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Social Work in Mental Health

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Dialectical Behavior Therapy

Cedar R. Koons

To cite this article: Cedar R. Koons (2008) Dialectical Behavior Therapy, Social Work in Mental Health, 6:1-2, 109-132, DOI: 10.1300/J200v06n01_10

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Published online: 11 Oct 2008.

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Dialectical Behavior Therapy

Cedar R. Koons

SUMMARY. This chapter provides an overview of Dialectical Behav- ior Therapy (DBT), an evidence-based outpatient treatment developed for suicidal women with borderline personality disorder (BPD), and since adapted for other settings and populations. The chapter introduces the biosocial theory of the etiology of BPD and how DBT addresses each aspect of the disorder. It further describes the theoretical foundations of DBT in behaviorism, Zen and dialectics. The reader learns about DBT structures of treatment and what client behaviors are targeted in each stage of treatment. Finally, the chapter uses a clinical case example to il- lustrate how a therapist would get started with a new client using DBT. doi:10.1300/J200v06n01_10 [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@ haworthpress.com> Website: <http://www.HaworthPress.com> © 2008 by The Haworth Press. All rights reserved.]

KEYWORDS. Dialectical behavior therapy, borderline personality dis- order, emotion dysregulation, invalidation

INTRODUCTION

Dialectical Behavior Therapy (DBT) is an evidence-based treatment for borderline personality disorder, developed by Marsha M. Linehan,

[Haworth co-indexing entry note]: “Dialectical Behavior Therapy.” Koons, Cedar R. Co-published si- multaneously in Social Work in Mental Health (The Haworth Press) Vol. 6, No. 1/2, 2008, pp. 109-132; and: Borderline Personality Disorder: Meeting the Challenges to Successful Treatment (ed: Perry D. Hoffman, and Penny Steiner-Grossman) The Haworth Press, 2008, pp. 109-132. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

Available online at http://swmh.haworthpress.com © 2008 by The Haworth Press. All rights reserved.

doi:10.1300/J200v06n01_10 109

Ph.D, and colleagues (1993a, 1993b) at the University of Washington, and described in a book and treatment manual. Linehan, a behaviorist, was working with chronically suicidal, self-injurious women and found that these severely disordered, multi-problem individuals did not re- spond well to standard behavioral treatment. They were impulsive, had mood instability, problems with a sense of self and with relationships, and could look thought disordered under emotional stress. These fac- tors, combined with suicidal and non-suicidal self-injurious behaviors contributed to treatment dropout and frequent inpatient admissions. Most met criteria for borderline personality disorder (BPD).

Linehan theorized that the common factor underlying all these be- haviors had to do with regulation of emotion. These individuals expe- rience stronger than usual emotions and have trouble controlling emotional behavior. They also try to avoid emotions in problematic ways, such as with alcohol or drugs. This central problem, emotion dysregulation, contributes to all the other problems. For example, emotion dysregulation is a direct cause of mood swings and problematic anger behavior. Emo- tion dysregulation prompts suicidal and self-injurious behavior as well as other high-risk behaviors and is a factor in impulsivity. Emotion dysregulation contributes to relationship dysregulation, resulting in intense, unstable or chaotic relationships. With these individuals, emotion dysregulation can cause problem thinking, including dichoto- mous thinking, paranoia, dissociation and hallucinations. Finally, chronic emotion dysregulation results in problems with the sense of self and feelings of emptiness.

THE BIOSOCIAL THEORY

Where does emotion dysregulation originate? Linehan theorized that borderline personality disorder developed as the result of a pronounced biological vulnerability to emotion, transacting over time with a learn- ing history characterized by pervasive invalidation. This theory seeks to explain the etiology and maintenance of BPD, and also guides thera- pists in the way they understand and treat many of the problems they encounter interacting with BPD patients.

The biological component of the biosocial theory refers to the tem- perament of the individual who develops BPD. These individuals could be called emotionally vulnerable in that (1) they have a low threshold of emotional activation; (2) their emotions reactions are extreme; and (3) the biological arousal associated with emotion is slow to subside, mak-

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ing the individual more vulnerable to the next event that prompts emo- tion. For example, a stimulus in the environment, such as a co-worker making a critical comment about one’s messy desk, might cause mild anger in the non-disordered person while prompting rage in the person with BPD. The non-disordered person would probably recover in 24 hours or less. The person with BPD might ruminate about the comment for days or even weeks, re-experiencing the initial emotion and power- ful secondary emotions and being more vulnerable to other stressors as a result.

Emotional vulnerability alone, however, is not enough to produce the disorder. To produce emotion dysregulation, vulnerability to emotions must be combined with an inability to regulate emotions once they are activated. The ability to regulate emotions is a learned behavior that basic research tells us is made up of several important skills. These in- clude: (1) directing attention away from upsetting stimuli; (2) regulat- ing physiological arousal, such as using deep breathing to reduce heart rate associated with fear or anger; (3) avoiding urges that result in mood-dependent behavior, such as not skipping work because of shame; and (4) continuing to pursue goals not related to current mood. People can learn to manage even very vulnerable temperaments if they are taught the necessary skills. Unfortunately, individuals who develop BPD, in addition to their problems with emotion vulnerability, also have problematic learning histories. The social settings that contribute to their problems are called “the invalidating environment.”

An invalidating environment is one in which a person’s private expe- riences, such as emotions, preferences, sense of pain, as well as their ob- servable behaviors are pervasively dismissed, criticized or attributed to negative traits. This invalidation takes place repeatedly and over time. Invalidating environments provide little if any recognition of the valid- ity of a person’s needs or feelings, and do not provide instruction in how to regulate emotions or solve problems. Instead they attribute the diffi- culties in problem solving to negative characteristics of the person with the problem, such as lack of motivation, while also over simplifying what is needed to solve the problem. In addition, invalidating environ- ments respond unhelpfully to demands placed upon them. When de- mands are at an appropriate level of intensity the environment may ignore them, thereby extinguishing moderate asking behavior. When the intensity of the demand escalates, however, the environment may punish, or, intermittently reinforce an elevated level of demand.

The invalidating environment, while not teaching the skills needed to regulate emotions, teaches some other very unhelpful things. By invali-

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dating private experiences, the environment teaches the individual not to trust or respect their own inner experiences as valid, but to look to others to explain to them what they think or feel. As a result, individuals may not know how to label their own emotions, let alone regulate them. By over simplifying problem solving, the environment encourages un- realistic self-expectations, perfectionism and the tendency to become hopeless and self-invalidating in the face of difficult problems. Finally, when environments routinely ignore appropriate levels of request and intermittently reinforce escalated demands, the individual is shaped to go back and forth from inhibition of emotions to extreme displays of emotion, behavior that is very ineffective in most settings.

The biosocial theory explains not only the etiology of BPD, but also its maintenance. For example, treatment environments often function as invalidating environments, as do many school and work environments. Even very skillful individuals may have great difficulty coping with these environments when they are vulnerable because of being tired or sick. When therapists understand the biosocial theory they are less likely to stigmatize individuals with BPD. And since so many problem- atic client behaviors arise out of the interaction of biological vulnerabil- ity with pervasive invalidation, therapists become adept at attending to what is needed to help their borderline clients unlearn maladaptive be- haviors and learn new, more helpful ways to manage themselves and their environments.

THE THREE FOUNDATIONS OF DBT

DBT is constructed from three very different branches of knowledge, each contributing useful principles to its foundation. Behaviorism con- tributes the technology of change, Zen contributes the technology of ac- ceptance, and dialectics contributes a worldview and a striving for balance between acceptance and change.

Behaviorism

DBT is a behavioral therapy in that it seeks to understand how maladaptive behaviors are learned and to replace maladaptive behav- iors with new, more skillful behaviors. Whether behavior is observable or private, it is influenced by the modeling and conditioning available in the environment.

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Modeling in DBT is used in both individual therapy and in skills training. The model presented is not one of having perfected skillful be- havior; rather, it is a coping model. As in other cognitive and behavioral therapies, DBT does not attempt to cultivate a transferential relation- ship. The therapeutic relationship is a real relationship between equals, at the same time that it is bound by all ethical and professional guide- lines. Therapists model skills use in their own life circumstances, while not burdening clients with problems they have not resolved. DBT also encourages the client to use other helpful models, such as individuals who have overcome great adversity to achieve a worthwhile life. These models can counteract maladaptive models such as parents, siblings, other patients, etc., and help the client learn new behaviors.

Conditioning in DBT is undertaken through examining specific in- stances of behavior in their full contexts (including the emotions, urges, thoughts and bodily sensations associated with the antecedents and con- sequences), and then choosing and implementing solutions to change problematic associations, stimuli and responses as they occur. The DBT therapist works collaboratively with the client to undertake these behav- ior and solution analyses, and to see how certain patterns tend to repeat themselves. Together, they discover how, in the presence of certain stimuli, the client is likely to feel, think, and experience; these experi- ences then lead to certain actions or non-actions, which have conse- quences that may be rewarding, punishing or neutral. For example, a client’s cutting often might occur as a response to a specific emotion, such as shame. The emotion is so overwhelming that there is an urge to seek relief. Cutting brings that brief sense of relief, but is nearly always followed by a sense of hopelessness and more shame. This understand- ing can help a client to understand that to change the cutting behavior, he or she will need to learn to tolerate the emotion of shame and begin to see the relief that cutting brings as something to be avoided. DBT also uses conditioning to construct a treatment environment where adaptive behavior of the client is rewarded and maladaptive behavior is not re- warded. For example, for a client who finds an extra session rewarding, the therapist is careful to offer it primarily for adaptive behavior, such as before a job interview, not solely because she is feeling suicidal.

Zen

Zen principles are another foundation of DBT that inform the skills cur- riculum as well as therapist’s attitudes toward clients and treatment. Zen emphasizes the wisdom inherent in each individual. DBT translates this

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principle as “wise mind,” a synthesis of information gathered from the emotions with information gathered from the facts. When wise mind is sought, one’s awareness in informed by something more than the sum of emotions and facts, and includes intuition, the middle path, or wisdom. Ac- cess to wise mind is central to the use of most of the other DBT skills. Ther- apists are also encouraged to practice mindfulness in order to improve their skills as therapists and their interactions with their team.

To get to wise mind, DBT offers the core mindfulness skills, which derive from Zen. These include the “what skills” (observe, describe and participate) and the “how skills” (non-judgmentally, one-mindfully and effectively). Observe and describe instruct the student to notice what is just as it is and describe a situation, using just the facts in the here and now. To participate is to enter fully into the experience of the moment, to throw oneself into acting while in contact with wise mind.

The first “how skill” is to adopt a nonjudgmental stance, the student must eschew describing things, people, or events as good or bad, instead focusing on the facts of the issue at hand and the consequences. For ex- ample, rather than calling a boss “hateful,” the individual looks at the fact that the boss required him to stay late at work and miss a child’s school performance and did not apologize. While the individual may still feel highly distressed, the nonjudgmental stance allows for some access to wise mind. In addition to not judging others, DBT emphasizes non-judgment of the self and of the behavior of judging.

The skill of “one-mindfully” directs one to focus all of one’s attention on one thing at a time, rather than allowing the mind to wander to go on auto- pilot. This allows the individual to slow down and notice what is, to reduce emotional arousal and accept the situation. Finally, the skill of “effectively” is used to help the individual adopt a course of action that is in concert with his or her goals and avoids impulsive urges, such as being vengeful, righ- teous or self-sabotaging. Being effective includes doing what works, play- ing by the rules and keeping focused on the desired outcome.

The mindfulness skills are crucial for anyone who is experiencing a lot of pain, since the circumstances, attitudes and behaviors contribut- ing to the pain are unlikely to change quickly, or may be exceedingly difficult to change. Therefore, acceptance of reality, a central tenet of Zen, can be seen as a necessary skill to endure the change process.

Dialectics

Dialectics is a western philosophical tradition that postulates that truth is found in the struggle of opposites. In contrast to absolute truth,

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dialectical truth proceeds from an argument between a thesis and its an- tithesis and moves toward synthesis. In DBT, the fundamental dialecti- cal dilemma is that between an individual’s profound and urgent need to change behaviors that are destroying her life and her equally compelling need to accept herself and her situation in the moment as she is. The struggle between these two opposites will inform the entire treatment course. For example, as a client gives up cutting (thesis) she may find she copes less well for a while and drinks more (antithesis) but over time will learn enough distress tolerance to sustain abstinence from both (synthesis). However, as she gives up her problem behaviors and is no longer in crisis (thesis) she will find her isolation intolerable (antithesis) and will have to confront her social anxiety (synthesis).

Dialectics stand in contrast to the dichotomous thinking characteris- tic of persons with BPD, as well as the systems that treat them. Dialec- tics see everything as connected to everything else, and in a constant state of transaction or struggle. For example, at the therapist consulta- tion meeting two therapists disagree about whether or not a client is “do- ing the best she can” in skills group, or needs to do better. The individual therapist insists that the client has at least been showing up to group and cannot be expected to do better right now. The skills trainer says that the client consistently comes late with no homework and gets angry when confronted. The two therapists struggle and the team high- lights “both/and” rather than “either/or.” Finally, the individual thera- pist is influenced to help the client with homework in individual therapy and to address timeliness with her. She remembers to tell the team that the client has recently gone off her ADD medication. Hearing about the medication change, the skills trainer becomes more accepting and promises to notice any skillful behaviors the client does demonstrate, for example, if she progresses from being 20 minutes late to being 10 minutes late.

Adopting a dialectical worldview is the prerequisite for the DBT con- sultation team and is essential for it to function effectively. Any position taken on an issue is likely to generate an equally convincing opposite position. Polarity is a natural fact of life. But rather than “split” on these difficult issues, or rush to a watered down compromise, a dialectical world view promotes a more thoughtful search for “what is left out of this picture?” Often, the piece left out can be crucial for the treatment issue at hand.

Dialectics function throughout DBT to help balance acceptance strat- egies, primarily validation (see below), with change strategies, primar- ily behaviorism. DBT also uses dialectics to manage the style of the

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therapist, balancing a more accepting, reciprocal style with a more change-oriented or irreverent style. Dialectics also inform the balance with which the therapist intervenes on the client’s behalf as a case man- ager. In this case, the emphasis is on consulting with the client on how to interact with her environment, as opposed to intervening in the environ- ment on behalf of the client. Finally, DBT offers some specific “dialec- tical strategies,” described in detail in the treatment manuals, which are used to move the client toward a synthesis, including the use of meta- phor, entering the paradox with the client, allowing natural change, and playing devil’s advocate.

STRUCTURE OF TREATMENT

Standard DBT is an outpatient treatment that uses four primary modes to deliver the functions of comprehensive treatment. The modes include individual therapy, skills training, the therapist consultation meeting, and telephone consultation, which is available to the client be- tween sessions for coaching on skills use. The functions of treatment in- clude enhancing motivation (individual therapy), increasing skills for the client (skills training), increasing skills for the therapists and skills trainers (therapist consultation), and generalizing skills to the environ- ment (telephone consultation). DBT recognizes that important treat- ment functions are also provided by agents outside the standard DBT team, including the pharmacotherapist and the clinic administrator. Pharmacotherapy, like individual therapy, can enhance motivation and increase the potential for skillful behavior. The clinic administrator plays a role in structuring the delivery environment so that it is condu- cive to effective treatment, for example, by providing paid time for team consultation.

Individual Therapy

In standard DBT, the individual therapist is in charge of treatment and attends to client motivation to remain in and progress through treat- ment and addresses anything that is interfering with treatment. The indi- vidual therapist elicits from the client his or her goals and establishes the agenda according the client’s stage of treatment. In at least one 50-min- ute session per week, the individual therapist keeps the treatment fo- cused on the target hierarchy, reinforces the use of skillful behaviors and establishes a strong, effective relationship. The individual therapist

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also provides the telephone coaching as needed to help the client use skills in daily life, both to avoid suicidal and self-injurious behavior and to repair any perceived rifts in the therapeutic relationship between sessions.

Skills Training

Skills training is usually provided in a class with two co-teachers, which meets for approximately two hours each week, to cover the skills curricula, assign and review homework assignments. The skills are taught in four modules, Mindfulness, Distress Tolerance, Emotion Reg- ulation and Interpersonal Effectiveness. The Mindfulness module, de- scribed above, is two weeks in length and is repeated at the beginning of each of the other modules. The remaining three modules last about eight weeks each. Most clients go through the entire cycle at least twice in or- der to over-learn skills; this process takes approximately one year.

Therapist Consultation

The therapist consultation includes all the therapists and skills train- ers treating a specific cohort of clients. This meeting is held weekly to allow therapists time to consult on their clients and apply DBT princi- ples to solve any problems arising in treatment. The function of the team meeting is to enhance the therapist’s capacity to treat effectively. To- ward this end, specific agreements are made and referenced regarding the DBT way to consult. These include the adoption of a dialectical phi- losophy of treatment and a willingness to look first for the most em- pathic explanation of a client or colleague’s behavior. DBT encourages therapists to acknowledge first their own fallibility and that of their team colleagues. Therapists agree to observe their own limits with cli- ents in each different context and need not be consistent with all their clients or with other colleagues. Finally, therapists are encouraged to observe their own limits with clients and also to be willing to stretch limits from time to time as needed in the context of treatment.

Telephone Coaching

DBT offers between-session telephone coaching for clients to (1) re- duce suicide crises and self-harm behavior; (2) increase generalization of skills; and (3) repair rifts in the therapeutic relationship that could in- terfere with between session functioning. Telephone coaching is not

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therapy on the phone, and contacts are typically brief and focused on us- ing skills to get through the crisis without engaging in maladaptive be- havior. Clients are instructed to call the therapist before they engage in their problem behavior and are forbidden to call for 24 hours after they engage in self-injurious behavior; this avoids giving therapeutic contact that might reinforce the behavior. The role of telephone contact in DBT is similar to in vivo behavioral therapy and is balanced by team consul- tation and by the limits of the individual therapist. The management of this mode of treatment is described by Linehan (1993b) and also by Ben-Porath and Koons (2005).

Stages of Disorder

DBT structures treatment for borderline clients based on the severity of their behaviors, and treats those behaviors in a specified order called a target hierarchy. There are four stages of treatment each with its spe- cific goals and treatment targets. The overarching goal of DBT is “a life worth living.”

Stage one of treatment is characterized by pervasive behavioral dyscontrol. Stage one behaviors threaten life, health, the functioning of a therapeutic relationship and a basic quality of life. In stage one, the goal is getting behavior under control, building connectedness to care givers, and learning behavioral skills. Thus, stage one targets first any intentional life threatening or self-harming behavior. This includes sui- cidal or homicidal thoughts, plans or attempts, and suicidal or non-sui- cidal intentional self-injurious behavior. The second target for stage one is any behavior that interferes with therapy, such as nonattendance, non- payment, noncompliance with medications, or hostile behavior directed at the therapist. The third target of stage one is any behavior interfering with an adequate quality of life, such as homelessness, drug or alcohol abuse or dependence, binging and purging, or being in a violent rela- tionship. The final target of stage one is learning and using behavioral skills to replace maladaptive behavior.

Stage two is characterized by “quiet desperation.” While clients are no longer in behavioral dyscontrol, they still exhibit problematic emo- tional inhibition, and symptoms of post- traumatic stress. In stage two, clients are often quite numb and miserable, even though they are able to use many skills and are no longer engaging in high-risk behaviors. The targets of stage two include decreasing symptoms of post-traumatic stress and increasing emotional experiencing. Stage two also targets in- creasing acceptance of traumatic events in the past, acceptance of emo-

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tions and acceptance of the self. It is important to note that the work of stage two cannot be undertaken with clients who lack the skills to man- age exposure to extreme emotion without engaging in the chaotic be- haviors of stage one. Effective treatment of common co-morbidities, such as depression, anxiety and OCD, can accelerate in stage two.

Stage three clients have achieved a life worth living, but continue to have ordinary problems of living. Stage three targets such common problems as decreasing interpersonal conflicts, coping with chronic health issues, and increasing a sense of mastery. Stage three clients use many behavioral skills in a variety of contexts and are capable of ex- pressing a wide range of emotions. They do not look significantly dif- ferent from other clients seen in CBT, except perhaps for their painful pasts and their emotional vulnerability.

Stage four deals with increasing the capacity for joy and freedom. Clients who have struggled for many years with BPD and have arrived at stage four often have a desire to express their newfound sense of self and their values more fully in their relationships and communities and desire more joy and meaning. They may be quite wise and skillful and often have as much to teach as to learn.

CORE STRATEGIES OF DBT

Given the enormous challenges of treating these severely disordered, multi-problem clients, it is not surprising that the armamentarium of DBT is large and varied. For the purposes of providing an overview, this chapter will address only the core strategies, which are prob- lem-solving (change) and validation (acceptance). These two strategies are expressed and kept in balance by means of dialectical, stylistic and case management strategies, which will not be covered in this chapter. Commitment strategies will be illustrated in the case study.

Problem Solving

As mentioned above, the tools of DBT problem solving come from behavioral and cognitive therapies, and from protocols of other evi- dence-based treatments. DBT problem solving begins with behavioral assessment. First, the problem is defined as a specific behavior that ei- ther needs to increase (such as showing up at work) or decrease (such as yelling at a family member), or appear in the right place and time (such as saying no to unreasonable requests). Once the behavior is defined, it

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is analyzed to gain insight into where and when it is most likely to occur and what are the most likely variables that control it. For example, does the client fight with her mother, feel fear, cut in response to fear, feel calmer and then hide the cuts from her mother? Or does she fight with her mother, feel rage, cut and then show the cut to her mother, who soothes her? In both cases the cutting behavior is at once a response to a stressor and an attempt to get a desired consequence. Yet in each case, the therapist would proceed differently to solve this problem. Once all the factors influencing the problem are understood, the therapist and cli- ent can work together to find solutions. These might include learning new behavioral skills, changing disordered thinking, changing the asso- ciations between stimuli in the environment, and changing the reinforc- ing or punishing consequences of problem behavior. DBT therapists need to be adept at getting and maintaining commitment to behavioral change, and at teaching what clients need to learn to deal with the many issues that present during therapy.

DBT is a principle-driven therapy that employs protocols of other ev- idence-based treatments as needed. For example, a client in DBT who had been raped in adolescence might need exposure treatment (an evi- dence-based protocol) for his or her trauma. DBT principles indicate this would not be appropriate until stage two of treatment, once any life-threatening, therapy-interfering or quality of life-interfering behav- iors were under control and the client had mastered sufficient skills to deal with the distress of exposure. DBT therapists are encouraged to learn as much as possible about effective treatment of such commonly co-occurring disorders as depression, panic, OCD, disordered eating, and substance abuse.

Validation

In order to balance the emphasis on change, DBT uses validation strategies. The therapist looks at the client’s behavior, feelings and thoughts for what can be confirmed, corroborated, or highlighted as having validity. In her treatment manual, Linehan has compared finding validity in client behavior to looking for a “nugget of gold in a bucket of sand.” Sometimes it can be very difficult to find something valid in be- havior that is clearly maladaptive. DBT teaches that it is always possi- ble to validate clients’ emotional pain, their difficulty in using skills, and the feeling that they are very far from where they would like to be. Just listening to what clients are saying about their experience, awake to

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all the unspoken aspects but without adding interpretations, is very validating for most clients.

Since the biosocial theory informs about how temperament and learning history can prompt maladaptive responses, the therapist can of- ten confirm what is understandable behavior in that context. For exam- ple, given that a client’s father often belittled his son as “effeminate,” it is understandable that when an authority figure at work teased him about the neatness of his attire he felt rageful and wanted to quit his job. In this circumstance, the therapist is validating that given the client’s problematic learning history, his reaction of rage is understandable. Far more validating would be a comment that any man whose boss com- mented in a teasing fashion about his attire might feel anger, given the homophobia common in the workplace. In the latter instance, the thera- pist manages to find a way to communicate a much less conditional vali- dation. Rage in either case is still probably an overreaction, and it is still unlikely that quitting one’s job, based on this instance alone, would be considered a valid response.

Validation creates a context of understanding in which the therapist can move toward problem solving. For example, a client threatens to leave her husband because she saw him laughing with his former girl- friend in the parking lot at church. The client became jealous, and rageful and threatened to make him move out. The therapist wants to ad- dress her client’s impulsive threat. She also wants to focus on skills the client can use to regulate her anger and help her check the facts about whether or not her jealousy is justified. However, if she goes immedi- ately to problem solving, the therapist runs the risk that the client will feel misunderstood. The client might feel the need to communicate even more forcefully how jealous and angry she truly is. If the therapist be- gins by validating that the client is very upset, and that given that she and her husband have not been getting along well, it is understandable that she would feel jealous to see him interacting warmly with a former girlfriend, the client can feel heard and understood. Her emotional arousal might then decrease and she might become more willing to par- ticipate in problem solving around how to handle her emotions of jealousy and rage.

Now that we have an overview of treatment, we turn our attention to how DBT would be provided in the treatment of a 29 year-old woman who is still dependent on her parents and who presents with a history of self-harm behavior, recent hospitalizations, a history of assault, signifi- cant drug use, underemployment and unstable relationships.

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CASE EXAMPLE

To address the case of Joan, it is helpful to understand how a DBT therapist–let us call her Barbara–might conduct the first four sessions. Relatively speaking, the first four sessions of DBT are crucial to instill- ing hope in clients who have had multiple therapeutic failures, getting the client committed and motivated to do the hard work ahead, and es- tablishing a collaborative and balanced therapeutic relationship.

Joan has been referred for DBT to a private, nonprofit agency, where a team of six therapists and two interns provide DBT and other evi- dence-based treatment. Joan comes for her intake, where she fills out some clinic forms and releases, and completes some self-report assess- ments to establish a baseline against which to measure progress. She then meets with the intake intern who explains clinic policies and gives her an overview of the DBT agreements for treatment. These agree- ments will be reviewed later by the individual therapist as part of the commitment process. The intern conducts a semi-structured interview to confirm the BPD diagnosis and uncover any co-morbid diagnoses. When the assessment is complete, the intern brings Joan’s case to the DBT team meeting. Barbara has an opening and calls Joan to set up their first meeting.

Barbara meets Joan prepared to focus on the six primary tasks of the first four sessions. These include: (1) orienting Joan to what to expect in individual therapy, skills group and telephone coaching; (2) gaining ini- tial commitment to work on reducing and eliminating suicidal and self-injurious behaviors and behaviors that will interfere with therapy; (3) gaining commitment to participate in each aspect of treatment; (4) assessing the stage of treatment and the specific relevant targets; (5) ori- enting to and preparing the diary card (see Appendix); and (6) establish- ing the groundwork for a therapeutic relationship based on specific agreements and assumptions. Throughout these initial sessions, Barbara will be attending to how Joan reacts to her, and how she reacts to Joan. She will focus on establishing a warm and straightforward relationship.

Session One

Barbara initially meets Joan with her parents, but after a quick orien- tation to what DBT can offer Joan, Barbara asks the parents to leave. She explains that they will be invited to a later session once Joan herself is in commitment, to learn more about DBT and how they can help Joan.

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It is made clear to the parents that if they need additional support, a re- ferral will be provided for them.

Commitment and Goals: Once the parents have left, Barbara begins by asking how much Joan wants therapy herself, versus how much her parents want her in therapy. Barbara briefly explores Joan’s relation- ship with her parents, keeping the biosocial theory in mind. It is clear to her that Joan’s interest in therapy is somewhat limited but that she knows she has to attend to continue to get support from her parents.

Joan wants her parents to understand her and how hard life is for her. After some probing by Barbara, Joan also admits she’d like to be inde- pendent of her parents, but fears it is impossible. She is even afraid to say it lest her parents hear and withdraw support. “They can afford right now to support me, but I don’t think they want to.” Barbara says that she thinks gaining independence is a great goal and that she and DBT can help with that, but it will take time. Meanwhile, Joan will need her par- ents’ support and will have to learn to interact with them more effec- tively. Joan agrees that she would like to do that but doubts that changing her behavior will help much. Barbara knows that gaining in- dependence from her parents will be a struggle for Joan because of the long pattern of dependency and the parents’ tendency to reinforce Joan’s crisis behaviors with more support.

Barbara tells Joan that the overarching goal of DBT is “a life worth living” and asks Joan what that would look like for her. Joan said she would like to have a boyfriend and maybe go back to school to become a veterinary technician, but she is pretty vague about her level of interest in her goals and about how she might attain them. Barbara accepts Joan’s goals with enthusiasm and then begins to explore what behaviors Joan feels might be getting in the way of her goals. Joan mentions con- flict with her parents, drugs, and alcohol, and Barbara adds self-harm and keeping the option to suicide open. Barbara orients Joan to the con- cept of learning new ways to manage her emotions using the skills of the DBT curriculum. Barbara also discusses the DBT assumptions about clients and about treatment, including that clients are doing the best they can but need to do better. Joan is interested in how both of these can be true.

Barbara shares with Joan the research on DBT and her own clinical experience with how the treatment has helped others with similar prob- lems. Joan expresses some interest. As Barbara conducts this initial ses- sion she is modeling a dialectical stance, keeping Joan a little off balance as to what to expect and encouraging Joan to consider her op- tions very carefully. Barbara outlines for Joan how difficult the process

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of therapy is likely to be and how long it will take. Barbara discusses the importance of coming to weekly sessions, attending a weekly group, and learning lots of new ways to deal with her emotions, including ac- cepting the feelings in the moment. Joan, though she might have arrived quite ambivalent about DBT is now more than a little curious. She likes Barbara’s “let’s get down to business” attitude and figures Barbara might really understand how hard therapy is for her. She secretly be- lieves she cannot give up self-harm. And, Joan is very wary about the skills group piece. (She doesn’t do groups!) But she won’t say anything about that just yet. Joan wants to hear more and says she will commit to four sessions to decide.

Targeting: Barbara makes note to return to the commitment strate- gies, but now turns her attention to a history of the events leading up to treatment. She knows Joan is in stage one but needs to explore Joan’s targets. Barbara asks whether or not Joan is still engaging in self-harm behavior and whether or not she considers suicide an option. Joan says she mainly self-harms after fights with her parents but has not done so in the last week. She says she wants to keep the option to kill herself open, but is not currently feeling suicidal. Joan has not been hospitalized in six months. Barbara asks for commitment to work on staying alive during at least the first year, and also to work on reducing self-harm behavior. Barbara highlights that these two commitments are necessary for DBT to proceed. Joan commits to staying alive for one month, until she de- cides whether or not she wants to do this treatment. She is not willing to commit to eliminating self-harm, but expresses interest in reducing it.

Session Two

In session two, Barbara summarizes what they accomplished in ses- sion one and highlights what she hopes to accomplish today. For her part, Joan wants to talk about a problem with one of her friends. Barbara sets the agenda: they will revisit commitment, discuss the specific prob- lems that are getting in the way of Joan’s goals, and begin making the diary card. After that, Joan can talk about her issue. Barbara asks about their one-month commitment to stay alive and reduce self-harm. Joan renews it willingly and even says she’s been thinking she really doesn’t want to kill herself at all, at least not today.

Target One: Barbara conducts a “pattern behavior analysis” of Joan’s self-harm behavior, looking at the frequency of this behavior, the inten- sity of the urges and actions, the duration of the urges and actions, and how the behavior has typically manifested itself. She discovers that

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Joan’s self harm behavior almost always functions as a relief valve, and that even though Joan feels shame about the behavior and fears that it could escalate, she doesn’t feel she can give it up. Barbara acknowl- edges Joan’s shame and fear and instills hope that through the use of DBT skills Joan will be able to reduce and eliminate self-harm, replac- ing it with new, more adaptive behaviors that will give some relief from emotional pain. Barbara validates Joan’s concern that if she stops cut- ting her suicidal thoughts might become worse and explains why DBT insists on eliminating both. Barbara remains aware through this process of its exposing nature and adopts a matter of fact tone of inquiry, careful not to introduce any emotion which could be activating or reinforcing. Barbara tells Joan she wants her to begin to see self-harm and keeping the option to suicide open as her “mortal enemy” rather than as a relief valve, and uses a metaphor to help Joan grasp this paradigm shift: “It as if you are lost at sea with your emotions and you are very thirsty. You have only a little bit of water until it rains, which it will do, and you can catch more in your sail. You have to ration your water, and if you do you will survive. But you keep feeling tempted to drink seawater. You know if you drink seawater it will moisten your mouth and relieve your thirst for a moment. But then your thirst will get so much worse and eventu- ally drinking seawater will kill you. That is how self-harm works for you.” Joan is very attentive to this metaphor and for the first time is ready to acknowledge that she wants to eliminate self-harm. Barbara ac- cepts this commitment and then briefly describes some of the skills Joan will learn to replace self-harm as a strategy.

Barbara also inquires into Joan’s assault history. Joan tells her that the incident happened four years ago under the influence of crack co- caine and that she had a great deal of shame about it. “I’m much more likely to hurt myself than anyone else,” Joan says, “but my boyfriend accused me of being a crack whore.” Joan denies using cocaine in the past two years. “Since I moved back home, I don’t even know where to get it.”

Target Two: Barbara then introduces the concept of “therapy-inter- fering behavior” and inquires into what behaviors of Joan’s might get in the way of therapy. Joan readily admits that attendance, filling out the diary card and doing homework will be hard for her and that in the past she has gotten kicked out of therapy for not coming to sessions or call- ing to cancel. Barbara reminds Joan about the clinic attendance and can- cellation policies and about the DBT attendance rule: that she is not allowed to miss four sessions in a row of either individual therapy or skills training. Barbara tells Joan that working on reducing this behavior

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will be of crucial importance and will make a huge difference in treat- ment. Joan agrees to work on reducing her therapy interfering behavior but asks Barbara for understanding about how hard it will be. Barbara introduces Joan to the concept of telephone coaching and to how they will use it in therapy. “One way I think we will be using the telephone is that I might call you to coach you to get to individual therapy or to skills group if I think you are not coming. How will you feel about that?” Joan admits that she will not want to come to group and might start avoiding. She feels that if Barbara called her it would only make her angry. Joan also says she cannot imagine “bothering” Barbara with a phone call. Barbara highlights for Joan how calling for coaching in DBT is actually skillful behavior and makes note to revisit the protocol in the next ses- sion. By now it is time to assign the final 15 minutes to Joan’s interper- sonal problem. Barbara helps Joan decide what to do with a friend who wants to borrow her car. As they work on Joan’s difficulties with saying no, Barbara highlights for Joan how she will learn skills to manage situations exactly like this in skills group.

Session Three

Behavior and Solution Analysis: Joan arrives to session 10 minutes late to her 9:00 a.m. appointment. Barbara immediately conducts a be- havior analysis of the lateness behavior and then a solution analysis. Joan, who has always been late to appointments, expresses surprise that Barbara gets so “uptight” about it. Barbara uses irreverence to disclose her limits with Joan saying, “You are right. I get uptight about anything that will interfere with our work together! And I want you to get uptight, too!” Joan laughs and feels validated by Barbara’s concern. She says she will work on being on time by not staying out late the night before therapy and by setting her alarm.

Barbara elicits Joan’s concerns about participating in the group and uses commitment strategies to build her willingness. Barbara knows that Joan is already becoming attached to her and somewhat hopeful and feels she can use that to leverage Joan’s attendance in the group. Barbara has already put Joan on the waitlist for an evening group and knows that she could start in three weeks

Target Three: Barbara is ready to explore target three with Joan, that is, behaviors that decrease the quality of life. She inquires first into Joan’s alcohol and drug use and finds out that when Joan comes home from work she usually has a glass or two of wine and smokes marijuana.

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She also has used ecstasy, cocaine and methamphetamine in the past but denies current use. Joan says she has some willingness to eliminate al- cohol she has no willingness to eliminate cannabis. Barbara explores Joan’s willingness to participate in AA and Joan says she is unwilling to attend. Barbara says, “It will be really hard to give up alcohol. Are you sure you are ready?” Joan says, “If I can still smoke, I’ll be okay. I really don’t like alcohol as much as weed.” Using a shaping strategy, Barbara leaves cannabis alone for now and focuses on the possibility of elimi- nating alcohol. “Let’s see if you can cut out alcohol,” Barbara says. “Just don’t come to therapy stoned. We will put cannabis on the diary card to monitor how much you are using.” Joan agrees.

Target-Relevant Emotions and Behaviors: The two then explore what emotions and events are most likely to contribute to Joan turning to suicidal thoughts, self-harm or substance-abusing behavior. Joan says that conflict with her father, feelings of inferiority toward her sib- lings, and conflicts with peers are directly related to her suicidality and linked to her drug and alcohol use. She admits to Barbara that she feels a lot of anger and self-loathing whenever these issues arise. Barbara sug- gests they put anger and self-loathing on the diary card. Joan agrees.

Orienting: Relationship of Targets and Goals: Barbara turns her at- tention to Joan’s new job and to how success at work will take Joan to- ward her goals. The final area of the diary card, then, will be for attending work, not only showing up, but staying for her full shift and staying on task. Joan comments on how all the targets now on the card are connected because drug use, anger, self-loathing and even self-harm contribute to not succeeding at her job. She states that it will be hard to keep the diary card because just looking at it will remind her of what a loser she is. Barbara validates the exposing nature of the card and points out that “thinking I am a loser” is one of Joan’s targets! The two laugh at this, and Barbara explains how each time she does the card the shame will decrease a little. After Barbara gets commitment from Joan to fill out the card daily, she spends the last five minutes of the session check- ing in with Joan about how she is feeling. “Pretty good, I guess,” Joan says, “This therapy is definitely different from what I’ve had before. I feel like you know what is up with me. I don’t want to get on your bad side!” Barbara says, “I like getting to know you. I like how honest you are with me. I feel pretty hopeful.” She smiles, “No, you don’t want to get on my bad side! But don’t worry, I’ll teach you how not to do that!”

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Session Four

Shaping: Joan is on time to her fourth session but doesn’t have her di- ary card. “I did do it,” she says, “I just forgot it.” Barbara hands her a blank copy and says, “I’m really glad you got here on time today, but we still can’t get started until you do your card. Fill this out and I’ll sit at my desk doing some paperwork.” Five minutes later Joan gives Barbara her diary card and the two review the card and set the agenda. Joan says she needs to talk about a fight with her parents.

Barbara looks over the diary card, noting that on two days Joan had self-harm urges but no actions. Barbara says, “Wow, how did you man- age not to cut?” “I thought about the drinking sea water thing,” Joan says, “and I didn’t want to do it.” Barbara acknowledges this as very skillful and asks how long the urges lasted. “Until I went to bed,” Joan says. Barbara notes, “Those were the nights you drank this week.” “Yes,” Joan says. “Instead of cutting, I drank to relieve the pressure.” Barbara then conducts two behavioral analyses of the self-harm urges. She discovers that in one incident the prompting event was encounter- ing an acquaintance at her retail job and feeling shame, and the other was having a fight with her father about a car repair bill, where she felt anger, then shame. Barbara points out how Joan has been quite skillful in not cutting but then has to turn to alcohol to soothe herself. Joan says that alcohol doesn’t soothe as quickly as cutting, and that it also costs money and gives her a headache. Barbara acknowledges that alcohol is not a good alternative to cutting, but that not cutting was still skillful. “But you managed not to drink the other five nights, is that true?” “I just smoked weed.” Joan said. Barbara refers again to how skills class will help Joan by teaching her ways to cope with her emotions that don’t have side effects. “Yeah,” Joan says, “I’m just about ready to do any- thing at this point. Even go to a group.”

Barbara then conducts another behavior analysis of Joan not bringing her diary card. “Actually, I didn’t really do it,” Joan admits. “I had every intention of doing it, but I left it in my car and never got it out. But I’ll do better this week. I don’t want to have to use my time in here to fill it out and besides, I can’t really remember what happened that well.” Barbara takes note that sometimes Joan lies to cover up behavior and muses that she also might lie about substance use. She will bring this up in the next session. Now she wants to focus with Joan on a plan to help her com- plete her card for next week.

Finally, Joan asks Barbara for her help with a problem with her fa- ther. Joan says that since she started DBT her father now expects her “to

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be cured” and has decided to cut down on her support. “He doesn’t want to pay for the repairs on my car and I have no money, whatsoever.” The rest of the session focuses on problem solving around this crisis and Barbara decides it is time to bring the parents back for a family session. She knows these parents have been very supportive but are exhausted and overwhelmed with their daughter’s needs. Barbara wants to give them information about DBT and wants Joan to talk with them herself in the session about her goals and commitments. The goal of the family session will be to come to agreement about how to manage their support for Joan over the year of treatment and how to encourage them to get into therapy also. Joan says she will invite them to the next session.

At the end of session four, Barbara asks Joan if she will be ready to start group in two weeks. Joan says she “as ready as she’s going to be” and then says she feels less worried about it because things are going well with Barbara. Barbara reflects that she feels they are off to a good start. Many problems still remain to be addressed and new problems will arise, but treatment is well begun. Next week in the team meeting, she will announce that Joan will be starting group and let the team know about her target behaviors and concerns about group. Barbara will re- ceive support and consultation from her team throughout the course of this treatment, especially from Joan’s skills trainers, and from the team- mate who begins seeing the parents.

CONCLUSION

DBT is a very promising treatment for individuals with BPD in that it has been shown to reduce the incidence and medical severity of self- harm behavior, the number of hospitalizations and length of stay, and client anger while increasing treatment compliance (Linehan et al., 1991). Some studies have shown reductions in depression and hopeless- ness in women veterans (Koons et al., 2001), suicidal behavior in ado- lescents (Rathus & Miller, 2002), and depression in the elderly (Lynch et al., 2003). For more discussion of the current research on DBT, see Robins and Chapman (2004).

Adaptations of DBT: Standard DBT has been adapted for other treat- ment delivery settings including inpatient, day treatment, vocational re- habilitation, and juvenile and adult forensic settings. In those settings, providing the four primary modes of treatment may not be feasible be- cause of the structure of treatment delivery. For example, many inpa- tient units do not offer individual therapy and the length of stay is short.

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However, the functions of comprehensive treatment have been adapted to these differing settings with some success. In some settings, e.g., in emergency departments, it is not possible to provide comprehensive DBT. In those cases, some clinicians have elected to offer “DBT-in- formed” treatment, such as awareness of the biosocial theory, behavior analysis or skills coaching only, even though there is no evidence that these component parts offered alone are effective treatment. Standard DBT also has been adapted to serve populations other than persons with BPD, including those with substance use disorders, suicidal adoles- cents, and persons with binge eating disorder, among others.

DBT is also a complex, time-consuming, difficult to learn and challenging treatment to implement in many settings. Training and sustaining a team of therapists is necessary, expensive, and time- consuming, a reality some clinic administrators may not want to face. And, while some third party payers appreciate the efficacy of DBT, others are unwilling to commit to the costs over time. Never- theless, for clinicians treating severely disordered individuals with BPD, the lasting change that can be achieved is well worth the ef- fort required to learn and implement this evolving, sophisticated, and exciting treatment.

REFERENCES

Ben-Porath, D. D., & Koons, C. R. (2005). Telephone coaching in dialectical behavior therapy: A decision-tree model for managing inter-session contact with clients. Cognitive and Behavioral Practice, 12, 448-460.

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q. et al. (2001). Efficacy of dialectical behavior therapy in women veterans with border- line personality disorder. Behavior Therapy, 32, 371-390.

Linehan, M. M., Armstrong, H. H., & Suarez, A. et al. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psy- chiatry, 48, 1060-1064.

Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality dis- order. New York: Guilford Press.

Linehan, M. M. (1993b). Skills training manual for treating borderline personality dis- order. New York: Guilford Press.

Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003). Dialectical behavior therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric Psychiatry, 11, 33-45.

Rathus, J. H., & Miller, A. L. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life Threatening Behavior, 32, 146-157.

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Robins, C. J., & Chapman, A. L. (2004). Dialectical behavior therapy: Current status, recent developments, and future directions. Journal of Personality Disorders, 18, 73-89.

Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158, 632-634.

Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1061- 1065.

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