Dialectical Behavior Therapy in the Treatment of Abusive Behavior

Summary

Research suggests that a subset of men who abuse their partners have characteristics associated with borderline personality disorder (BPD). Dialectical Behavior Therapy (DBT) has shown promise as a treatment for BPD, and thus may be useful for these men. This paper describes how DBT principles might be applied to address the problem of partner abuse, including discussion of why one might expect DBT to be a helpful treatment model for this population, and how implementation of the model might be designed.     

辩证行为疗法的回顾与前瞻

辩证行为疗法(DBT)是最近十几年来兴起的一种主要针对边缘性人格障碍(BPD)的有效治疗方法。就辩证行为疗法的基本理论与治疗模式、治疗阶段与治疗策略进行综述,并介绍了国外最近的临床研究进展,最后对该疗法的应用前景进行了展望。     

Principles of Skills Assessment in Dialectical Behavior Therapy

Since its inception, increasing clients’ capabilities in experiencing and managing emotions, interpersonal relationships, and crises has been central to both the theory and practice of Dialectical Behavior Therapy (DBT; Linehan, 1993a, Linehan, 1993b, Linehan, 2015a, Linehan, 2015b). Enabling clients to learn new skills, and to effectively implement them to change behavior, requires both capability and motivation on the part of skills trainers and individual therapists alike. The most effective DBT practitioners precisely assess at each stage of skills acquisition, strengthening, and generalization to determine how well their clients perform new skills. They assess what barriers are preventing effective skills use, in order to implement a focused endeavour to overcome any obstacles. This paper reviews principles of skills assessment within each treatment modality and provides therapists with checklists for identifying problems, and case vignettes illustrating helpful therapeutic strategies.     

Dialectical Behavior Therapy for Managing Interpersonal Relationships

Dialectical Behavior Therapy (DBT) is a treatment designed for individuals having borderline personality disorder (BPD), patients having binge eating disorder, co-morbid substance dependence and BPD, and depressed older adults. This paper aims to explore the use of DBT and to ascertain the status of DBT education in treating difficulties in handling interpersonal relationships among clients seeking counseling and psychotherapy. The skills training mode can be employed for teaching skills to solve relationship problems. Validation and acceptance strategies can lessen rejection sensitivity and negative feelings that make interpersonal situations chaotic. Black and white thinking can be resolved by finding a middle path through acceptance and change. This paper suggests the possible utility of DBT for enhancing psychological well-being in clients.     

Modifying Dialectical Behavior Therapy for Deaf Individuals

Therapies that rely on written materials, information, or procedures involving familiarity with the dominant culture (e.g., colloquialisms, history) often pose barriers to people who use another language, have low English literacy, or are less familiar with the dominant culture. All this applies deaf individuals. One of the most well-validated mental health treatments for reducing suicidality in those diagnosed with borderline personality disorder is Dialectical Behavior Therapy (DBT; Koons et al., 2001; Linehan et al., 1999; Linehan et al., 2006; Linehan et al., 2002; Verheul et al., 2003). Unfortunately, its heavy reliance on written materials, prevalent use of metaphors, and other culture-bound characteristics make DBT inaccessible to the average deaf consumer. We describe the potential benefits that DBT could offer deaf clients, some of which are uniquely related to the life experiences and societal challenges faced by deaf people. Barriers to accessing standard DBT treatment and the materials used are described. Modifications of DBT materials and methods that we have found effective with deaf clients are detailed. It is concluded that DBT materials and methods can be successfully modified for use with this population. Available resources and additional benefits of employing DBT with deaf clients are noted.     

A Cultural Adaptation of Dialectical Behavior Therapy in Nepal

Growing evidence exists on the potential for adapting evidence-based interventions for low- and-middle-income countries (LMIC). One opportunity that has received limited attention is the adaptation of psychotherapies developed in high-income countries (HIC) based on principles from LMIC cultural groups. Dialectical behavior therapy (DBT) is one such treatment with significant potential for acceptability in South Asian settings with high suicide rates. We describe a tri-phasic approach to adapt DBT in Nepal that consists of qualitative interviews with major Nepali mental health stakeholders (Study 1), an adaptation workshop with 15 Nepali counselors (Study 2), and a small-scale treatment pilot with eligible clients in one rural district (Study 3). Due to low literacy levels, distinct conceptualizations of mind and body, and program adherence barriers, numerous adaptations were required. DBT concepts attributable to Asian belief systems were least comprehensible to clients. However, the 82% program completion rate suggests utility of a structured, skills-based treatment. This adaptation process informs future research regarding the effectiveness of culturally adapted DBT in South Asia.     

Mastering the Art of Chain Analysis in Dialectical Behavior Therapy

Behavioral chain analyses, which are common in behavioral and cognitive-behavioral treatments more broadly, are the primary assessment tool in Dialectical Behavior Therapy (DBT). As such, they are conducted in nearly every DBT session. Despite their importance in the treatment, very little has been written about the “how-tos” of chain analyses in DBT or how to improve therapist skill in this area. This article describes the rationale and proposed functions of chain analyses, provides details about the various components of the chain analysis, and includes common problems that arise in conducting chain analyses. A case example of a detailed chain analysis is provided.     

Effectiveness of Dialectical Behavior Therapy for Treating Eating Disorders

This study evaluated the effectiveness of dialectical behavior therapy (DBT) for treating eating disorder episodes and co‐occurring depression symptoms among individuals diagnosed with eating disorders. Separate meta‐analytic procedures for between‐groups and single‐group studies were conducted and yielded large effect sizes, indicating that DBT may be efficacious for decreasing disordered episodes among women diagnosed with eating disorders; medium to large effect sizes were noted for treating depression symptoms. Implications for evidence‐supported practice and study limitations are discussed.     

Effectiveness of Dialectical Behavior Therapy in a Community Mental Health Center

Dialectical behavior therapy (DBT) has been shown to be effective in randomized controlled trials with women with borderline personality disorder and histories of chronic self-inflicted injury including suicide attempts. The present study is a pre-post replication of a comprehensive DBT program in a community mental health center for individuals who chronically injure themselves and/or have experienced multiple treatment failures. Twenty-four subjects were given the Treatment History Interview to obtain information regarding medically treated self-inflicted injuries and the use of crisis services. After 1 year of treatment, DBT showed a significant reduction in the number and severity of self-inflicted injuries, psychiatric-related emergency room visits, psychiatric inpatient admissions and days, and the number of crisis treatment systems engaged. Results are compared to benchmarks from 3 other clinical trials of DBT. While this pre-post comparison has threats to internal validity, it supports the feasibility of DBT when fully implemented in a community mental health clinic.     

辩证行为疗法：理论背景、治疗效果及作用机制

辨证行为疗法（Dialectical Behavior Therapy, DBT）于20世纪90年代初由美国治疗师Linehan创立。作为第三代行为治疗之一,该疗法以行为主义理论、辩证哲学、生物社会理论及禅宗为哲学基础,通过增加患者的技能使用,提高其情绪调节能力,以达到治疗目的。临床研究已证明其在边缘人格障碍,自杀及自伤行为中具有良好的治疗效果,除此之外也广泛适用于其他心理障碍及群体。DBT的临床效果、改变机制及拓展应用都需进一步研究。     

Affirmative Dialectical Behavior Therapy Skills Training With Sexual Minority Veterans

Minority stress theory posits that unique stressors create an invalidating environment, which places sexual minority individuals at increased risk for psychiatric morbidity. Sexual minority veterans’ experience of minority stressors results in elevated levels of emotion dysregulation, anxiety, depression, and suicidality. Clinical interventions designed to address minority stress and treat emotional dysregulation and related disorders among sexual minority veterans are warranted. Professional guidelines recommend the adaptation of evidence-based treatments to address the unique features of sexual minority and veteran mental health. Dialectical Behavior Therapy (DBT) is a treatment for emotion dysregulation and related problems that addresses an invalidating environment, which is an appropriate framework for sexual minorities. The current research adapts the Emotion Regulation module of DBT Skills Training. This adaptation highlights minority stress as part of the invalidating environment and adds new teaching points to address the unique features of sexual minority mental health to create Affirmative DBT Skills Training. Six sexual minority veterans completed Affirmative DBT Skills Training meeting on a weekly basis for 10 consecutive weeks. Before and after treatment, participants completed measures of emotion regulation, anxiety, and depression as well as assessments of minority stress processes. Affirmative DBT Skills Training was well received in this sample. Results suggest that the intervention was effective in decreasing emotion dysregulation and symptoms of depression. These findings suggest Affirmative DBT Skills Training is a promising treatment, although more research is warranted, particularly given the small sample size and lack of a control group.     

Efficacy of Dialectical Behavior Therapy for Adolescents in a Partial Hospitalization Program

This study evaluated dialectical behavior therapy for adolescents (DBT‐A) vs. treatment as usual within a 6‐week partial hospitalization program. The 103 adolescent participants (mean age = 15.27 years) were predominantly girls (n = 63, 61%) with a variety of primary mental health diagnoses. Results indicated that DBT‐A was superior for decreasing symptoms of depression and interpersonal sensitivity, but no statistically significant difference was detected for anxiety or hostility. Implications for treating youth with transdiagnostic identities are discussed.     

Challenges and Potential Solutions to Implementing Phone Coaching in Dialectical Behavior Therapy

Dialectical Behavioral Therapy (DBT) is an effective treatment for borderline personality disorder (BPD), yet many health care facilities struggle to implement one of the modes of DBT, phone coaching. The aims of this study were to present barriers and reported solutions regarding the implementation of DBT phone coaching. We conducted a sequential mixed methods national program evaluation that included a quantitative self-report survey completed by Department of Veterans Affairs (VA) facilities (N = 59) offering any of the four modes of DBT. Subsequent qualitative interviews using a semistructured interview guide informed by the Promoting Action on Research Implementation in Health Services (PARIHS) were completed with DBT providers and administrators from a subset (n = 16) of these VA sites. Four themes—the lack of tools and policies, compensation for phone coaching, clinician willingness to conduct phone coaching, and consistent program and leadership support—were identified and illustrated in a case study. This study also offered concrete recommendations for those health care organizations, managers, administrators, and clinicians who may be interested in implementing phone coaching at their health care facilities.     

Assessment of Parents,Couples, and Families in Dialectical Behavior Therapy

Family intervention in Dialectical Behavior Therapy (DBT) is a core part of multiple required functions of DBT, providing opportunities for skill training (including relationship-specific skills that are not covered in individual DBT), skill generalization, and direct intervention into the social and family environment. In order to intervene with parents, partners and other family members efficiently and effectively, therapists must first conduct a careful assessment. The core relationship transaction of emotion vulnerability/dysregulation and inaccurate expression leading to invalidating responses (and vice versa) is highlighted, as are the treatment targets in DBT with families, which inform assessment targets. Then, two core assessment procedures are explored, with clinical examples: (a) conducting “double chain” analyses, demonstrating how one person’s social or relationship responses affect the other’s emotional arousal (and vice versa); and (b) direct behavior observation of family interactions, which allow treatment targets to be identified efficiently. These two assessment strategies may also be combined. Implications for family interventions are discussed.     

Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis

Dialectical Behavior Therapy (DBT) prioritizes suicidal behavior and other self-directed violence as the primary treatment targets, and has been demonstrated to reduce self-directed violence in clinical trials. This paper synthesizes findings from controlled trials that assessed self-directed violence and suicidality, including suicide attempts, non-suicidal self-injury (NSSI), suicidal ideation, and accessing psychiatric crisis services. Eighteen controlled trials of DBT were identified. Random effects meta-analyses demonstrated that DBT reduced self-directed violence (d = -.324, 95% CI = -.471 to -.176), and reduced frequency of psychiatric crisis services (d = -.379, 95% CI = -.581 to -.176). There was not a significant pooled effect of DBT with regard to suicidal ideation (d = -.229, 95% CI = -.473 to .016). Our findings may reflect the prioritization of behavior over thoughts within DBT, and offer implications for clinical practice and future research concerning the implementation of DBT for acute suicidality.     

Dialectical Behavior Therapy: An Emotion-Focused Treatment for Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment for borderline personality disorder (BPD) that is based on the theory that emotion dysregulation is the core feature of BPD. This article focuses on aspects of DBT theory and techniques that specifically address emotion. The dialectical and biosocial theories that underlie DBT are reviewed with an emphasis on how each relates to emotional experiencing in BPD. Selected treatment strategies that address emotion dysregulation and their hypothesized mechanisms of change are also described. Relevant research findings are incorporated throughout to provide an empirical foundation for the DBT theories and strategies that are discussed.     

An Examination of the Effectiveness of Dialectical Behavior Therapy Skills Groups

This study implemented a multiple‐phase, contrast, single‐case research design to examine the effectiveness of the 4 core dialectical behavior therapy skills group modules in reducing emotion dysregulation. Three participants completed four 6‐week skills modules over 9 months. Examination of calculated estimates of treatment effect indicated that 2 out of the 3 participants experienced meaningful changes in their degree of emotion dysregulation over the course of treatment. Implications for counseling practice are discussed.