Dialectical

Behavioural
Therapy
Presenter – Dr Athul Raj E.R
DNB Trainee

Chaired by – Mrs. Sowmya K

Clinical Psychologist
 Introduction

• DBT is a structured psychotherapy based on cognitive

behavioural principles

• Focuses on increasing an individual’s ability to cope with

intense emotions in healthy ways

Developed by Marsha Linehan

Originally intended to treat Persons with Borderline

Personality Disorder

2012 Cochrane review –

Treatment of choice for Persons with BPD 10

 CBT DBT
Cognitive errors , schemas , and ANT, which Genetic vulnerability , invalidating
occurs because of past experiences experience and emotional dysregulation

Wrong with the client Nothing is wrong with the client

Searching for dysfunctional thoughts and Acceptance of self and improving for growth
changing it

Usually completed in 3 months 12 months is needed for completion

Thinking focused Emotion focused

Protocol driven Principle driven

Individual / Group Both of the modalities mandatory ( Hybrid )

Borderline Personality Disorder
PROBLEMS IN MANAGING PERSONS WITH
BPD
BPD is one of the most stigmatized mental disorders

There is 50x higher risk of suicide among persons with borderline personality disorder compared to
general population

No single efficient pharmacological treatment for BPD

Crisis are triggered during therapy and also between therapy

Cognitive Therapist’s unrelenting focus on changing the patients problems often lead them to feel
invalidated

Individuals with BPD had higher risk of treatment drop out and relapse

Therapist burn out

How DBT Works ?
EMOTIONAL
DYSREGULATION
EMOTIONAL CUE

PROBLEMATIC
BEHAVIOUR

TEMPORARY RELIEF
Theorotical aspects
Dialectics

Biosocial
 • DBT incorporates a philosophical process
What are Dialectics? called dialectics
• Discovering what is true by considering
opposite theories ( Cambridge)
• It reduces extreme way of thinking
 PLANNED TO GO FOR A MOVIE, FRIEND DROPS OUT IN THE LAST MOMENT

BADLY WANTS TO SEE THE MOVIE, ACKNOWLEDGING THAT

FRIEND MIGHT BE BUSY
FEELING UPSET

DIALECTICS-

ASK FRIEND TO EXPLAIN THE REASON

ACCEPT APOLOGY , PLAN FOR THE MOVIE THE VERY NEXT DATE
From the Therapist’s Perspective
 Biosocial theory
Emotional
Dysregulation

Emotional Environmental
vulnerability Invalidation
EMOTIONAL ENVIRONMENTAL
VULNERABILITY INVALIDATION

Pervasive criticizing , Trivializing,

Biologically mediated Punishing
predisposition for affective
instability Chronically pathologizing for
having undesirable traits
Heightened sensitivity
Heightened reactivity Childhood sexual / Physical abuse
Slow return to basal level
INVALIDATION AFTER
DIAGNOSIS
How to address

• Borderline PD
• Borderline Person
• Person with BPD
• BPD patient
Two Main Treatment Settings
Individual Therapy
• Consists of one-on-one contact with a
trained therapist
• Therapist helps individual:
o stay motivated
o apply DBT skills within daily life
o address obstacles that might arise
over the course of treatment.
Skills Group (Group Sessions)
• Group led by one trained therapist
• Each session lasts ~ 2 hours
• Group meets weekly for 6 months
• Group members share experiences /
provide mutual support
• Assigned homework or exercises
• Groups can be shorter/ longer –
depends group members’ needs
DBT Assumptions
1. Clients are doing best
2. Clients want to get better
3. Clients want to grow out of their problem
4. Clients need to solve their problem irrespective of origin
5. Lives of the suicidal clients are unbearable
6. Clients need to learn skills to deal with problems in all areas of the lives
7. Clients cannot fail in psychotherapy

8. Therapist needs support

9. Therapist needs guidance from the DBT consultation team
10. Observing ‘Limits’ – Phone call is allowed, but Limiations +
 Stages of DBT

Pre-treatment Stabilization Symptom Problems in Completeness

• Orientation to DBT Targets: Reduction living Targets:
• Establishing • Life Threatening Targets: Targets: • Increasing capacity
commitment Behavior • Reduce Symptoms • Improve self-worth for joy and freedom
• Therapy Interfering • Problem solving
Behavior • Utilize supports
• Quality of Life
Interfering Behavior
B
Components of DBT

Individual Skills
Individual
Group Coaching Consultation
Training Telephone
Therapy Skills
Therapy Phone
consultation Team
Training Calls

Individual Telephone Consultation

Skills Therapy consultation Team
Individual
Training
Therapy
 Skill Training
• DBT assumes that the problems exhibited
by
individuals are caused by skills deficits.

• Failure to use effective behavior is often a

result of not knowing skillful behavior, or
when / how to use it

23
 Mindfulness Skills
Founded by Jon Kobat Zinn (1979)

Paying attention In a particular way on

purpose, in Present moment, without
judgement .

Steps to follow

1. Observe
2. Describe
3. Non judgemental
4. One mindful
5. Effectiveness

Follows Wise Mind Principle

Distress Tolerance
Extreme emotional distress can lead to problematic behaviors like self injuries ,
impulsivity , anger

Distress tolerance skills are to interrupt and change habitual and problematic responses

Crisis survival
• TIP
• STOP
• Temporary Distraction
• Self soothing skills

Reality acceptance
• Radical acceptance
• Half smile
• Willing hands
 Radical Acceptance

100% accepting the reality as it is

Doesn’t mean approval

Suffering = pain + non acceptance of situation

By accepting the pain , the suffering reduces

Accepting reality with bodily movements –

Half smile
Willing of hands
Emotion Regulation
• Reducing the intensity of emotion states
that can cue engagement in problem
behaviors

• Steps involved

Observing emotions

Psychoeducational overview
about emotions

Reduce emotional vulnerability

Changing emotional responses

Observing emotions
Changing unwanted emotions
Changing unwanted emotions
Reduce emotional vulnerability
Tools for interpersonal effectiveness
Identify factors associated with Interpersonal effectiveness

Challenge common cognitive distortions in Interpersonal situations

Determine appropriate level of intensity for making requests or saying no in a

given situation

Patients are taught what to say , how to say and what they say depending on
their priority in an interpersonal situation
Priorities for Interpersonal Effectiveness

D Describe

Express

E Assert G Gentle F Fair

Reinforce
I Interested Apologies

A
Validate
A Stick to Values
M Mindful V S Truthful
A Appear Confident E Easy Manner
R Negotiate Self Respect Effectiveness Relationship

N T Effectiveness

Objectives Effectiveness
 37

Skills Coaching Therapist

Individual Training Phone Calls Consultation

Therapy

• Behavioral Targets
• Diary Cards
• Behavioral Chain Analysis
• Developing Commitment
Behavioral Targets (Stage 1)
● Pre-treatment Symptom Problems in
Incompleteness
● • Orientation to DBT Reduction living
Interventions:
● • 1:1 meeting with Interventions: Interventions: • 1:1
Stabilization
Therapy
Interventions:
●therapist • 1:1 Therapy • 1:1 Therapy • 1:1 Therapy • Pursuing meaning

● • Establishing • Skills Training

• Skills Training • Skills generalization and
• Phone coaching
purpose • Consultation Team
●commitment • Phone coaching
● • Consultation Team
Targets:
Targets:
1 • Life Threatening
Behavior

2 • Therapy
BehaviorInterfering
●
Targets:
• Increasing capacity
• Ancillary Treatments • Improve self-worth
3 • Quality of Life
● • Problem solving for joy and freedom
Interfering Behavior ● Targets:
 Diary Cards
33
Individual Incidents of behavioral targets, urges to engage in the
Tracks behavior (scale of 1-5)

Incidents of substance and alcohol use Review

only in
Individual
therapy
Consistency with medication regimen

Practice of skills over the last week Review in

Individual therapy
& Skills Training
Behavioral Chain Analysis

• How is the behavior conditioned?

o Classically conditioned –Under the control of antecedent behaviour
o Operantly conditioned - Under the control of Consequent events

o Dysfunctions are replaced with more adaptive response during Solutional

analysis
Consequences/
Unskillful Reinforcers
Triggering
Event Behavior
• Following the
• Cues problem
preceding the behavior
behavior
 43
Individual Skills Therapist
Therapy Training Telephone Consultation

consultation

• Brief < 10 minutes

• When unable to implement skills
• Needs to happen BEFORE the problem
behavior has occurred, not after- otherwise
having your therapist on the phone becomes
reinforcement of behavior (24 hour rule)
 Coaching
Telephone consultation Phone Calls

Skills Generalization

Validating patient’s need of contact

Intervention on suicidal behavior

Crisis Coaching
 45

Individual Skills Coaching Ancillary

Therapy Training Phone Calls Therapist Treatments
Consultation
Team

• Support for the therapist

• Problems in therapy
• Providing Dialectical
Balance
Newer Research
Meta analysis of 16 studies , DBT was associated most with reduction in
suicidal and self-injurious behaviors

In substance use disorders , leads to enchanced emotional regulation

In eating disorders , can lead to decreased bingeing and purging behaviour

In Depression , faster remission compared to medication alone

Also being studied in the context of ADHD

THANK YOU

References
CTP
Marsha Linehan DBT Manual