Dialectical Behaviour Therapy (DBT)

Dialectical Behaviour Therapy (DBT) is a cognitive behavioural therapy developed as a treatment for self harming, particularly in borderline personality disorder (Low et al., 2001). Underpinning ideas of DBT suggest that invalidating environments that may have occurred during upbringing can inhibit the effective development of coping methods to deal with sudden intense surges of emotion (Linehan, 2003).

The primary treatment goal of DBT is to reduce self harming behaviour by helping clients develop new coping skills and addressing obstacles that may prohibit the client from using those skills. This is achieved by implementing a hierarchical stage model that provides a guiding structure for the therapy using a number of treatment modalities including individual sessions, group therapy and coaching (Swales, Heard & Williams, 2000). Treatment consists of weekly individual psychotherapy combined with group behavioural skills training. The skills taught include emotional regulation, distress tolerance and problem solving (Low et al.2001).

Psychotherapy sessions focus on the problem behaviour and events that occurred that may have triggered the client to self-harm. The therapist explores alternative solutions that the client could use in times of crises and investigates what prohibited the client from using those adaptive solutions during crises in the first place.

The role of the therapist adopting a DBT approach is to teach and reinforce adaptive behaviours. The emphasis is on teaching clients how to manage emotional trauma rather than reduce crises (Swales, Heard & Williams, 2000; Muehlenkamp, 2006). An overview of the DBT approach is outlined below.

The Pre-Treatment Stage

This preliminary stage or area of focus involves building rapport and the therapeutic alliance with the client. This is something that, once established, must continue to be monitored and upheld.

Stage 1

The first stage focuses on reducing self harming behaviours, reducing distress and maintaining the client’s therapy compliance. This is achieved by employing strategies such as:

1) Validation of the client’s experience

This is achieved mainly through empathetic reflection from the counsellor. For example:

Client: “it’s not something that I’ve ever questioned. The moment I feel things becoming unbearable around him or even just thinking about him, I start to feel like I can’t escape this strong feeling of anxiety and anger that just wells up inside me, So I get all tense just thinking about being alone with him for any length of time and so then… to calm myself down and relax myself… I tend to cut… it seems to work ok…”

Counsellor: I can understand why you might feel so angry and anxious and uneasy to be alone with your father… He violated your trust in such a significant way. You’ve been deprived of a caring and kind father, haven’t you?”

2) Teaching alternative adaptive behaviour

This is achieved progressively whereby, as a first step, alternative behaviours may be a close mimic of the self-harming behaviour but without the enduring physical consequences. Below are example behaviours that a client could adopt as an alternative adaptive behaviour in the progression away from the self-harming behaviour.

“When feeling angry, frustrated or anxious…”

Try something physical that is not a violent act directed at a living thing. For example:

• Punch a boxing bag.
• Slash an empty plastic soda bottle or a piece of heavy cardboard or an old shirt or sock.
• Make a soft cloth doll to represent the things you are angry at. Cut and tear it instead of yourself.
• Flatten aluminium cans for recycling, seeing how fast you can go.
• Use a pillow to hit a wall, pillow-fight style.

“When feeling depersonalised, dissociating, feeling unreal…”

Do something that creates a sharp physical sensation. For example:

• Squeeze ice hard (putting ice on a spot you want to burn gives you a strong painful sensation and leaves a red mark afterward, kind of like burning would, it really hurts but does not have long term consequences).
• Put a finger into a frozen food (like ice cream) for a minute.
•  Bite into a hot pepper or chew a piece of ginger root.

“Wanting to see blood…”

• Draw on yourself with a red felt-tip pen on the areas you want to cut.
• Paint yourself with red paint.

“Wanting to see scars or pick scabs…”

• Get a henna tattoo kit. You put the henna on as a paste and leave it overnight; the next day you can pick it off as you would a scab and it leaves an orange-red mark behind for a period of time.

3) Behavioural skills training in mindfulness, emotional regulation, interpersonal effectiveness and distress tolerance

Examples:

Distraction

Distraction is simply doing other things to distract self from self-harming. Most of the techniques mentioned above are distraction techniques; whereby you bring something else in to change the feeling. Using ice, rubber bands, etc., work as a distraction from and substitute for other intense self injurious responses. Other distractions/substitutes include experiences that change the client’s current feelings.

This includes tasks (like counting the colours seen in the immediate environment) that do not require much effort but do take a great deal of concentration thereby distracting from the desire and act of self harming. Volunteer work could also play a part in distracting the client from self harming behaviours if they would otherwise be idol a lot throughout the day.

Evaluating the Pros and Cons of Tolerating Distress

This involves evaluating the benefits and costs of self-harming. The client needs to consider what the pros or benefits are and what the cons or bad things are about self harming. Sometimes writing this down can help the client come to a decision not to self-harm.

An example list of pros and cons is presented below.

Pros:

• Makes me feel high
• Releases my frustrations
• I like to see my own blood
• I can communicate my distress
• I cope with physical pain better than emotional pain

Cons:

• Upsets people who love and care for me
• My family would be devastated if I die
• There are better ways of dealing with my problems
• I’m permanently scarring my body
• I feel ashamed and, embarrassed

Self-Soothing

This, like distraction, is a distress tolerance technique. It’s quite straightforward. The client is encouraged to use things that are pleasing to their senses to soothe themselves. Some people find that active distraction works better for violent angry feelings and self-soothing is more effective for soft, sad feelings.

Reducing Vulnerability to Negative Emotion

This involves the client employing ongoing global self-care strategies in order to minimize the times when the urge to self-harm occurs. For example, balanced eating, sleeping, and exercise can help in the management of overwhelming emotion thus helping to reduce the motivation to self-harm.

Interpersonal Effectiveness

This involves helping the client become clear on what they want and how to communicate these priorities effectively in an interaction with others. Effective expressions like using “I” statements to state feelings play an important part in this process to help the client identify and express their thoughts, feelings, preferred actions and choices

Stage 2

At this stage, the therapist addresses ways of processing and dealing with traumatic experiences and invalidating environments. Some practical tools which may be used to aid the trauma sufferer in terms of processing such events include:

Writing about trauma

Writing may often provide the client with a cathartic release as it is one practical means of getting all the chaotic thoughts resulting from a traumatic experience out of one’s mind and on to paper. Through expressing in words exactly how they felt leading up to, during and after, a traumatic experience it may help the client gain a better understanding of why it is so painful and why they need time to make sense of it all and process everything constructively (Smyth, True & Souto, 2001).

Painting or drawing the trauma

While some people are able to express themselves more easily using the written word, others are far more comfortable with using art to get their feelings out and on to paper. Colours may be used to symbolise pain and a whole host of emotions resulting from the trauma such as fear, anger, guilt, shame, despair and anxiety (Smyth, True & Souto, 2001). Ultimately the goals are the same as when writing in words about the trauma.

A significant outcome for this stage of therapy is a reduction in the level of emotional distress experienced by the client (Swales, Heard and Williams, 2000).This stage only takes place when the client has developed sufficient skills to cope with the intensity of emotions that can be resurfaced when remembering and processing traumatic events. This is achieved by revisiting and reinforcing the skills that were implemented at stage 1.

Stage 3

This stage focuses on increasing the client’s self-respect and achieving relevant goals. The therapist aims to help the client learn to; trust themselves, validate their own thoughts, opinions and emotions and to learn self-respect. Some of the strategies used in this stage include goal setting and problem solving. A problem-solving approach is suitable for self-harm, provided the client’s problems can be specified, the goals seem realistic, and there is an absence of severe acute psychiatric illness that would impede the therapeutic process.

The first step is to draw up a list of problems with the client. Each problem should be clearly defined. The therapist may have to ask the client to describe each problem in great detail in order to obtain a clear account of each difficulty. In some cases, it may not be possible to identify a specific problem, and so the client may be asked to keep a diary over 1 or 2 weeks, and record times when he or she feels upset or anxious. Key problem areas may then be identified (Guthrie, 2003).

Problem-solving attempts to harness the client’s own resources and skills to overcome difficulties. Self-harm clients often have poor levels of social support, and may be socially isolated or estranged from their families. Assessment of the client’s personal assets and strengths and the degree of support he or she has from friends, family and other professionals is important. How the client has coped in the past with problems, particularly those similar to current difficulties will provide some indication of how he or she may react or cope in the future.

Key aspects of problem-solving treatments in self-harm are:

• Exploration of the meaning placed on self-harm episodes
• Clarification and identification of specific problems
• Generation of problem solutions
• Exploration of alternative strategies to self-harm
• Agreement about goals of treatment
• Assessment of support and the client’s personal strengths and assets

(Guthrie, 2003)

References:

• Guthrie, E. (2003). Psychological treatment for deliberate self harm. Psychiatry: The Medicine Publishing Company. Retrieved on the 18th of August 2010 from World Wide Web www.asia.cmpmedica.com.
• Linehan M (1993) Cognitive-Behavior Therapy for Borderline Personality Disorder. New York: Guilford Press.
• Low, G., Jones, D., Duggan, C., Power, M., Macleod, A. (2001). The treatment of deliberate self harm in borderline personality disorder using dialectical behaviour therapy: A pilot study in a high security hospital. Behavioral and Cognitive Psychotherapy, 29, 85-92.
• Muehlenkamp, J. (2006). Empirically supported treatments and general therapy guidelines for non suicidal self injury. Journal of Mental Health Couselling.
• Smyth, J., True, N & Souto, J. (2001). Effects about writing about traumatic experiences. The necessity for narrative structuring. Journal of Social and Clinical Psychology, 20, 161-170.
• Swales, M., Heard, H.L. & Williams, J.M.G. (2000). Linehan’s dialectical behaviour therapy for borderline personality disorder: Overview and adaption. Journal of Mental Health, 9, 7-23.

Source: www.mentalhealthacademy.com.au