They likely have grown up around important others who allowed them to experience and express their lives and responded to their needs in appropriate ways.
Emotional vulnerability is defined as high sensitivity and intense response to emotional events and a slow return to the nonemotional, or baseline, state.
In invalidating environments, the expression of experience (particularly emotion) is not supported by caretakers or, if it is, such support is inconsistent. In fact, the expression of inner experience is often punished or ignored, according to Linehan. The child is told that she is not hungry/hurt/scared, or in other instances she is told that what she believes or wants is not really true. This invalidation seems to particularly apply to negative emotional states such as anger. The tendencies of the environment and the individual interact in a pattern of reciprocal influence. The consistent invalidation of experience leads to the child never learning how to (a) process emotion, (b) tolerate distress, or (c) trust her own view of life, as she is constantly being told that her feelings, views, and experiences are wrong.
Invalidation also leads to deficits in problem-solving skills because the child is not taught ways in which emotional states can be address. Instead, the child may learn dysfunctional ways of regulating emotion, such as self-harming, suicide attempts, or maladaptive eating patterns. The inability to adaptively process and respond on the basis of emotion is called emotional dysregulation, which is a core characteristic of BPD.
Nature of therapy
Assessment
Linehan asserted that a thorough assessment includes a diagnostic interview, used to obtain a detailed history and the client's previous counseling experiences. She recommended the use of the Structured Clinical Interview for DSM-IV and the Diagnostic Interview for Borderlines.
In DBT, a distinction is made between primary and secondary behavioral targets. Primary targets are life- or therapy-threatening behaviors. Secondary targets are emotional regulation, problem solving, self-validation, and other life skills. Assessment in DBT consists of reviewing the client's presentation in these categories. Primary targets are addressed first.
The counselor assigns the client the task of completing diary cards to track progress from week to week. The primary purpose of the cards is to track critical behavior such as suicidal ideation, drug use, and client mood so that the DBT counselor can intervene if primary target behavior surfaces.
Overview of the therapeutic atmosphere
and roles of client and counselor
DBT therapists assume that clients want to get better and that they are doing the best they can. Although they may not be responsible for their problems, they are responsible for solving them, and they must work hard to do so. The DBT therapist also takes the position that clients can't fail -- only the therapy or therapist can. A particularly interesting principle of DBT is that the counselor needs support to deal with the difficult clients with whom they work with.
The counselor first conducts an extensive orientation with the client, beginning with the assessment described above, followed by the presentation of the biosocial theory on which it is based. During the orientation (which can last multiple sessions), the therapist and client typically agree to a length and format of treatment. In full-scale DBT, this means a commitment of 1 year, and it includes attendance at individual therapy and skills-training groups. In these sessions, it is very important that the therapist establish a strong alliance with the client, so validation is used liberally. Stylistically, DBT blends a matter-of-fact, somewhat irreverent, and at times outrageous attitude about current and previous parasuicidal and other dysfunctional behaviors with therapist warmth, flexibility, responsiveness to the client, and strategic self-disclosure.
The therapeutic relationship is critical to success in DBT and validation of the client is an essential component of the approach. Validation is considered a core therapeutic strategy that is described by six different levels:
(1) accurately listening to the client and demonstrating interest in her experiences
(2) accurate reflection, or letting the client know that she is understood
(3) the counselor verbalizes aspects of the client's experience that the client has not overtly described
(4) validating the connection between the past and the client's current feelings and behaviors
(5) communicating that the client's current feelings or behaviors are reasonable or functional
(6) radical genuineness, or validating the inherent strengths of the client; the therapist conveys that they believe that the client has the capacity to behave in effective ways and overcome her troubles (while maintaining basic empathy for her).
Goals
According to Linehan, the goals of DBT are to teach clients to:
(a) modulate intense emotions and reduce or eliminate maladaptive behaviors associated with these, and to
(b) trust in teh self, thoughts, feelings, and behaviors.
Ultimately these changes are in the service of achieving a life worth living.
Process of therapy
DBT is based on principles derived from three underlying theories: DBT's biosocial theory, behavior theory, and dialectical philosophy.
DBT has four treatment modes: individual therapy, group skills training, telephone consultation, and therapist consultation groups.
Individual therapy in DBT has four stages:
Stage 1: addressing life-threatening behaviors along with those that disrupt the client's quality of life or the therapeutic process in significant ways
Stage 2: helping the client experience distressing emotions
Stage 3: helping the client to make greater connection with the world and increase self-respect, while also decreasing behaviors that are still in the way of achieving desired life goals
Stage 4: addressing any leftover feelings of incompleteness
The DBT practitioner uses a structured approach with careful attention to balancing the opposites of problem solving and validation, change and acceptance. It is recognized that both therapist and client are influenced by contingencies; the client will reinforce or punish the counselor's behaviors, and sometimes these contingencies are problematic.
Telephone consultations with clients serve several purposes:
(a) decrease self-injurious behavior
(b) help clients learn to generalize skills learned in therapy across situations
(c) address any problems in the therapy relationship
These calls also help teach clients appropriate ways to ask for help because they tend to not ask or they ask in demanding, inappropriate ways.
The therapist consultation team
Therapeutic techniques
Core mindfulness skills
Wise mind
Distress tolerance skills
Emotion regulation skills
Four categories of treatment strategies: core, dialectical, stylistic, and case management