The Dialectical Behavior Therapy Primer

How DBT Can Inform Clinical Practice

Beth S. Brodsky, Barbara Stanley

• Publisher: Wiley
• Year: 2013
• Print ISBN: 9781119968931
• eBook ISBN: 9781118556610
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Dialectical Behavior Therapy (DBT) has quickly become a treatment of choice for individuals with borderline personality disorder and other complicated psychiatric conditions. Becoming proficient in standard DBT requires intensive training and extensive supervised experience. However, there are many DBT principles and procedures that can be readily adapted for therapists conducting supportive, psychodynamic, and even other forms of cognitive behavioral treatments.Despite this, there is a dearth of easily accessible reading material for the busy clinician or novice.

This new book provides a clinically oriented, user-friendly guide to understanding and utilizing the principles and techniques of DBT for non-DBT-trained mental health practitioners and is an ideal guide to DBT for clinicians at all levels of experience.

Written by internationally recognized experts in suicide, self injury and borderline personality disorder, it features clinical vignettes, following patients through a series of chapters, clearly illustrating both the therapeutic principles and interventions.

Chapter 1

Introduction

For whom is this book intended?

In this volume, we hope to provide (a) an accessible, easy-to-understand primer for ­clinicians wanting to adopt Dialectical Behavior Therapy (DBT) as their treatment approach; (b) guidance, tools, and, more importantly, a way of thinking about treating borderline personality disorder (BPD) for clinicians who want to incorporate aspects of DBT principles and techniques into their practice but do not wish to adopt the entire model and (c) an introduction to DBT for the patients and their families and friends who want to learn the basics of this treatment approach. While becoming proficient in DBT requires intensive training, supervision, and feedback on therapeutic performance, there are many DBT principles, strategies, and techniques that can be understood and utilized by clinicians using other therapeutic modalities and models. For example, psychopharmacologists who have knowledge of DBT may better understand and manage their BPD patients’ medication requests and suicidal behavior. Furthermore, their clinical approach to patients with BPD may be enhanced by a better understanding of the importance of validation (a central DBT concept) with this population. While we recommend utilizing DBT as developed since that is what has the empirical support behind it, we recognize that not all clinicians will choose to do so. And we believe that, whatever the treatment approach, clinicians can benefit from incorporating aspects of DBT into their practice. Thus, the primary purpose of this book is to provide a clinically oriented, user-friendly guide to understanding and utilizing the ­principles and techniques of DBT.

The challenge of treating Borderline Personality Disorder and disorders of emotion dysregulation

Individuals with BPD and disorders in which there is pervasive emotion dysregulation generally present many challenges in psychotherapeutic treatment for even the most trained and dedicated clinicians. The BPD diagnosis is one of the most stigmatized of the mental illnesses, notorious for treatment resistance [1], high treatment utilization [2], high dropout rates , high comorbidity with other diagnoses [3], and recurrent suicidal and non-suicidal self-injurious (NSSI) behaviors [1]. Therapist burnout with this population is common. The severity and chronicity of BPD symptoms cause individuals with the disorder and those involved with them a great deal of anguish and frustration. The clinicians treating those with the disorder are not immune to this sense of frustration and, consequently, act in ways that they find uncharacteristic and, ultimately, not helpful, despite initial and ­perhaps long-sustained intentions to help. Why?

More specifically, we ask, “Why do mental health clinicians who are ordinarily empathic and who have chosen the helping profession as their career become ­exasperated, off balance, or unwilling to continue trying to help certain patients? Why may they resort to measures they would not take with their other patients?”

Most psychotherapists have a story to tell regarding their most “difficult” patient. Chances are this patient was either clearly diagnosed with BPD or was given multiple Axis I ­diagnoses that shifted over time and, in retrospect, was best understood as BPD. What is it about BPD that individuals with this disorder are experienced as “difficult” and even as the most difficult patients to treat? Are their problems more severe than those ­diagnosed with schizophrenia or bipolar disorder? We do not think so.

Is it the fact that their problems are often manifest in the interpersonal domain that ­creates the difficulties?

Is it that their triggers to extreme emotional dysregulation may seem trivial and unpredictable to the therapist?

Is it that the emotional dysregulation itself is experienced as so extreme by the ­clinician that it is difficult to tolerate?

We think that all three factors contribute to the problems clinicians report in working with patients with BPD and severe emotion dysregulation problems. Clinicians become “burned out” and discouraged by the difficult symptomatology presented by ­borderline patients. These patients experience intense anger, sometimes directed at therapists and at any other person to whom they become emotionally attached. They engage in disturbing and frightening self-destructive behaviors including suicide attempts, nonsuicidal self-injury, and substance abuse. These behaviors are often triggered by interpersonal interactions, including even well-intentioned therapeutic interventions.

Individuals with BPD can be very dependent on those around them for self-definition and self-esteem [4]. They often develop an intense need for concrete contact with people important to them. This need for contact can be experienced as overwhelming and ­impossible to satisfy. Furthermore, the functioning of individuals with BPD is highly mood-dependent, can fluctuate dramatically, and can depend on the “emotional valence” of the situation. For example, individuals with BPD can do extremely well in work or school settings where they meet with success and positive feedback. Their underlying vulnerability may not be seen or provoked. To those who do not fully appreciate the nature of the disorder, this can create the impression that individuals with BPD are ­capable of high functioning in all circumstances and are deliberately behaving in a “­helpless, manipulative” manner when their functioning is compromised by their emotional state or by the nature of their interpersonal relationships. So, the same individual who can ­produce a high-quality well-researched legal brief may fall apart when her boyfriend cancels a date at the last minute because of work commitments. On a very basic level, it does not seem possible that the dysfunctional behaviors are genuine. But they are.

These are some direct quotes from therapists with whom we have consulted or supervised.

My patient with BPD is so unbelievably manipulative. She gets great grades at that Ivy League college she attends and does independent research for one of her professors that draws great praise. Yet she gets distraught and can’t function if her boyfriend doesn’t call her or if I’m a few minutes late for our appointment. She’s so melodramatic and self-centered. I find myself continually annoyed with her.

I have a really “bad borderline” who keeps calling me and I can’t stand to take her calls any more. She never has a good reason for the calls. Everything is an emergency to her.

I’m sick and tired of my borderline patient’s repeated suicide gestures and the inevitable calls from the ER in the middle of the night. Next time she does it, I’m going to tell the ER that she has been terminated from my care.

This type of clinician response is not an infrequent occurrence when the patient is ­diagnosed with BPD. We have been suicide researchers and clinicians for many years and experienced a sense of our own limitations as we began to do psychotherapy with suicidal and self-injuring individuals who had BPD. We were both trained in a ­traditional ­psychodynamic model which we found did not provide the tools or a useful framework to help our patients manage their suicidal urges, their self-injury, their out-of-control ­emotions, and their relationships. Many clinicians who have sought our advice and ­consultation in working with their BPD patients have echoed this experience.

Why are we focusing on the clinician’s reactions here instead of the enormous ­suffering of individuals with BPD? Because we recognize that BPD is a very common disorder and many individuals with BPD are desperately in need of treatment, and, therefore, most clinicians are likely to be asked to treat individuals with BPD. Some clinicians choose (when they have the option) not to treat this population or are not as helpful as they might be. By helping clinicians feel and, in fact, be more capable in working with individuals with BPD, we hope to decrease the suffering of the patients afflicted with this disorder who seek treatment. Are there approaches in which clinicians can better maintain a sense of balance and perspective while being understanding of and helpful to their patients with BPD? DBT offers one such approach.

What is DBT?

DBT is a treatment for individuals with pervasive emotion dysregulation and has quickly become a psychotherapeutic treatment of choice for individuals with BPD, particularly for those with suicidal and self-injurious behaviors, the population for whom the ­treatment was originally developed [5]. It was not until Marsha Linehan, the treatment developer, worked with patients with chronic self-injury and suicidal behavior that she concluded that her patients had the diagnosis of BPD in common. And, thus, DBT became a ­treatment for BPD, and more recently is being more broadly considered to be a treatment for severe emotional ­dysregulation, a core feature of the BPD diagnosis [6]. But its focus on self-harm behaviors lent it to ­adaptations for similar problems in which there is a pattern of self-destructive behaviors, such as substance abuse and eating disorders. Furthermore, in clinical practice, DBT has been extended for use with ­individuals who have a broad range of difficulties with regulation of emotions.

The beauty of DBT is that, through its structure, it provides a road map for clinicians (and their patients) to navigate the path toward improving the lives of multiproblemed patients with chaotic, crisis-driven, and often self-destructive patterns of living. The structure of DBT focuses therapists and patients on crucial problems that must be addressed (e.g., suicidal behavior and self-injury), helps them stay on track, and prevents detours that can easily be taken when the patient has a crisis-driven life. This road map keeps the therapeutic dyad moving toward mutually agreed upon goals.

The basic components of DBT include individual psychotherapy (conducted in a fairly structured manner); skills training, which typically takes place in a weekly seminar-type format and during which skills are taught to help individuals with severe emotion ­regulation problems; intersession patient coaching; and clinician team consultation to ­provide support to fellow therapists and to help each other stay on track in their work with this multiproblem population. These components are described to the patient in the initial ­sessions (pretreatment phase) so that the patient’s agreement to be in DBT is with full ­knowledge of the treatment components and expectations for each of these components. There is misunderstanding by some in the field that DBT is only about teaching skills in a group format. And while the skills component is crucial, it is only one component. There are no studies yet that demonstrate that skills alone or added to other forms of treatment are effective. However, in our clinical work, we have certainly seen where it has been beneficial for patients who are struggling in other forms of therapy but do not wish to leave that treatment, to add a skills training group to their therapeutic experience. Interestingly, the recommendation for a DBT skills group often comes from the primary therapist who adheres to a model other than DBT. In order for this arrangement to be helpful to the patient, the primary therapist must be open to helping the patient apply the skills.

Why the name DBT? The B (behavior) in DBT is easy to understand. DBT is rooted in principles of behavior therapy with an emphasis on the application of learning ­principles, including operant and classical conditioning. And while it is a form of ­cognitive behavioral therapy (CBT), most adaptations of CBT place an emphasis, while not excluding the other, on either the cognitive or behavioral aspects of a CBT model and can be described as emphasizing the cognitions or behaviors, that is, big C (CbT) versus big B (cBT) approaches. The orientation of DBT is cBT, whereas Aaron Beck’s approach is CbT [7]. These differences are more than an academic distinction because they determine the route these approaches take to change. The term “dialectical” in DBT requires more clarification. Dialectics is a philosophical concept that includes several assumptions: (a) all things are connected; (b) change is inevitable and ­continual; and (c) opposites can be integrated to develop a closer approximation of the truth. It is this last point that it is stressed in DBT and is at the core of the ongoing and ­continual explicit balance of acceptance and change that we will describe as present throughout the treatment [7].

As clinicians and researchers who have taken a particular interest in understanding and improving treatment efficacy for individuals with BPD, we have been inspired and informed by DBT. In particular, we have come to see that the philosophical assumptions underlying DBT serve to both orient and maintain morale in the clinician, a major aspect of improving treatment for individuals with BPD. As one patient put it, “Oh yes, I was in DBT therapy. It helped me but it also helped the therapist feel ­better about ­working with me.”

Helping therapists feel better about treating individuals with BPD is no small feat. Of course, therapists would not “feel better” unless they were able to experience a sense of increased efficacy – their patients showed up for sessions, stayed in treatment, and improved. We believe that the theoretical stance inherent in DBT, as well as the specific interventions, effectively targets both the clinician and the patient.

The usual clinical training can leave clinicians ill-equipped to accurately interpret and intervene, and, therefore, be effective in the face of the severity and multitude of problems experienced by individuals with BPD. Notably, many standard approaches do not have protocols for treating and managing suicidal behaviors and nonsuicidal ­self-injury. In fact, some training programs refrain from exposing their trainees to suicidal patients with BPD because it is felt that they are too “difficult.” We maintain that this is the ideal time because of the available support and structure. However, there has been ­little guidance for clinicians in tolerating and minimizing the emotional toll of frantic calls for help, the seemingly “bottomless pit” of dependency needs, the emotional intensity, lability, unpredictability, and genuine extreme sensitivity of these individuals. Conventional ideas regarding boundaries and limit setting do not prepare clinicians for finding the appropriate balance between autonomy and dependence in BPD patients. Nor are they particularly effective.

Many individuals with BPD experience therapeutic “neutrality” as uncaring and this, in turn, can breed resentment in a clinician who feels that their well-meaning efforts are being willfully misinterpreted. Furthermore, in BPD, what is neutral ­clinician behavior can be misread as “rejecting,” “angry,” “disinterested,” or worse, as tacit approval of maladaptive and self-destructive behavior. While it is important for those with BPD to learn that they have a tendency to misread, they may experience this as too upsetting early on in treatment and withdraw before they have the opportunity to address this.

Toward this end, we present a clear, comprehensive summary of DBT principles and techniques illustrated with rich clinical vignettes. It should be noted that while we have tried to stay as true as possible here to the DBT model as developed by Linehan, our writing is inevitably affected by our training and our experience in applying the model. Thus, we also include DBT-informed conceptualizations and interventions that we have developed based on our experience over the years of conducting DBT in both research and clinical settings with individuals at risk for self-harm behaviors. We try to state explicitly where our thinking is informed by the DBT model but is an ­expansion of it.

“Top 10 questions” therapists ask about working with individuals who have BPD

We have identified the “top 10” most frequently asked questions about how to effectively intervene with borderline patients. While we set the questions in a neutral format, they are often asked with a great deal of anger, worry, and judgmental tone. We note the questions here and will demonstrate throughout the book how DBT ­effectively addresses each of these questions.

1 How can clinicians maintain empathy for their borderline patients?

2 What can clinicians do to help patients who are extremely sensitive to criticism ­tolerate change interventions and not leave prematurely in ­response to a change-oriented intervention?

3 How do clinicians help patients manage their chronic suicidal ideation, threats, and gestures in an outpatient setting without becoming dysregulated themselves? How can clinicians refrain from becoming either overly anxiou...

Table of contents

• Cover
• Title page
• Copyright page
• Dedication
• About the Authors
• Foreword
• Acknowledgments
• Chapter 1: Introduction
• Part I: Theoretical, research, and clinical foundations
• Part II: Using DBT in clinical practice
• Index