Dialectical Behaviour Therapy

Question 1

What is Dialectical Behaviour Therapy?

Answer 1

Designed for treatment of
- suicidality or parasuicidality not responding to CBT or others
- often for borderline personality disorder (BPD)
- BUT do not all have suicidal behaviour
- now conceptualized as transdiagnostic intervention
- recognize that patients may have behaviours that interfere with therapy
- also include support for the therapist

Question 2

What is Linehan’s Biosocial theory of BPD?

Answer 2

• if put emotionally vulnerable person + very neglectful environment → lead to very bad consequences
• usually genetic + environment transmission because parents more likely to also be emotionally vulnerable

Question 3

What is the dialectic dilemma for patients in DBT?

Answer 3

For patient
- emotional vulnerability VS self-invalidation
- active passivity (approaching life in helpless way) VS apparent competence
- unrelenting crisis vs. inhibited grieving (hard to make themselves feel for it)

Question 4

What is the dialectic dilemma for the therapist in DBT?

Answer 4

For therapist
- Accept client as he/she is, BUT encourage change
- Centered and firm, BUT flexible when needed
- Nurturing, but benevolently demanding (also pushing the client beyong where they think they can go)

Question 5

How is DBT structured?

Answer 5

Weekly individual therapy sessions
- but very different from CBT
Weekly group skills training session
Telephone contact
- in middle of crisis, encourage to call the therapist
Therapist consultation team meeting
- for therapist to feel supported
Client must commit to all parts of treatment package for at least 1 year

Question 6

What are the five functions of DBT?

Answer 6

Enhancing capabilities
- Improve several life skills in the context of weekly skills group session

Generalizing capabilities
- Homework assignments to practice skills in natural environment

Improving motivation and reducing dysfunctional behaviours
- Primarily accomplished in individual therapy

Enhancing and maintaining therapist capabilities and motivation
- Therapist consultation meetings provide support,
validation, skill-building, and feedback

Structuring the environment
- Want to reinforce effective behaviour/progress and not reinforce maladaptive or problematic behaviour
- ex→ if patient call therapist after engaging in suicidal behaviours→ do not engage with the patient
- Patients also need to modify their own environment

Question 7

What is the hierarchy of therapy targets in DBT?

Answer 7

Hierarchy of therapy targets
- Suicidal and parasuicidal behaviours
- Therapy interfering behaviours→ missing a session
- Behaviours that interfere with quality of life→ substance use, ED
- Behaviours related to post-traumatic stress
- Improve self-esteem
- Individual targets negotiated with client

—>not necessarily client-initiated topic
—>client not necessarily going to be able to talk about what they want until stop suicidal behaviours
—>have to make the client agree not to kill themselves at least for a period of time (until next session)
- present them with the ideal of a life in which they do not want to kill themselves
- hard for them to even imagine it

Question 8

What is a diary card in DBT?

Answer 8

Diary card
- Track behaviours such as self-harm, suicide attempts, emotional misery
- Used to prioritize session time
- note the urge to, the actual behaviour and what they did instead

Question 9

What are the skills trained in DBT?

Answer 9

Mindfulness skills
- observe, describe and participate
- 5 senses

Interpersonal Effectiveness Skills
- Objectiveness, Relationship, and Self-respect effectiveness
- three components of interpersonal relationships

Emotion Regulation Skills
- Identify and describe emotions
- Riding the wave of emotion
- opposite to emotion action→ do something when just want to stay in bed
- help them to recognize different emotions
- factors that makes them vulnerable to emotion regulation→ missing sleep
- also see changes in brain region like amygdala, insula, anterior cingulate
—>really core to BPD
—>combine mindfulness and cognitive restructuring

Distress Tolerance Skills
- Distraction; Self-soothing; Radical acceptance
- just need to get through that moment

Question 10

What are the evidence for DBT form Linehan et al, 2006?

Answer 10

Linehan et al., 2006
- Dismantling study to examine specific ingredients of DBT
- Control for DBT non-specific factors→ hours of therapy, availability of group consultation…
- Participants were women with BPD with recent suicidal behaviour (attempt or self-injury)
- Patients were matched to treatment condition on five prognostic variables
- Community therapists were nominated based on expertise treating difficult clients and identified as nonbehavioral or psychodynamic

Results
- DBT < dropout and change in therapist than CTBE (community treatment by expert)
- DBT half the rate of suicide attempts than CTBE
- No difference in non-suicidal self-injury between treatments
- DBT < use of crisis services and hospital admissions than CTBE
- Depression, suicidal ideation, and reasons for living improved in both condition

Question 11

What are other evidence for DBT?

Answer 11

Other evidence
- shortened DBT efficacious for self-harm, suicidal ideation, and depressive symptoms for adolescents
- Efficacy data for BN and BED, but no evidence of superiority over CBT
- preliminary evidence that DBT skills can be used as a stand-alone treatment for a variety of conditions

Moore et al, 2018
- 64% of jail inmates have clinically significant mental health problem
- 8-week skills group in jail setting for male inmates unselected for emotional or behavioural problems (n = 16 with complete data)
- No statistically significant changes in coping skills or emotional/behavioural dysregulation, likely owing to small sample size
- Participant feedback generally positive→ would have like it to be longer