Center for Life Management

DIALECTICAL BEHAVIOR THERAPY (DBT)

Dialectical Behavior Therapy, or DBT, is a holistic approach to viewing a client, the therapeutic relationship with a client, and treatment strategies applied to effect change. Dialectics directs our attention to the immediate and larger contexts of behaviors, as well as to the interrelatedness of individual behavior patterns.

SKILL BUILDING IN DBT

The general goal in DBT Skills Training is to learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems in living, that is, those causing misery and distress. The specific goals are to decrease the following: (1) Interpersonal chaos, (2) Labile emotions and moods, (3) Impulsiveness, and (4) Confusion about self, cognitive dysregulation.

This means skills training is set up to increase the following behaviors: (1) Interpersonal effectiveness skills, (2) Emotion regulation skills, (3) Distress tolerance skills, and (4) Core mindfulness skills. These skills can be set up in group and individual treatment. The treatment groups are run with each skill set being learned and practiced.

Before any skill set can be mastered, a client learns and practices a “Chain Analysis”. A Chain Analysis refers to the client becoming aware of their own patterns of behavior and how these patterns continue to cause misery, and get in the way of client recovery. They become aware by noticing events trigger beliefs, which trigger body sensations and reactions, which then trigger feelings. The client notices the pattern of what they may “feel like doing”, versus what they actually do, and then the aftereffect of the entire “chain” process. The client also notices the emotions have a timely function. The process teaches a client to notice these aspects instead of ignore them. In other words, in order to correct a “build up” of anger, resentment, etc., a client can then manage these feelings at the initial time of onset. This Chain Analysis is completed in a collaborative way with the therapist and the group.

From Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan. 1993, Guilford Press.

Behavior Therapy
Particular behavioral accounts vary from disorder to disorder; however, common to behavioral interventions is the use of volitional behavior and experience to modify pathological emotions and cognitions.

By way of illustration, think back to that scenario in which you are sitting on a park bench relaxing when you notice your heart racing, face flushed, etc. That might be an objectively fearful, aversive experience. Imagine further that you associate that fearful, aversive experience with trying to relax on the park bench (a process one can think about in classical conditioning terms). The next day, you might get a nervous flutter of the heart thinking about going back to that park bench, but you promised your children you would take them to the park and set off to do so. Imagine further that your anxiety rises when the bench comes into view, and fearing another experience of such arousal, you turn around and take your children for ice cream instead. You might experience a great deal of relief, but this action might have unintended consequences. Not only have you failed to learn that the bench is safe and that you can cope with anxiety, your avoidance is negatively reinforced by that relief. One might expect that it will be harder to go back to the bench next time. Behavioral treatments would involve going to that bench repeatedly and for prolonged periods of time without escaping the anxiety (physically or mentally), until the bench is no longer associated with anxiety - i.e., a process of extinction.

Behavioral treatments for depression, in contrast, capitalize less on the classical conditioning process of extinction, and more on reinforcement. From a behavioral perspective, depression is thought to result from an absence of environmental reinforcers, and treatment involves increasing involvement in activities that the depressive individuals previously found enjoyable before they became depressed and in engaging in tasks that provide a sense of mastery and competence.

Although behavioral conceptualizations differ from disorder to disorder, a common thread is that behavioral therapists encourage clients to engage in adaptive behaviors and not to allow pathological internal experiences to dictate the ways in which they act.

In sum, behavioral interventions are based on the following principles:
• Classical conditioning
Unhelpful or pathological emotional responses to neutral or benign stimuli are often learned by association. Those responses can be modified by repeated and prolonged exposure to the neutral stimuli without physical or mental avoidance, a process known as extinction.

• Operant conditioning
Behavior is influenced by its consequences. We are more likely to engage in behaviors for which we receive positive or negative reinforcement, and less likely to engage in behaviors for which we are punished. Interventions that are based on principles of operant conditioning encourage clients not to avoid situations that lead to negative affect, and to increase positive behaviors that lead to adaptive and helpful reinforcement.

Features common to CBT
Despite the differences between cognitive and behavioral approaches, these therapies share a great deal in common and CBT therapists tend to draw from both approaches. Common features of both approaches are:

• In CBT, the therapist and client work together, in the spirit of collaborative empiricism, to explore, test, and modify maladaptive patterns of behavior and thought. It is of critical import that the client understands and accepts the treatment rationale in general and also for particular exercises. To that end, the therapist seeks to be open and honest, with the explicit mutual understanding that the therapist has theoretical and technical expertise, but the client is expert on himself or herself.

• CBT is often short-term, is skills-based and involves active client participation, in and out of session. As with learning a new language, one cannot show up in class for an hour every week and expect to develop facility; one must rather practice continually. Overall, clients learn problem solving skills through application of CBT techniques to real-life problems in their daily lives.

• Unless presented with a compelling reason otherwise, the CBT practitioner is present focused, seeking to understand the functional role of the client's behavior and experience in their current life. This focus might mean, for instance, that the therapist evaluates the ways that idiosyncratic safety or avoidance behaviors maintain anxiety in their ongoing daily life, but does not necessarily explore the developmental origins of the anxiety. Given a difficult history of circumstances in a client's life, the CBT therapist's inclination would be to help the client consider what they can do now to resolve their present difficulties. Typically, this involves working step-by-step to achieve operationalized proximal goals with an eye toward ultimate distal goals. This focus on the client's present does not mean that CBT therapist never consider developmental histories; often it is helpful for the therapist and the client to have some sense of how their idiosyncratic experiences emerged. It does mean that the client's history is not likely to be a major focus of treatment.

• CBT therapists often seek to help the client discover that they can tolerate negative affect, that emotions are not dangerous, and that the client has the efficacy to choose their behavior regardless of they feel.

• In addition, symptom relief is an explicit aim, and the CBT practitioner's role is to facilitate the fastest attainment of maximal and enduring improvement, as evidenced by self-report and behavioral indices, subjective and objective. The emphasis on tracking and assessing treatment outcome during therapy is consistent with the use of the empirical literature to inform treatment choice.

• Finally, throughout treatment, the CBT therapist develops hypotheses about the client's experience, but remains cognizant of how tendencies such as confirmation bias may influence their own objectivity in evaluating those hypotheses as well as treatment progress.

Given the emphasis in empiricism and the necessity of continued investigation into effective treatment, cognitive-behavioral approaches to treatment are continually evolving to respond to new developments in research and clinical practice. The elements described here are the basic building blocks for most cognitive and behavioral interventions.

COGNITIVE THERAPY