| Dialectical Behaviour Therapy (DBT) is a therapeutic | | | | Therapist Agreementso Make an effort to conduct |
| methodology developed by Linehan, a psychology | | | | competent Therapyo To be ethical and professional |
| researcher at the University of Washington to treat | | | | as per professional guidelineso To maintain |
| people with Borderline Personality Disorder (BPD). DBT | | | | confidentialityo Obtain consent when necessaryo Be |
| combines Cognitive Behavioural Therapy with | | | | available for Therapy sessions and back up when |
| concepts of methodologies from various practices | | | | needed |
| including Eastern mindfulness techniques. Research has | | | | None of these components are used by |
| shown that DBT is the first therapy that has been | | | | themselves. The individual component is considered |
| effective for treating BPD. Further research has been | | | | necessary to keep suicidal urges or uncontrolled |
| carried out and appears to show that it is also | | | | emotional issues from disrupting group sessions, while |
| effective in treating people with spectrum mood | | | | the group sessions teach the skills unique to DBT, and |
| disorders including self harming behaviour. Linehan | | | | also provide practice with regulating emotions and |
| created DBT after realising that other therapies were | | | | behaviour in a social context. |
| ineffectual when used for BPD. She recognised that | | | | The Four Modules |
| the chronically suicidal people that she worked with | | | | Mindfulness |
| had been brought up in invalidating environments and | | | | Mindfulness is one of the core concepts behind DBT. It |
| required unconditional acceptance in order for them to | | | | is the capacity to pay attention, in a non-judgmental |
| develop a successful therapeutic relationship. She also | | | | way, to the present moment. Mindfulness is all about |
| maintained that people need to recognise and accept | | | | living in the moment, experiencing one's emotions and |
| their low level of emotional functioning and be ready to | | | | senses fully, yet with perspective. It is considered a |
| make a change in their lives. | | | | foundation for the other skills taught in DBT, because it |
| Helping the person with Borderline Personality Disorder | | | | helps individuals accept and tolerate the powerful |
| to make therapeutic changes in their lives is | | | | emotions they may feel when challenging their habits |
| extraordinarily difficult for at least two reasons. Firstly, | | | | or exposing themselves to upsetting situations. The |
| focusing on patient change, either of motivation or by | | | | concept of mindfulness and the meditative exercises |
| teaching new behavioural skill, is often experienced as | | | | used to teach it are derived from traditional Buddhist |
| invalidating by traumatised individuals and can | | | | practice, though the version taught in DBT does not |
| precipitate withdrawal, non compliance, and drop out | | | | involve any religious concepts. |
| from treatment on the one hand, or anger, aggression, | | | | Interpersonal Effectiveness |
| and attack, on the other. Secondly, ignoring the need | | | | Interpersonal response patterns taught in DBT skills |
| for the patient to change (and thereby, not promoting | | | | training are very similar to those taught in many |
| much needed change) is also experienced as | | | | assertiveness and interpersonal problem-solving |
| invalidating. Such a stance does not take the very real | | | | classes. They include effective strategies for asking |
| problems and negative consequences of patient | | | | for what one may need, learning to say no, and coping |
| behaviour seriously and can, in turn, precipitate panic, | | | | with interpersonal conflict. Individuals with Borderline |
| hopelessness and suicidal ideation. | | | | Personality Disorder frequently possess good |
| DBT involves two components: | | | | interpersonal skills in a general sense. The problems |
| 1. An individual component in which the therapist and | | | | arise in the application of these skills to a specific |
| patient discuss issues that come up during the week, | | | | situation. An individual may be able to describe |
| recorded on diary cards, and follow a treatment target | | | | effective behavioural sequences when discussing |
| hierarchy. These sessions typically last for 45-60 | | | | another person encountering a problematic situation, |
| minutes and are held weekly. Self Harming and Suicidal | | | | but may be completely incapable of generating or |
| behaviours take first priority, followed by therapy | | | | carrying out a similar behavioural sequence when |
| interfering behaviours. After this there are issues | | | | analysing his or her own situation. The interpersonal |
| surrounding quality of life and working towards | | | | effectiveness module focuses on situations where the |
| improving one's life in general. During the individual | | | | objective is to change something (e.g., requesting that |
| therapy, both the therapist and the patient work | | | | someone do something) or to resist changes someone |
| towards improving skill use to survive and manage | | | | else is trying to make (e.g., saying no). The skills taught |
| difficult feelings. The whole session should be working | | | | are intended to maximise the chances that a person's |
| towards a setting that is validating for the patient. A lot | | | | goals in a specific situation will be met, while at the |
| of attention should be paid to the immediate problems, | | | | same time not damaging either the relationship or the |
| feelings and actions. Often, a skills group is discussed | | | | person's self-respect. Emotion Regulation |
| and obstacles to acting skillfully are addressed. | | | | Individuals with Borderline Personality Disorder and |
| 2. The group, which usually will meet once a week for | | | | suicidal individuals are frequently emotionally intense |
| two to two-and-a-half hours, once a week, learns to | | | | and labile. They can be angry, intensely frustrated, |
| use specific skills which can be broken down into four | | | | depressed, or anxious. This suggests that these clients |
| modules: Core Mindfulness Skills, Interpersonal | | | | may benefit from help in learning to regulate their |
| Effectiveness Skills, Emotion Regulation Skills, and | | | | emotions. Dialectical Behaviour Therapy skills for |
| Distress Tolerance Skills. The room should be arranged | | | | emotion regulation include:o Identifying and labeling |
| like a classroom with the trainers (usually two) placed | | | | emotionso Identifying obstacles to changing emotionso |
| at the front. Issues and emotions are discussed and | | | | Reducing vulnerability to emotion mindo Increasing |
| dealt with if they are life threatening or interfering with | | | | positive emotional eventso Increasing mindfulness to |
| the group therapy. For example if someone is | | | | current emotionso Taking opposite actiono Applying |
| behaving badly this would only be addressed if it was | | | | distress tolerance techniques |
| causing a problem with the running of the group. | | | | Distress Tolerance |
| Otherwise, it would be ignored. Skills Training is run | | | | Many current approaches to mental health treatment |
| around a manual that gives details of the programme | | | | focus on changing distressing events and |
| that has to be followed. This gives guidance and | | | | circumstances. They have paid little attention to |
| advice about how it should be taught. It also contains | | | | accepting, finding meaning for, and tolerating distress. |
| handouts for individuals. Group work can include | | | | This task has generally been tackled by |
| role-play and, as in CBT, homework is encouraged. | | | | psychodynamic, psychoanalytic, gestalt, or narrative |
| | | | | therapies, along with religious and spiritual communities |
| Commitment Before DBT can begin, the patients have | | | | and leaders. Dialectical behavior therapy emphasises |
| to make a commitment to participate in the therapy. | | | | learning to bear pain skillfully. |
| This is an exercise in itself and may take several | | | | Distress tolerance skills constitute a natural |
| meetings. Both the patient and the therapist make | | | | development from mindfulness skills. They have to do |
| explicit commitments. In practice, the therapist may | | | | with the ability to accept, in a non-evaluative and |
| initially 'play hard to get' and lead the patient, to | | | | nonjudgmental fashion, both oneself and the current |
| persuade him or her that the programme is indeed | | | | situation. Although this is a nonjudgmental stance, this |
| justified. | | | | does not mean that it is one of approval or resignation. |
| People with BPD have often experienced treatments | | | | The goal is to become capable of calmly recognising |
| that have been at best unrewarding. Consequent | | | | negative situations and their impact, rather than |
| wariness needs to be validated and the new | | | | becoming overwhelmed or hiding from them. This |
| therapeutic endeavour presented in a realistic way as | | | | allows individuals to make wise decisions about |
| promising but also demanding. Time spent on | | | | whether and how to take action, rather than falling into |
| commitment before therapy is a good investment. | | | | the intense, desperate, and often destructive emotional |
| Likewise, if the therapeutic relationship becomes | | | | reactions that are part of borderline personality |
| wobbly or threatens to break down, then time needs | | | | disorder. |
| to be spent on maintaining this commitment. It is usual | | | | Skills for acceptance include radical acceptance, turning |
| for there to be an agreement that if three consecutive | | | | the mind toward acceptance, and distinguishing |
| sessions of one kind are missed for any reason then | | | | between "willingness" (acting skillfully, from a realistic |
| the patient is out of the DBT programme. | | | | understanding of the present situation) and "willfulness" |
| Common Commitments in DBT | | | | (trying to impose one's will regardless of reality). |
| Patient Agreementso Agree a time limit to stay in | | | | Participants also learn four crisis survival skills, to help |
| Therapyo Work towards reducing suicidal behaviourso | | | | deal with immediate emotional responses that may |
| Attend all Therapy sessionso Participate in Skills | | | | seem overwhelming: distracting one-self, self-soothing, |
| Training | | | | improving the moment, and thinking of pros and cons. |