Dialectical Behavior

Therapy
Presentor: Dr.Madhu Mathew
Chair: Dr. Abhinav Chichra
Introduction
• A modified, structured cognitive behavioral approach

• Developed in the late 1980s for people with frequent suicide

attempts, self harming behaviour
Origin
• Developed by Dr. Marsha Linehan at University of Washington

• Originally developed to treat chronically suicidal clients diagnosed

with Borderline Personality Disorder

• Found to be effective for suicidal clients with multiple other co-

occurring behavioural problems

• The Goal of DBT: “Create a life worth living.”

Why DBT ?
CBT did not work for clients with chronic suicidality and BPD

• Change focus was invalidating

• Clients unintentionally reinforced therapists for behaviours that
were not helpful and punished/extinguished helpful behaviours
• Unrelenting crisis interfered with treatment/skills acquisition

- Acceptance and Change

 DBT vs CBT
CBT DBT
Focus on change Dialectic of acceptance and
change

Exposure to distress Exposure to distress with

acceptance of distress

Specific problem focus Broad problem focus with a

hierarchy
Dialectics

- Focuses on the dynamics of opposing points (thesis and antithesis)

- Two opposite and contradictory ideas can exist and be true

simultaneously

• Hegel: “Process of change in which a concept or its realization passes

over into and is preserved and fulfilled by its opposite.”

• Bohr: “The Universe is so constructed that the opposite of a true

statement is a false statement, but the opposite of a profound truth is
usually another profound truth.”
Dialectical dilemma in BPD

• Blame of others vs blame of self

• Unrelenting crises vs inhibited grieving

• Active passivity vs Apparent competence

• Emotional vulnerability vs self invalidation

 Dialectical Dilemmas
Emotional
Vulnerability
Unrelenting Active
Crisis Passivity

Biological
Social

Apparent Inhibited
Competence Experiencing

Self-Invalidation
Biosocial Model of BPD
9
8
• High Sensitivity
7

• High Reactivity 6
5

• Slow Return to Baseline 4

Emotions
3
• Often “Transactional” with the Environment 2
1
0
EMOTIONAL VULNERABILITY Se-
+ ries
1
INVALIDATION
=
BORDERLINE PERSONALITY DISORDER
Challenges
• Polarity of needs

• Skill / Capability deficits

• Inhibited by motivational factors and experiences

• Failure of the bridge

Firstly
Stages of Treatment
• Stage I: Stabilization

• Focus:
• Treatment Hierarchy:
• Reduce Life-Threatening Behaviours
• Reduce Therapy-Interfering Behaviours
• Reduce Quality-of-Life-Interfering Behaviours
• Increase Skills that Replace Ineffective Coping

• Goal:
• Move from behavioural dyscontrol to control to achieve a
normal life expectancy
• Stage II: Suffering in Silence

• Focus:
• Address inhibited emotional experiencing
• Reduce PTSD symptoms

• Goal:
• Move from quiet desperation to full emotional experiencing
• Stage III: Build a Life Worth Living

– Focus:
• Problems in Living

– Goal:
• Life of ordinary Happiness and Unhappiness
• Stage IV: Address Issues of Meaning (Optional)

– Focus:
• Spiritual Fulfilment
• Connectedness to Greater Whole

– Goal:
• Move from incompleteness to ongoing capacity for Experiences
of Joy and Freedom
Core DBT Strategies

VALIDATION :

• Communicating to the client that their responses make sense and

are understandable within current life context
Chain Analysis
• Choose a specific instance of behavior

Describe

• Topography

• Frequency

• Intensity
Determine antecedents

• Link client’s behavior to environmental events

• Internal and external events

Determine consequences

• Those influencing problem behaviour by maintaining,

strengthening, or increasing it
• Assess external and internal events

Determine function of the behaviour

 Sample Chain Analysis
Behaviour: Overdose (with suicidal intent)
Thought:
• Event: Fight Thought:
“I can’t
Vulnerability: “He will Emotion:
with live
Intoxicated leave Panic
boyfriend without
me”
him”

Thought: Action:
Emotion: Urge: Take “Will be Walk to Action:
Despair pills to better if bathroom Take pills
forget I’m dead” and get pills

Event: Picked Event: Emotion:

up Boyfriend Love and
by EMS visits in affection
hospital
 DBT Skills
• Distress Tolerance

• Emotion Regulation

• Interpersonal Effectiveness

• Mindfulness
1. Distress Tolerance
• CRISIS SURVIVAL SKILLS are needed:
– When client is in a situation that is
• Highly stressful
• Short-term
• Creating intense pressure to resolve the crisis now
STOP Skills

Stop

Take a step back

Observe

Proceed mindfully
TIPP Skills
• TIP YOUR TEMPERATURE

• INTENSELY EXERCISE

• PACE YOUR BREATHING

• PROGRESSIVELY RELAX YOUR MUSCLES

 Pros and Cons
• Use PROS and CONS anytime you have to decide between two
courses of action.
Pros Cons

Acting on Crisis
Urges

Resisting Crisis
Urges
 Distraction

Activities:

Contributing:

Comparisons:

Different Emotions:

Pushing Away:

Other Thoughts:

Other Sensations:
 Self-Soothing
Vision:
• Stars at night; pictures in a book, nature, candles
Hearing:
• Soothing music; invigorating music; sounds of nature; sounds of
the city
Smell:
• Soap, incense, coffee, essential oils, boil cinnamon
Taste:
• Favourite foods; soothing drinks; chew gum
Touch:
• Hot baths; pet your dog or cat; creamy lotion; comfortable clothing
2. Emotional regulation
• Prompting Event
• What set off the emotion?
• Emotion
• i.e., anger, fear, joy
• Interpretations
• Thoughts, judgments, beliefs
• Experiencing
• Body changes
• Action Urges
• e.g., withdraw, attack, eat
• Expressing
• Behaviours – what you said or did
• Aftereffects
• Consequences – your state of mind; others’
reactions; reinforcements
 Opposite Action
Changing ineffective emotions by ACTING OPPOSITE to the emotion
• Fear
• Urge: Freeze, run, avoid
• Opposite action: Approach

• Anger
• Urge: Attack, hit, yell
• Opposite action: Gently avoid; do something nice

• Sadness
• Urge: Withdraw, cry, isolate
• Opposite action: Get active

• Guilt/Shame
• Urge: Hide/avoid
• Opposite action: Face the music; repair mistakes
3. Interpersonal Effectiveness
DEAR MAN
• Describe

• Express

• Assert

• Reinforce

• Mindful

• Appear confident

• Negotiate
4. Mindfulness
“WHAT” SKILLS
• Observe
• Describe
• Participate
“HOW” SKILLS
• Non-judgmental
• Effective
• One-mindful
 Individual Therapy
• Focused more on ensuring adherence

• One hour once a week

• Diary cards

• Behavioural analysis

• Effective, but not as much as skills training

 Telephone consultation
• Promote an ‘equal’ relationship

• 5-10 minute conversations

• Avoid reinforcing problem behaviours (refuse

to speak after self harming behaviour)
 Consultation teams
• Weekly meetings

• Keep therapists ‘on track’/ ‘treating the

therapist’

• Help overcome therapeutic nihilism / over-

involvement
 Research Findings
• DBT has been found to reduce
– Suicidality
– Parasuicidal behavior
– Treatment drop-out
– Hospitalizations
– Substance Use
– Depression, Hopelessness, Anger
(Linehan et al., 1991;1999; Koons et al., 2001, Verheul et al., 2003)
• Cochrane review for psychological intervention showed
best and most extensive data for DBT (though still
recommends further studies)

• Various RCTs show about half the rate of suicide attempts

vs control (TAU) with a NNT of 4-5

• Decreased rates of emergency treatment utilization

• Better follow up and adherence (83% vs 42%)

Uses in other situations
• Substance Use
• Adolescents/Children
• Binge Eating
• Bipolar Disorder
• Couples
• Inpatient
 Criticisms
• Methodological problems in studies

• Pre selected clients with higher insight and better

motivation?

• ‘Treating the symptom’. Does depression go down?

• High costs, highly intensive. ? Cost effective

 Summary
• A modification of cognitive and behavioural strategies with
incorporation of mindfulness techniques and Socratic principles

• Dialectical principles of ‘synthesis of opposites’

• A team based highly structured 1 year treatment

• Better empirical evidence than others for BPD;

treatment of choice
 References
Comprehensive textbook of Psychiatry; Kaplan and SadockDimeff, L. A., & Koerner, K. (Eds.) (2007).
Dialectical Behavior Therapy in clinical practice: Applications across disorders and settings. New York:
Guilford Press.

Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York:
Guilford Press.

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral
treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K.,
Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of Dialectical Behavior Therapy in Women Veterans
with Borderline Personality Disorder. Behavior Therapy, 32, 371-390.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical
Behavior Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on
Addiction, 8, 279-292.

Miller, A. L., Rathus, J. H., & Linehan, M. M. (2006). Dialectical Behavior Therapy with suicidal
adolescents. New York: Guilford Press.

Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , Stijnen, T., & Van Den Brink, W.
(2003). Dialectical Behaviour Therapy for Women with Borderline Personality Disorder, 12-month,
Randomised Clinical Trial in The Netherlands. British Journal of Psychiatry, 182, 135-140.

Linehan MM, Comtois K, Murray AM, et al. Two-Year Randomized Controlled Trial and Follow-up of
Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality
Disorder. Arch Gen Psychiatry. 2006

Dialectical Behavioral Therapy and emotion ; McKain and Korman

Koerner, K. (2011). Doing Dialectical Behavior Therapy: A practical guide. New York: Guilford Press.
Thank You
• Radical acceptance