Dialectical Behavior Therapy

A Contemporary Guide for Practitioners

Lane D. Pederson

• Publisher: Wiley-Blackwell
• Year: 2015
• ISBN:
  9781118957899
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

A definitive new text for understanding and applying Dialectical Behavior Therapy (DBT).

• Offers evidence-based yet flexible approaches to integrating DBT into practice

• Goes beyond adherence to standard DBT and diagnosis-based treatment of individuals

• Emphasizes positivity and the importance of the client's own voice in assessing change
• Discusses methods of monitoring outcomes in practice and making them clinically relevant

• Lane Pederson is a leader in the drive to integrate DBT with other therapeutic approaches

1
Why Learn DBT?

When therapy models are compared, the consistent finding is that no one approach is superior to others, dialectical behavior therapy (DBT) included (Clarkin et al., 2007; McMain et al., 2009; Wampold, 2001). The virtual ties from hundreds of horserace therapy studies beg the question: Why learn DBT when you probably already know effective approaches?

The research is clear that therapy is contextual, not prescriptive, and as such successful therapists need to learn and become competent in a variety of treatments to find a goodness of fit between clients, therapists, and approaches. To paraphrase an amalgamation of experts who advocate a contextual approach to therapies and evidence-based practices (EBPs), to be effective, therapists ought to learn contemporary treatments sought by clients and payers, so long as therapists can coherently deliver them with belief, expectancy, and sufficient adaptation to clients' needs and preferences. And DBT fits the bill, as it is a highly sought contemporary approach for a number of reasons.

First, DBT's privileged status generates tremendous interest in its applications across settings and populations. Therapists gravitate to the approach, and they find that its philosophies and interventions fit nicely with their personalities and beliefs about what works with clients. Many therapists develop a natural allegiance to DBT, and DBT marketing has reached clients who tend to have significant buy-in with DBT therapists and programs. Therapists' and clients' belief and expectancy in DBT will enhance outcomes in many cases, as this therapeutic factor affects outcomes as much as or more than actual therapy models or techniques (Lambert, 1992; Wampold, 2001). As an example, DBT enhances the belief that difficult-to-treat populations such as those with chronic and severe suicidality and borderline personality disorder can be successfully treated, positively impacting the field and treatment results. Positive perceptions and successful outcomes contribute to DBT's credibility and popularity, increasing demand for the approach.

Second, there is a tremendous variety of interventions that comprise DBT, to the point that it can be argued that it approximates an eclectic therapy in practice. DBT interventions include mindfulness practice, skills training, relationship strategies, cognitive and behavioral techniques, and environmental interventions among others. Heard and Linehan (1994) point out that DBT has commonalities with client-centered, psychodynamic, gestalt, paradoxical, and strategic therapies. Marra (2005) also makes convincing comparisons between DBT and other approaches. Further, in a study of common therapeutic factors in empirically supported treatments for borderline personality disorder, 12 categories of interventions were rated from extremely important to proscribed, as indicated by each respective treatment manual. Of these categories, 11 of the 12 were rated extremely important in DBT with only one of the 12 being proscribed (making an interpretation) (Weinberg et al., 2010). This variety of interventions assists therapists in customizing the approach to clients, a hallmark of EBP.

Among its interventions, DBT places strong emphasis on acceptance and validation. Validation is perhaps the most fundamental method of building the therapeutic alliance and “represents a logical application of common factors research” (Duncan & Moynihan, 1994, p. 297). DBT also emphasizes active commitment to therapy and early agreement on goals, treatment targets, and methods of therapy, enhancing important elements that underlie the therapeutic alliance (DeFife & Hilsenroth, 2011; Linehan, 1993a).

Third, DBT is a teachable and practical treatment, making it accessible to therapists of all levels. Hawkins and Sinha (1998) evaluated the conceptual mastery of over 100 therapists following DBT training and found that therapists from diverse backgrounds were able to demonstrate understanding of the approach. Comtois et al. (2007) emphasize that DBT programs can be staffed with graduate therapy students who are often eager to learn the approach. This recommendation highlights that properly supervised therapists new to the field can effectively use DBT with clients. In my clinics, talented master- and doctoral-level students and interns successfully lead skills groups and conduct individual and group DBT after a few months of intensive training and mentoring by our team.

Last, DBT's dialectical philosophies fit with integrating research and practice, applying DBT with a formal consistency while customizing it to individuals, and balancing allegiance to a therapy, DBT, with allegiance to the therapeutic factors that transcend all therapies.

2
Introduction to DBT
Brief Background and Current Controversies

DBT was developed by Marsha Linehan in the late 1980s and early 1990s at the University of Washington. Interested in helping those with chronic suicidality and self-injury, Linehan specialized in the treatment of women diagnosed with borderline personality disorder.

Linehan's (1993a) initial work with this population used cognitive-behavioral therapy (CBT). However, she found that traditional CBT administered with too much problem and solution focus was ineffective and left her clients feeling misunderstood and invalidated. To compensate, Linehan began to incorporate acceptance strategies, but she found that too much acceptance focus was also ineffective, leaving her clients demoralized and thinking nothing would change. Linehan observed that her clients responded best to fluid combinations of acceptance and change strategies rather than the emphasis of one over the other. The balanced movement and flow between acceptance and change is a fundamental dialectic in DBT.

As DBT evolved, Linehan (1993a) searched for and integrated philosophies, relationship practices, and interventions that distinguished DBT from traditional CBT. Dialectical philosophies were used to bring balance and save clients and therapists from all-or-nothing concepts and behaviors. Treatment assumptions were drafted to orient clients and therapists to effective treatment. Mindfulness practices, taught from a secular perspective, emphasized nonjudgmental experiencing in the moment and effective rather than reactive behavioral responses in life. Systematic skills training bridged the gap between behavioral deficits and desired behavioral change. Treatment stages and a hierarchy to prioritize treatment targets decreased chaos and increased therapeutic focus. Functional behavioral analysis structured sessions with systematic pattern recognition aided by problem-solving with skills. And validation underpinned a strong relationship focus that included communication styles ranging from reciprocal to irreverent. Last, Linehan created a multimodal treatment-delivery framework to structure and administer DBT. Called the “standard model,” the treatment-delivery modes of standard DBT include weekly individual therapy, weekly group skills training, weekly therapist consultation, and individual therapists providing 24/7 telephone-coaching availability to their clients.

The prodigious changes from CBT seemed to better fit the needs and preferences of clients with borderline personality disorder, and therapists were inspired by this radically new yet highly derivative theoretical orientation. The therapy became in high demand, and Linehan with her associates founded a training company dedicated to teaching teams of therapists how to implement and deliver standard DBT as it was researched in Linehan's clinical trials.

The dedicated focus on one delivery of DBT, the standard model, makes historical sense given that DBT's initial development happened during the empirically supported treatment (EST) zeitgeist,¹ when a major emphasis was placed on diagnosis-specific treatments, forever pairing DBT with borderline personality disorder. During this time period, therapists were compelled to adopt evidence-based treatments (EBTs) with fidelity to how the models were researched, with adherence² to the specific ingredients prescribed by treatment manuals. In the case of DBT, treatment fidelity meant also following the researched treatment-delivery framework, the standard model.

With a paucity of evidence, the EBT movement created and perpetuated a myth that stubbornly persists today: that specific models of therapy and their interventions should be applied prescriptively to diagnoses vis-à-vis a medical model of treatment, as if clients, therapists, and other important mediating factors are irrelevant in psychological treatment.³

Despite the EBT movement and Linehan's efforts to promote fidelity to the standard model, DBT has been widely disseminated as a theoretical orientation for a broad variety of diagnoses in many adapted treatment frameworks (Andion et al., 2012; Apsche et al., 2006; Christensen et al., 2013; Chugani et al., 2013; Engle et al., 2013; Erb et al., 2013; Evershed et al., 2003; Federici et al., 2012; Goldstein et al., 2007; Harley et al., 2007; Hashim et al., 2013; Iverson et al., 2009; Keuthen et al., 2010; Klein et al., 2013; Kroger et al., 2005; Linehan et al., 1999; Low et al., 2001; Lynch & Cheavens, 2008; Rakfeldt, 2005; Ritschel et al., 2012; Roosen et al., 2012; Rosenfeld et al., 2007; Simpson et al., 1998; Sneed et al., 2003; Soler et al., 2009; Steil, 2011; Sunseri, 2004; Vitacco & Van Rybroek, 2006; Ward-Ciesielski, 2013; Wasser et al., 2008; Wolpow et al., 2000). In fact, research articles on adapting DBT to differing diagnoses and settings, frequently with changes from the standard model in service delivery, outnumber articles on standard DBT. As therapists continue to customize DBT to diverse populations in new settings, levels of adherence to the standard model differ, and, while DBT's reputation as a go-to treatment for borderline personality disorder and other difficult-to-treat issues has been enhanced by successful treatment adaptors, this has not happened without controversy.

A segment of self-described adherent therapists assert that only the standard model is “real” DBT, claiming a specious empirical high ground⁴ while ignoring a large body of research evidence and current guidelines on evidence-based practice (EBP). With varying applications and treatment frameworks, the natural question is: “Who is following the evidence?”

Standard DBT is an EBT for borderline personality disorder, but it may surprise many that adherence to an EBT is not necessarily EBP. Whereas adherence to an EBT meets a “minimum standard of empirical support,” EBP “is a process of applying research that involves clinical expertise and judgment in the context of client needs and preferences” (Duncan and Reese, 2012, p. 1009). EBP supersedes prescriptive therapy applications because it recognizes the important contextual roles played by therapists and clients in determining therapeutic outcomes, roles that have significantly greater impact than models and their techniques.

Movement to EBP is based on a larger view of the evidence, illuminating a cogent answer to the “who is following the evidence” question. We know therapy works, and its effect size is robust (Smith et al., 1980; Wampold, 2007), but the reasons why therapy is effective differ from those therapists and researchers often promote. The jury has been in for some time, and empirical evidence overwhelmingly supports the thesis that therapy works due to pan-theoretical therapeutic factors⁵ that operate within a contextual model. As noted in Chapter 1 and further explained...