Download PDF Dialectical Behavior Therapy in Clinical Practice APPLICATIONS ACROSS DISORDERS AND SETTINGS by Linda A. Dimeff

Sinopsis

DBT is a cognitive-behavioral treatment originally developed by Marsha M. Linehan, PhD, as a treatment for chronically suicidal individuals, and first validated with suicidal women who met criteria for borderline personality disorder (BPD). Those with BPD represent 14–20% of inpatients (Widiger & Frances, 1989; Widiger & Weissman, 1991), include 8–11% of outpatients (Widiger & Frances, 1989; Kroll, Sines, & Martin, 1981; Modestin, Abrecht, Tschaggelar, & Hoffman, 1997), and consume a disproportionate amount of mental health resources, often up to 40%. Adequately addressing the needs of individuals with BPD poses several challenges. Individuals with BPD typically require therapy for multiple, complex, and severe Axis I problems, often in the context of unrelenting crises and management of high-risk suicidal behavior. With many of these clients, the sheer number of serious (at times life-threatening) problems that therapy must address makes it difficult to establish and maintain a treatment focus. Following the concern most pressing to the client can result in a different crisis management focus each week. Therapy can feel like a car veering out of control, barely averting disaster, with a sense of forward motion but no meaningful progress.

Treatment decisions are made yet more complicated because clients with chronic suicidal behavior and extreme emotional sensitivity often act in ways that distress their therapists. Suicide attempts, threats of suicide attempts, and anger directed at the therapistcan be very stressful. Regardless of their training and experience, therapists can struggle with their own emotional reactions when a client is recurrently suicidal and both rejects the help that the therapist offers and demands help that therapist cannot give. Even when the therapist is on the right track, progress can be slow and sporadic. All these factors increase the chance of therapeutic errors, including making premature changes to the treatment plan, and may contribute to the fact that those with BPD have high rates of treatment failure (Perry & Cooper, 1985; Tucker, Bauer, Wagner, Harlam, & Sher, 1987). Intense distress, treatment failure, and repeated suicidal behavior, in turn, contribute to the high use of psychiatric services by this population. Individuals who meet criteria for BPD typically have sought help repeatedly and from multiple sources; in one study, 97% of those seeking treatment had received prior outpatient treatment from a mean of 6.1 previous therapists and 72% had had at least one psychiatric hospitalization (Skodol, Buckley, & Charles, 1983; Perry, Herman, Vander Kolk, & Hoke, 1990; Bender et al., 2001). Legal and ethical concerns about suicide make it difficult to limit hospital use, even when “revolving door” use of involuntary inpatient facilities may itself inadvertently cause harm (i.e., be iatrogenic). The experience for individuals who meet criteria for BPD and their treatment providers has historically been a discouraging path of recurrent treatment failures despite their best efforts.

It was within this context that DBT evolved. As Linehan began to use standard clinical behavior therapy (Goldfried & Davison, 1976), she was led by the nature of her clients’ problems to balance and complement behavior therapy’s change orientation with other therapeutic strategies. Linehan’s careful observation of successes and failures resulted in treatment manuals (1993a, 1993b) that organize strategies into protocols and that structure therapy and clinical decision making so that therapists can respond flexibly to an ever-changing clinical picture. Although DBT shares elements with the psychodynamic, client-centered, gestalt, paradoxical, and strategic approaches to therapy (cf. Heard & Linehan, 1994), it is the application of behavioral science, mindfulness, and dialectical philosophy that are its defining features.

DBT has evolved into a sophisticated treatment, yet most of its concepts are quite straightforward. For example, DBT emphasizes an organized, systematic approach in which members of the treatment team share fundamental assumptions about therapy and clients. DBT considers suicidal behavior to be a form of maladaptive problem solving and uses well-researched cognitive-behavioral therapy (CBT) techniques to help clients solve life problems in more adaptive ways. DBT therapists take every opportunity to strengthen

clients’ valid responses, which alone and in combination with CBT interventions facilitate change (e.g., Linehan et al., 2002). Because difficult clinical problems naturally provoke strong differing opinions among treatment providers, and because DBT clients’ problems themselves include dichotomous, rigid thinking and behavioral and emotional extremes, dialectical philosophy and strategies offer a means of reconciling differences so that conflicts in therapy are met with movement rather than with impasse. Below we discuss each of these in turn as a way to lay out DBT in a nutshell.

Content

1. Overview of Dialectical Behavior Therapy
2. Adopt or Adapt?: Fidelity Matters
3. Implementing Standard Dialectical Behavior Therapy in an Outpatient Setting
4. Dialectical Behavior Therapy on Inpatient Units
5. Implementing Dialectical Behavior Therapy in Residential Forensic Settings with Adults and Juveniles
6. Dialectical Behavior Therapy for Individuals with Borderline Personality Disorder and Substance Dependence
7. Dialectical Behavior Therapy and Eating Disorders
8. Dialectical Behavior Therapy with Families
9. Dialectical Behavior Therapy for Adolescents
10. Dialectical Behavior Therapy for Depression with Comorbid Personality Disorder: An Extension of Standard Dialectical Behavior Therapy with a Special Emphasis on the Treatment of Older Adults
11. Dialectical Behavior Therapy for Assertive Community Treatment Teams
12. Evaluating Your Dialectical Behavior Therapy Program

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