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D.B.T.= Real Hope for the Anxious, Depressive and Self Harming Individual

Having lived with clinical depression for many years I can vouch for this system of therapy as it was offered to me and accepted years ago. The methodology has allowed me to maintain a helpful outlook of and fairly effective interaction with the world outside my front door. If I had not been offered the treatment I feel I may well not have survived to spread the word.
Pictured: Marsha M. Linehan

Marsha Linehan is a Professor of Psychology, Adjunct Professor of Psychiatry and Behavioral
Sciences at the University of Washington and Director of the Behavioral Research and Therapy
Clinics, a consortium of research projects developing new treatments and evaluating their
efficacy for severely disordered and multi-diagnostic populations. Her primary research is in the
application of behavioral models to suicidal behaviors, drug abuse, and borderline personality
disorder. She is also working to develop effective models for transferring efficacious treatments from the research academy to the clinical community.
She has received several awards recognizing her clinical and research contributions, including
the Louis I. Dublin Award for Lifetime Achievement in the Field of Suicide and the Distinguished Scientist Award from the Society for a Science of Clinical Psychology, American Psychological Association, as well as awards for Distinguished Research in Suicide (American Foundation of Suicide Prevention), Distinguished Contributions to the Practice of Psychology (American Association of Applied and Preventive Psychology), Distinguished Contributions for Clinical Activities, (Association for the Advancement of Behavior Therapy), and Distinguished Scientific Contributions to Clinical Psychology (Society of Clinical Psychology, American
Psychological Association). She is the past-president of the Association for the Advancement of Behavior Therapy, a fellow of the American Psychological Association and the American Psychopathological Association and a diplomat of the American Board of Behavioral Psychology.
The treatment she has developed combines the technology of change derived from behavioral science with the radical acceptance, or “technology of acceptance,” derived from both eastern zen practices and western contemplative spirituality. The practice of mindfulness, willingness, and radical acceptance form an important part of her treatment approach.
She has written three books, including two treatment manuals: Cognitive-Behavioral Treatment for Borderline Personality Disorder and Skills Training Manual for Treating Borderline Personality Disorder. She serves on a number of editorial boards, and has published extensively in scientific journals.
She is founder of Marie Institute of Behavioral Technology, a non-profit organization that owns the company she founded, Behavioral Tech LLC, a behavioral technology transfer group. With them she is actively involved in developing effective models for transferring efficacious treatments from the research academy to the clinical community.

Dialectical behavior therapy (DBT) is a therapeutic methodology developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat persons with borderline personality disorder (BPD). DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of mindful awareness, distress tolerance, and acceptance largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD. Research indicates that DBT is also effective in treating patients who represent varied symptoms and behaviors associated with spectrum mood disorders, including self-injury.
Linehan created DBT in response to her observation of therapist burnout after repudiating patients’ motivation to cooperate in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments and required a climate of unconditional acceptance (not Carl Rogers’ humanistically "positive" version, but Thich Nhat Hanh’s metaphysically neutral one) in which to develop a successful therapeutic alliance. Her second insight concerned the need for a commensurate commitment from patients to (be willing to) change—subject to their skillfulness in the present moment—based on 'radical acceptance' of their dire level of emotional dysfunction.
DBT strives to avoid having the client/patient see the therapist as an adversary rather than an ally in the treatment of psychological issues. Accordingly, in DBT the therapist aims to accept and validate the client’s feelings at any given time while nonetheless informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives.
Linehan united commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress, in which thesis + antithesis → synthesis, and proceeded to assemble a modular array of skills for emotional self-regulation, drawn from Western (e.g., cognitive behavioral therapy and an interpersonal variant, “assertiveness training”) and Eastern (e.g., Buddhist mindfulness meditation) psychological traditions. Arguably her signal contribution was to elide the adversarial paradigm implicit in the hierarchical modernist therapeutic alliance, using the deconstructive spirit of Hegel and the Buddha to substitute a postmodern alliance based on intersubjective tough love.
All DBT involves two components:
  1. An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards, and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
  2. The group, which ordinarily meets once weekly for two to two-and-a-half hours, learns to use specific skills that are broken down into four modules: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.
Neither component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.

Contents


  • 1 The four modules
    • 1.1 Mindfulness
    • 1.2 Interpersonal effectiveness
    • 1.3 Emotion regulation
    • 1.4 Distress tolerance

The four modules

Mindfulness

Mindfulness is one of the core concepts behind all elements of DBT. Mindfulness is the capacity to pay attention, nonjudgmentally, to the present moment. Mindfulness is all about living in the moment, experiencing one's emotions and senses fully, yet with perspective. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts.

Interpersonal effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.
Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing his or her own situation.
The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.

Emotion regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and changeable. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:
  • Identifying and labeling emotions
  • Identifying obstacles to changing emotions
  • Reducing vulnerability to emotion mind
  • Increasing positive emotional events
  • Increasing mindfulness to current emotions
  • Taking opposite action
  • Applying distress tolerance techniques

Distress tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.
Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although this is a nonjudgmental stance, this does not mean that it is one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.
Skills for acceptance include radical acceptance, turning the mind toward acceptance, and distinguishing between "willingness" (acting skillfully, from a realistic understanding of the present situation) and "willfulness" (trying to impose one's will regardless of reality). Participants also learn four crisis survival skills, to help deal with immediate emotional responses that may seem overwhelming: distracting oneself, self-soothing, improving the moment, and thinking of pros and cons.

IT WORKS!

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