Clin Soc Work J (2011) 39:170–179 DOI 10.1007/s10615-010-0283-4
ORIGINAL PAPER
To Integrate or Not to Integrate Dialectical Behaviour Therapy with Other Therapy Approaches? Alexander L. Chapman • Brianna J. Turner Katherine L. Dixon-Gordon
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Published online: 11 July 2010 Ó Springer Science+Business Media, LLC 2010
Abstract With mounting evidence for its efficacy in the treatment of borderline personality disorder and related problems and increasing dissemination nationally and internationally, front line clinicians in practice settings are increasingly aware of dialectical behavior therapy (DBT). Indeed, it is likely that this treatment is reaching individuals who practice from a variety of theoretical frameworks, such as psychodynamic, humanistic, cognitive, or some combination thereof. Therefore, this paper considers the ways in which DBT is an integrative approach, as well as the issues that may arise in the integration of DBT with other theoretical frameworks or with practices spawned by these alternative frameworks. We recommend that therapists practicing DBT adhere to the behavioral and dialectical theoretical foundations of the approach, in order to provide therapy that is effective, coherent, and consistent. Keywords Dialectical behavior therapy Integration Psychotherapy Theoretical frameworks
Introduction With mounting evidence for its efficacy in the treatment of borderline personality disorder (BPD) and related problems (see Robins and Chapman 2004, and Lieb et al. 2004 for reviews) and increasing dissemination nationally and internationally, front line clinicians in practice
A. L. Chapman (&) B. J. Turner K. L. Dixon-Gordon Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada e-mail:
[email protected]
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settings are increasingly aware of dialectical behavior therapy (DBT; Linehan 1993a, b). There have been several large scale efforts to develop and implement DBT in the public sector across the United States and Canada, spearheaded by the dissemination and training organization founded by Dr. Marsha Linehan—Behavioral Tech, LLC. With an increasing number of clinicians aware of and implementing various aspects of DBT, it is likely that this treatment is reaching individuals who practice from a variety of theoretical frameworks, such as psychodynamic, humanistic, cognitive, or some combination thereof. Moreover, there is growing evidence in support of treatments for BPD that espouse alternative perspectives (e.g., Mentalization-Based Treatment; Bateman and Fonagy 1999, 2004; Schema-Focused Therapy; Kellogg and Young 2006; Transference-Focused Therapy; Clarkin et al. 2005). Therefore, it is important to consider the ways in which DBT is an integrative approach, as well as the issues that may arise in the integration of DBT with other theoretical frameworks or with practices spawned by these alternative frameworks. Recent evidence suggests that, when asked to identify their theoretical orientation, most therapists identify themselves as ‘‘eclectic’’ or ‘‘integrative’’ (Bechtoldt et al. 2001; Norcross et al. 1997, 1988). Although some aspects of the field of psychological treatment may be moving toward a more integrative approach to psychotherapy, it is important for therapists to consider how they can best select or integrate therapeutic styles or perspectives, as well as how to decide which approach to use for treatment planning. At present, little evidence exists to guide these decisions (Norcross and Prochaska 2003). Within this article, we discuss some important issues to consider with regard to the integration of DBT with alternative theoretical frameworks and practices.
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Two Primary Ways to Integrate Therapies Although there are countless mixes of therapeutic theories and practices, there are two primary ways in which clinicians can integrate different psychotherapeutic approaches (e.g., Borden 2009). One method of integration, theoretical eclecticism, uses concepts and theory from multiple therapeutic approaches to guide treatment planning and case conceptualization. The clinician may, for example, conceptualize different aspects of her or his cases from both a DBT perspective and a psychoanalytic perspective (e.g., that adopted by Bateman and Fonagy, in MentalizationBased Treatment; 1999, 2001). In contrast, technical eclecticism involves the integration of intervention strategies, rather than theory, from different therapeutic approaches. An example of technical eclecticism may include a therapist conducting DBT but utilizing the ‘‘empty chair’’ technique from Gestalt Therapy (Yontef 1993) in order to help a client determine how to express her or his feelings toward a family member. Therapists may be theoretically eclectic, technically eclectic, neither, or both. To Integrate or Not to Integrate? Issues Regarding Theoretical Eclecticism and DBT DBT is not a perfect treatment for all clients with BPD, and neither is any other approach. For some clients or therapists, the therapeutic style in DBT may not fit with their own style or personality. For others, the behavioral approach to conceptualizing client problems and the focus on current rather than past functioning might violate important expectations about therapy (e.g., that the therapist will help the client explore her or his past, prompt cathartic emotional experiences, or offer deep insights). Perhaps due to these issues, theoretical eclecticism is common and can be intuitively appealing. For instance, it may seem logical and useful to conceptualize a client’s problems from differing theoretical frameworks as needed.
Clinical Example 1: Case Presentation Rebecca is a 27 year old female who arrived at her first session complaining of overwhelming feelings of despair. Recently, Rebecca has been struggling with her functioning at work, as she often feels intense shame and anger when she perceives criticism, sees a slightly negative look on her coworkers’ faces, or receives negative feedback from her boss. She has lost several jobs following blow-ups or absences related to these difficulties. Additionally, she is currently in a tumultuous relationship with her boyfriend, and their fights escalated to screaming matches on a weekly basis. Rebecca stated that she generally engaged in
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self-harm following such conflicts, which typically results in emotional relief and, periodically, increased support/ warmth from her boyfriend. She reported feeling like her life was out of her control and was desperate to lessen her emotional pain. A clinician treating Rebecca may elect to conceptualize her developmental responses to abuse and neglect from a psychoanalytic perspective, viewing these experiences as integral in the development of her personality structure, object relations, and ego defenses (e.g., Caligor et al. 2009; Kernberg 1975). In contrast, the same clinician may utilize a behavioral framework to conceptualize Rebecca’s current behaviors that make it hard for her to hold a job. Although it may be appealing and may ‘‘feel right’’ to integrate differing theoretical perspectives in this manner, we would argue that clinicians practicing DBT and treating clients with BPD would be best off avoiding this type of theoretical eclecticism. Essentially, the integration of different theories within a DBT framework can muddy the waters of an already swirling, turbid river. As an example, before beginning DBT, Rebecca spent several years in Health Realization Therapy. The central tenet of this therapy is that negative emotions are indicators of problematic thoughts. The Health Realization therapist encourages patients to ‘‘think positive.’’ When Rebecca began DBT, her therapist noticed that Rebecca often did not complete her diary card. Upon discussion, Rebecca revealed that she was uncomfortable writing down her negative emotions and thus ‘‘give them life,’’ as she had learned through her previous experiences in therapy. This interaction exposed the conflict between the underlying assumptions of DBT and Health Realization Therapy. This provided an opportunity for the therapist and client to discuss these theoretical differences, and how they impacted her homework compliance. A clear theoretical foundation provides an organizing principle to address the multitude of difficulties faced by the client. A psychotherapy theory provides ‘‘a consistent perspective on human behavior, psychopathology, and the mechanisms of therapeutic change’’ (Prochaska and Norcross 2003, p. 5). Therefore, both the therapist and the client can use theory to guide what they will talk about, how they will approach the client’s problems, and why these targets are thought to be important. It is important to have a consistent theory for therapy for three primary reasons. First, consistent theory is essential for case conceptualization. A theory should posit how the client’s problems are thought to have developed; thus, the theory can guide the therapist in deciding what aspects of a client’s life or experiences to target for intervention (e.g., Borden 2009). A theory which underscores the importance of maladaptive thoughts in the development of BPD would target different facets of client behavior than a treatment
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which focuses on the skills deficits in BPD as primary in maintaining the disorder. Further, a consistent theory can guide treatment planning and can help the therapist decide what to attend to in each session. For example, the DBT framework provides the therapist with a hierarchy of treatment targets to guide decisions regarding which behaviors to target in each session. This is particularly the case with clients who have BPD. These individuals face what is often referred to as ‘‘unrelenting crises.’’ For instance, with a client who arrives late to therapy, with an increase in suicidal ideation, and an episode of binge eating over the past week, both the therapist and client may be at a loss as to what to focus on for the 50-minute session. The high rates of co-occurring disorders (Tadic et al. 2009; Grant et al. 2008; Straussner and Nemenzik 2007; Zanarini et al. 1998, 2004; Shea et al. 1992) which are often present with BPD increases the complexity of treatment planning, and makes having a consistent theory to guide sessions that much more crucial. Lastly, a clear theoretical foundation facilitates generalization of therapeutic gains outside of the therapist’s office. With a clear understanding of factors which increase symptoms, and effective behaviors, clients with BPD are more likely to be able to identify maladaptive patterns of behavior in their lives, and to implement skillful behaviors. Theory in DBT: The Importance of Consistency and Coherence As a therapeutic package, DBT is a technically eclectic but theoretically consistent approach. DBT is rooted in behavioral theory and science (primarily social behaviorism; Staats 1999) and dialectical philosophy, yet incorporates aspects of practices from Zen and interventions from humanistic and existential traditions. From the DBT theoretical framework, the client’s biological factors and her learning history (based on classical and operant conditioning principles) interact dynamically to create her personality, or ‘‘basic behavioral repertoire.’’ In turns, this basic behavioral repertoire transacts with the environment to produce behavior. Another aspect of the theoretical underpinnings of DBT is dialectical philosophy (Marx and Engels 1970). From this perspective, reality consists of a continual, dynamic interplay of opposing forces (the ‘‘thesis’’ and the ‘‘antithesis’’). Dialectical change occurs when these bipolar positions are integrated (‘‘synthesis’’) to form a more balanced, harmonious state. This state, in turn, becomes a thesis which must be integrated with its antithesis, thus forming a system of continual change. According to dialectical philosophy, both the thesis and the antithesis are recognized as true, but each is incomplete on its own. Dialectics are used in DBT to continually move towards a
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more complete, balanced view of the client’s problems. Thus, dialectical philosophy guides the therapist and client to continually examine what is missing from their current understanding of the problem. Following from this worldview, DBT conceptualizes the client’s difficulties as a series of dialectical dilemmas, wherein the client and the therapist struggle to reconcile opposing forces. Borderline personality disorder, in particular, can be viewed as stemming from failure to integrate opposing views (Linehan 1993a). In DBT, the therapist helps the client to recognize these conflicting forces, and helps the client to reconcile these into a more balanced view. The primary dialectic in DBT centers on the need to accept the client just as he or she is, and to make necessary changes to improve the client’s quality of life. According to the principles of dialectics, indulging either of these forces on its own would be incomplete, and could jeopardize the effectiveness of treatment. For example, if a therapist pushes a client too hard to change his or her behavior, the therapist may risk conveying that she does not understand the client’s experience, and the client may become defensive or drop out of treatment. Alternatively, if a therapist is too accepting of the client, she also risks invalidating the client, as individuals with BPD have serious difficulties which require change. In order to balance acceptance and change, DBT combines Zen practice (through Mindfulness Skills), acceptance-oriented interventions, and validation within a behavioral approach. Both the client and the therapist are encouraged to identify circumstances which cannot be changed or which are beyond their control, and then practice radical acceptance of these circumstances, accepting the circumstances exactly as they are. For example, if a client finds the music in her office aversive but is not able to work to change the music, she would be encouraged to accept the music exactly as it is. In addition, therapists teach mindfulness skills in a skills group and reinforce the use of these skills in individual therapy sessions in order to help the client accept negative or painful emotions, rather than to avoid them. At the same time, the therapist employs traditional cognitive-behavioral strategies, including exposure, problem solving, cognitive restructuring, and behavioral skills training. The Biosocial Theory of Borderline Personality Disorder In DBT, as with other approaches, the theoretical foundations of the treatment inform and guide the therapist and client’s view of the client’s difficulties. Drawing from the unique blend of behaviorism and dialectical philosophy, the biosocial theory (Linehan 1993a) of the development of BPD provides a model for therapists and clients to
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understand how BPD develops as well as how the client’s behaviors are maintained. According to the biosocial theory, BPD arises from the transaction between a biologically-based emotional vulnerability and childhood experiences of invalidation. This theory places emphasis on the interplay of biological factors, contextual factors, and learning history, consistent with social behaviorism. The biosocial theory posits that individuals with BPD have a biological propensity to be more emotionally reactive and emotionally intense than individuals without BPD. Individuals with BPD may have a low threshold for emotional responding, reacting to stimuli which others might not find distressing. Once emotionally aroused, individuals with BPD are thought to experience more intense arousal and to take longer to return to baseline than individuals without BPD. This emotional vulnerability can be likened to the sensory sensitivity of a burn victim—these individuals may be described as having virtually no protection from the environment, and being excruciatingly sensitive to emotional triggers (Linehan 1993a). Biological vulnerability to affective instability is not sufficient to cause BPD, according to the biosocial theory. Instead, BPD arises when this biological vulnerability is coupled with an invalidating environment, primarily involving caregivers during childhood, but also involving society at large (where there is considerable stigma associated with mental illness generally and BPD specifically). An invalidating rearing environment is one that communicates to the child that his or her emotional reactions are not warranted, justified, or valid. Many caregivers have difficulty responding appropriately to children with such emotional temperaments, particularly if they become distressed when the child becomes emotionally aroused. As a result, caregivers may punish, ignore, or trivialize the child’s emotional reactions. Over time, the emotionally vulnerable individual learns to mistrust and fear emotions, does not learn how to regulate emotions, and thus may rely on maladaptive ways of managing emotions. From the biosocial perspective, this intense affective lability leads to the unstable sense of self and stormy interpersonal relationships characteristic of BPD. The impulsive, self-damaging behaviors common to BPD such as substance use and self-harm are viewed as extreme efforts to manage intense, aversive emotional experiences.
Clinical Case Example: The Biosocial Theory Rebecca reported that she had always experienced more intense emotional responses compared to her family. She had been told by her mother that she even cried more frequently as an infant, and was often inconsolable when she became upset or angry. Rebecca had felt ashamed of
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her emotional reactions, especially when her parents and brother were frustrated with her emotions, or told her to ‘‘just get over it.’’ When this happened, she felt like the ‘‘black sheep’’ of the family and tried to suppress or avoid her emotions, but inevitably, she blew up, and her family became even more invalidating. In an effort to find another way of managing her emotions, Rebecca turned to selfharm in adolescence. Although she reported a brief respite from her emotional pain following self-harm, she ultimately experienced a great deal of shame and guilt about this behavior. She felt that she should not have such intense emotional experiences, and wished that all her emotions would just ‘‘go away.’’ As the biosocial theory provides a clear direction for treatment interventions, it is critical that the therapist and client have a clear and consistent understanding of this model. For instance, the biosocial theory is primarily a skillsdeficit model, suggesting that clients need to learn new skills to regulate emotions and manage interpersonal relationships (among other domains). As a result, there is a strong focus in DBT on the development and application of skills in a variety of contexts. In addition, the role of invalidation in the development of BPD suggests the importance of a therapeutic relationship characterized by validation, compassion, and acceptance. Although the latter is consistent with the assumptions of other therapies, the former (skills deficit model) is not. As a result, a therapist blending the biosocial theory with an alternative understanding of BPD (e.g., psychodynamic or even cognitive, which do not emphasize skill deficits; see Bateman and Fonagy 1999, 2004; Kellogg and Young 2006; Clarkin et al. 2005) may essentially steer therapy off course by de-emphasizing the importance of skills training and generalization. Further, DBT therapists want their clients to ‘‘grow’’ out of therapy, and consistent and clear communication of the theoretical model of BPD can help the client learn how to view her or his own behavior and result in lasting changes even following therapy. A desirable outcome is that the client becomes her or his own therapist, and a clear model of behavior can point the client and the therapist in the direction of effective problem solving. A therapist who blends models runs the risk of giving and inconsistent or potentially confusing message, thereby making it harder for the client to understand and change her or his own behavior. As an example, Rebecca struggled with phobias and fears, and the treatment plan involved exposure therapy. As it turned out, the client had continued to see her previous therapist. This therapist, espousing a different theoretical perspective, communicated to the client that exposure therapy would be counterproductive, and also indicated to the client that talking about problem behaviors (the client struggled with self-harm) would cause her problems to
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worsen. Both of these suggestions were inconsistent with the behavioral model of DBT and with the approach in DBT of the therapist directly targeting and helping the client to change maladaptive behavior. The inconsistency in these messages left the client confused and hopeless about therapy. Of course, the advantages and disadvantages of having two separate therapists have been thoroughly discussed in the literature (e.g., Liotti et al. 2008; Farina and Liotti 2005; Dinnen and Bell 1972; Woody 1972), but just imagine if these two therapists had been the same person, at times suggesting that exposure therapy and skill building were the answer, and at other times indicating that these types of interventions could exacerbate the client’s problems. Most therapists who integrate theoretical perspectives probably do so in a more skillful manner than suggested by this example, but it is important to remember that theoretical perspectives represent fundamental assumptions regarding human behavior. If these fundamental assumptions are inconsistent or combined in an ad-hoc manner, the therapist runs the risk of threatening the integrity and cohesiveness of the therapeutic approach, and leaving the client confused and less likely to make progress. Key Assumptions in DBT Another area in which theoretical consistency in DBT is important has to do with a set of specific assumptions that DBT therapists espouse and convey to their clients (Linehan 1993a) As these assumptions are central to the type of attitude with which the therapist embarks upon DBT, it is essential that therapists practicing DBT become familiar with and embrace these assumptions. This, of course, is one of the points of departure between DBT and other approaches and another reason to be careful with efforts to integrate DBT with these other approaches. If a therapist conducting DBT takes a theoretically eclectic approach, using theory and assumptions from other therapy frameworks, some of these assumptions could easily be lost, potentially resulting in less effective or compassionate treatment. 1.
Clients are doing the best they can
This assumption refers to the stance of the therapist that, at any given moment, the client is doing the best she or he can, given the client’s life context and available skills. Although a client’s behavior may seem self-destructive, confrontational or self-defeating, it is important for the therapist to recognize that these behaviors are often the client’s attempt at solving a problem. Linehan (1993a) recommends that clients who claim that they are not trying be encouraged to reflect on what they are doing, rather than told to simply try harder, as this can be profoundly
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invalidating for a client who is struggling to change her or his behavior. 2.
Clients want to improve
This assumption follows from the first and reflects the therapeutic stance that failures to improve are not due to failures of motivation. It is important to note, however, that assuming that a client wants to improve does not preclude the examination of factors which might decrease motivation in therapy. Often, clients may struggle with motivation to do the types of things they may have to do in order to change (e.g., give up self-harming behaviors, learn new skills, attend therapy sessions, change other long-standing behaviors). 3.
Clients need to do better, try harder and be more motivated to change
At first glance, this assumption may seem to contradict the first two. This assumption, however, is consistent with the idea that clients are doing the best they can, but therapists have to help clients learn to do better. This assumption highlights the role of the therapist in helping the client examine factors that interfere with a client’s attempts to improve, and then helping the client overcome these obstacles. In fact, DBT incorporates several techniques which are specifically aimed at increasing the client’s motivation and commitment to therapy, for example the ‘‘foot in the door’’, ‘‘door in the face’’ and ‘‘devil’s advocate’’ techniques (Linehan 1993a). 4.
Clients may not have caused all of their own problems, but they have to solve them anyway
This assumption highlights the fact that, in DBT, the bulk of the work and the bulk of the responsibility for change is placed on the client. This assumption also indicates that therapy must be an active process, and that simply giving the client insight into his or her problems, or giving the client nurturing and support, will not be sufficient to alleviate the client’s suffering over the long-term. 5.
The lives of suicidal, borderline individuals are unbearable as they are currently being lived
This assumption affirms the validity of the client’s complaints about the severity and the urgency of his or her problems. Further, it suggests that the only possible solution must be to change the client’s life. 6.
Clients must learn new behaviors in all relevant contexts
Given that individuals with BPD are most likely to encounter difficulties when they are extremely stressed or upset, it is important for therapists to provide the opportunity to learn new skills under precisely these conditions.
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Indeed, between-session telephone consultation from the therapist is provided for precisely this reason, as this intervention allows the therapist to be present when the client needs to enact new behaviors (e.g., during a crisis). This assumption also highlights the fact that a DBT therapist generally avoids hospitalization of the client, even during crisis (within reasonable limits and standards of care). A DBT therapist aims to care for, rather than take care of, the client when he or she is distressed. As such, a DBT therapist must accept and tolerate the possibility that the client may commit suicide; the job of the therapist is to assist the client in creating a life worth living. 7.
Clients cannot fail in therapy
At times, clients may drop out of therapy, may fail to make changes, or could get worse. On these occasions, the assumption is that the therapy, the therapist, or both, have been insufficient to help the client, rather than placing the blame on the client. It is the therapist’s responsibility to provide the treatment in an effective manner, and at times, even if this happens, the treatment itself may not be sufficient. 8.
Therapists treating clients with BPD need support
Clients with BPD often present challenges for therapy, such as high rates of drop out, problems with attendance, confrontational behaviors towards the therapist, etc. These behaviors can be frustrating, exasperating, or demoralizing for the therapist. Thus, therapists working with these clients should make frequent use of the therapist consultation team, of supervisors and of consultants. Further, it is the therapist’s responsibility to monitor their emotions, and to take appropriate action to alleviate distress or frustration. The Structure and Primary Interventions in DBT The theory behind DBT has informed the way in which the treatment is structured as well as the primary treatment interventions. According to the biosocial theory, many of the difficulties faced by individuals with BPD arise from their vulnerability to intense, unstable emotions. Based on their learning history, clients with BPD simply never learned effective strategies of managing these intense emotions. Therefore, DBT was tailored to explicitly target emotion dysregulation through multiple treatment modalities: (1) individual therapy; (2) group skills training; (3) telephone consultation, and (4) a therapist consultation team. Weekly individual therapy sessions provide a forum for individual treatment planning, work on motivational issues, reinforcement and generalization of skills learning, and problem solving regarding ongoing or day-to-day difficulties. Weekly group skills training sessions provided a venue for skills training in four areas: mindfulness,
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interpersonal effectiveness, emotion regulation, and distress tolerance. These skills group sessions typically last one and a half to 2 hours, with the first half used to review homework and troubleshoot any problems with the skills, and the second half used to teach new skills. A client’s individual DBT therapist is also available for telephone consultation, during which clients are encouraged to generalize new skills to their daily lives by receiving in vivo coaching on skills use. In order to mitigate stress and maintain compassion while working with chronically suicidal clients, DBT therapists also participate in a therapist consultation team, which typically meets weekly to provide support, consultation and ongoing training to therapists. Communication Style in DBT Because of the challenging nature of the difficulties faced by the borderline client, therapists often find themselves either overly invested in therapy, or withdrawn or frustrated with the therapeutic process. Drawing on the ‘‘middle path’’ emphasized in Zen Buddhism, the DBT therapist strives to convey warmth and interest. As noted below, this warmth is not necessarily unconditional— overall, it is more important for the DBT therapist to be genuine. Thus, it is important to acknowledge aversive emotions on the part of the therapist, and address these appropriately, as described below. Although there is an inherent power differential between therapist and client, the DBT therapist relies on reciprocal communication strategies, which involves empathy and responsivity to the client. This style of communication emphasizes the collaborative nature of the relationship. Consistent with dialectical philosophy, therapists in DBT may search for and validate the kernel of truth in the client’s position during times of tension. This provides the therapist with many avenues for providing validation to the client. At other times, DBT therapists may use an irreverent style of communication to shift the client’s perspective. Irreverence is an off-beat strategy which may involve overly matter-of-fact presentation, the use of humour, or direct confrontation of maladaptive behavior (e.g., ‘‘You did what?!’’). Irreverent styles of communication should be used strategically and compassionately, and must be genuine for the therapist. The therapist continually strives to strike an effective balance between irreverent and reciprocal styles of communication, as shown in the example below. Rebecca:
I’ve just got too much going on, with Ben freaking out all week, and now I need to start looking for work. I’m just so mad that he won’t support me when I’m already trying so hard! All he does is criticize me.
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Therapist:
Rebecca:
Therapist: Rebecca:
Therapist:
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It makes sense that you might notice some anger when he’s not giving you the support you’d like, and you’re feeling you’re already doing everything you can to solve this problem. [reciprocal style communication] I just have no idea how I’m going to support myself. Everything is going to hell. Things are awful with Ben, I can’t find a job, I have no money, and I’m sure I’m just going to bomb this job interview on Tues. There’s really no point to all of this; I’d just be better off dead. What do you mean by that? I mean, I don’t know why you keep telling me to get suicide off the table, when I just need a way out, and things are never going to get better. Well, I have to say that, if you kill yourself, you’re definitely not going to get that job [irreverent response]
Technical Eclecticism in DBT Despite theoretical roots in behaviorism and dialectical philosophy, DBT includes practices (i.e., is technically eclectic) originally developed from within a variety of different cognitive-behavioral, humanistic, existential, and even Buddhist traditions (particularly Zen practice). For example, techniques of validation and cheerleading were borrowed from humanistic and emotion-focused approaches; from cognitive-behavioral approaches, DBT incorporated the strategies of exposure, problem solving and cognitive restructuring; and the concepts of mindfulness and radical acceptance were drawn from Zen practice. The same dialectical principles that give DBT its name are highlighted in many therapeutic approaches. In psychodynamic traditions, there is a focus on the dynamic nature of intra-individual tensions, and in cognitive therapy, there is a dual focus on observing reality in the moment, as well as working towards change. Thus, by its nature, DBT is technically eclectic. The theoretical perspective of DBT binds together these seemingly disparate techniques. The biosocial theory and social behaviorism guide the therapist in case formulation and treatment. For instance, these perspectives suggest potential therapy targets (e.g., lack of emotion regulation skills). Furthermore, the philosophical foundation provides the therapist with an avenue for enacting change (e.g., changing the operant properties of the problem behaviors). Thus, although DBT integrates strategies from a wide range of therapeutic approaches, how and why these strategies are applied is unique to the biosocial model and theoretical assumptions underlying DBT. Clinically-
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relevant foci such as the therapeutic relationship and client motivation, and commonly-used treatment techniques such as validation and insight-related strategies are implemented in a manner consistent with the DBT framework. Below, we further discuss these strategies, which are common in approaches spawned by other theoretical frameworks. Insight-Related Strategies in DBT As in all psychotherapy (Frank 1973), the offering of insight and the increasing of clients’ awareness of their problems and patterns is important to the DBT therapist (Linehan 1993a). In DBT, insight-oriented strategies take the form of the therapist highlighting client behavior, its implications, or summarizing what a client has said in a manner which emphasizes specific issues. For instance, the therapist may comment on in-session behavior which is linked with target-relevant behaviors, or help the client to observe recurrent patterns (in thought, emotions, or behaviors) and describe the associations or triggers of various behaviors, or consequences which reinforce, extinguish, or punish these patterns. These insight strategies theoretically increase the client’s awareness of her or his behavior and the contingencies that maintain it. For example, a therapist might say to Rebecca, ‘‘I’ve noticed that, whenever you feel really overwhelmed and things aren’t going well with Ben, you often think about suicide or escaping in some other way, such as missing therapy. I’m wondering if we have to start by helping you practice accepting that you feel overwhelmed in the first place, instead of escaping it. Then, we can work on getting you less overwhelmed.’’ These insight strategies are typically focused on DBT target-relevant behaviors, particularly behaviors which are observable to the therapist, are consistent with DBT assumptions, and are thus generally non-pejorative and empathetic. The therapist considers interpretations as hypotheses, and avoids stating that behaviors prove the presence of motives. In this manner, DBT practitioners take a post-positivistic stance, from which interpretations are tentative and data-driven, rather than empirical and certain (Rubovitz-Seitz 1998). In DBT, these interpretations are judged by their usefulness, and not by whether or not they are true. Several therapeutic orientations have formulated how interpretations should be used when working with BPD clients. Some theorists suggest on focusing on problem behaviors which occur outside of session (Masterson 1990), whereas others focus on in-session behaviors (Kernberg 1975). Other clinicians emphasize the importance of maintaining a therapeutic relationship and interpreting transference (Gabbard and Westen 2003), but indicate the utility of balancing appropriate interpretations,
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particularly as relevant to the here-and-now of the therapeutic interaction (Gabbard and Horwitz 2009). Whereas some schools of thought advocate confronting the client’s interpretations (e.g., Kernberg 1975), other approaches, including DBT, emphasize the importance of balancing such interpretations with affirmative insights (Schaffer 1986), and providing interpretations within a supportive environment (Gabbard et al. 1994). Insight strategies in DBT are differentiated by their emphasis on observable behaviors which are relevant to DBT targets, and their congruency with DBT assumptions. Transference and Countertransference in DBT A frequent focus of interpretation across psychotherapies is on transference or countertransference in the therapeutic relationship. For instance, some clinicians advocate an explicit emphasis on interpreting the negative features of transference in session (Kernberg 1975). Indeed, transference-focused interpretations are the basis of transferencefocused psychotherapy for BPD (Clarkin et al. 2007). In DBT, the therapist is not seen as a mirror through which to work though transferential issues. It is key to the treatment, however, that the therapist be genuine. Clients with BPD often are quite attuned to the therapist’s emotional reactions, often picking up quickly on artificial neutrality, distance or inconsistencies on the part of the therapist. This is not to say that therapists should have no limits within the relationship. Rather, limits are a natural part of human interaction, and therapists should be clear about their natural limits. In this regard, DBT focuses on behaviors within the therapeutic relationship as relevant to target-related behaviors, as noted above. It is essential in DBT for therapists to attend to their responses to the therapeutic interaction. These responses can often become natural contingencies reflective of how interactions occur in the outside world. A therapist may become warm in response to homework completion, or more matter of fact when discussing therapy-interfering behaviors. Ideally, the therapist is mindful of these responses and employs them strategically. If a therapist repeatedly notices negative emotions arising within the therapeutic interaction, this is often a clue that a problem must be solved. The first step is for therapists to take a mindful approach to monitoring their reactions to the client’s behavior. The therapist may turn to his or her consultation team for assistance in identifying the controlling variables in the interaction. Often, aversive feelings on the part of the therapist are indicators that the client is engaging in therapy-interfering behaviors, or that the therapist is not observing her or his own limits. Finally, the therapist may be engaging in problem solving regarding
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the relationship, trouble-shooting therapy-interfering behaviors, or clarifying the therapist’s limits. A therapist who notices feelings of disinterest during therapy sessions may take these experiences as a cue to examine problematic behaviors on the part of the therapist or the client (or both). Similarly, therapists working with individuals with BPD may experience anger. Borderline clients often express suicidality, have inconsistent attendance to therapy, and may criticize aspects of the therapist’s behavior. Together, these behaviors can lead to anger and even rage directed towards the client. Frequently, these feelings of anger may be related to some implicit judgment about the client. To counter these emotions, it is important for the therapist to take an empathic approach and ‘‘jump into the client’s shoes.’’ Ultimately, the therapist may use here-and-now statements to highlight natural contingencies in the therapeutic relationship. Rebecca: Therapist: Rebecca:
Therapist:
Sorry, I know I’m late again. True, and this is a problem we have to fix. I know, but I tried this time! I just ran out of gas, and then had to fill up and I had to call Ben, because I didn’t have any cash on me. That does sound like it would be timeconsuming, and I know it’s hard to plan all this in advance. It’s also frustrating for me, because we’ve spent so much time in the last few sessions planning how to help you get to therapy on time. I’m worried that you’re not going to get a lot out of sessions when we only have 30 minutes. And with all this frustration and worry about how to make the most out of such a brief time, I don’t think I can be the best therapist [self-disclosure about emotions and highlighting contingencies]
Managing Motivation and Commitment Clients suffering from BPD are widely known to ‘‘fall out of therapy.’’ Therefore, the task of monitoring and maintaining motivation is often daunting for clinicians working with these clients. Following from the assumptions of DBT, the DBT therapist acts on the assumption that clients want to improve, but still sometimes need to increase their motivation. Thus, it is the therapist’s task to identify barriers to motivation, and use problem solving and motivating-enhancing strategies in bolster clients’ motivation for change. Therapist:
Ok, so after walking through what happened earlier today, it looks like one thing that got in the way of being on time to therapy was the fact that you were out late last night. Is that what happened last week as well?
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Rebecca: Therapist: Rebecca:
Therapist:
Rebecca:
Therapist:
Rebecca:
Clin Soc Work J (2011) 39:170–179
Yeah, I’m pretty sure I was out then—I usually go out on Thursdays. Do you think if you were not out late on Thursdays you would still be late to session? No, because I was on time 2 weeks ago, and that’s when I didn’t go out because I had the flu. I’m so glad we’re really zeroing in on what’s happening here. It seems like this may be one of the biggest barriers to making it to therapy on time. What are some of the benefits of going out on Thursdays? I’m usually pretty stressed out by Thursday, and I’m kind of lonely as well because I’m not working. That makes sense. So by Thursday, your friends are able to go out, and you get to let loose and forget your stress for awhile. Any downsides? Well, I’m not here. So I guess I lose out on money by paying for session time that I don’t get. Plus, I never end up figuring out other ways of tolerating stress. Maybe what I could do is wait until Friday to go out, or just do dinner on Thursdays.
Conclusions As the evidence accumulates for the efficacy of DBT for BPD and related problems (Harned et al. 2008; Linehan et al. 2006; Robins and Chapman 2004), and as research continues to highlight and clarify the mechanisms of change associated with this treatment (Lynch et al. 2006), the awareness and use of DBT in a variety of clinical settings will likely continue to increase. It is important for therapists practicing DBT adhere to the behavioral and dialectical theoretical foundations of the approach, in order to provide therapy that is effective, coherent, and consistent. Although we recommend that therapists generally avoid attempts at the integration of alternative theoretical frameworks into DBT, eclecticism and flexibility in terms of technique can be effective in DBT. DBT therapists use a variety of strategies derived from other systems of thought, such as Zen practice, humanistic or Gestalt traditions, and even psychoanalysis. As such, DBT therapists frequently use insight-enhancing strategies commonly associated with psychodynamic therapies, such as interpretations or statements that address issues in the therapeutic relationship (what might be called transference or countertransference), in addition to acceptance and mindfulness strategies derived from Zen and humanistic traditions. We recommend, however, that the therapist use the theoretical foundations of DBT as guiding
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principles with which to steer the ship in the most effective course for clients who struggle with BPD.
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Author Biographies Dr. Alexander L. Chapman, Ph.D. Assistant Professor and Associate Chair of the Psychology Department at Simon Fraser University, received the National Education Alliance for BPD 2007 Young Investigator’s Award. He has authored over 45 publications and three books. In addition, Dr. Chapman is President of the DBT Centre of Vancouver (www.dbtvancouver.com). Brianna J. Turner is a graduate student in the Clinical Psychology program at Simon Fraser University working with Dr. Chapman, where she completed her bachelor’s degree in psychology. Her research focuses on the identification of risk and relapse factors associated with self-injury and other self-damaging behaviours. Katherine L. Dixon-Gordon is a doctoral student in the Clinical Psychology program at Simon Fraser University, where she completed her M.A. working with Dr. Chapman. She received her bachelor’s degree in psychology from the University of Washington, where she completed a research assistantship with Dr. Marsha Linehan. Her research focuses on borderline personality disorder (BPD), psychophysiological measures of emotion regulation, and how emotion dysregulation impacts social problem solving and impulsivity.
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