Welcome
DBT Overview
“At least 135 Million people suffer with severe problems from emotional regulation in their lives” (The Linehan Institute, 2021).
Standard DBT is an intensive treatment program that consists of individual therapy, group skills training, inter-session contact/telephone coaching (e.g., real-time or text), and a therapist consultation team (Linehan, 2015). If the therapist does not have a team, it is not DBT (Schaller, 2015 ). Generally, the client commits to a one year treatment plan, with 3-4 hours of weekly interactions in individual therapy, group skills training, inter-session contact, and out-of-session activities, such as maintaining a diary card. An overarching goal of DBT is to keep clients in their lives, connected with family, friends, work, school, and other important relationships (Schaller, 2015).
DBT clinicians ascribe to certain beliefs or assumptions in order to effectively treat, such as the client/therapist relationship is a real, transactional relationship between equals; and the client is doing the best they can and wants to improve whilst also maintaining the client needs to do better, try harder, and be motivated to change. (Vaughn, 2021). This is a core feature of DBT— the "D" or dialectics of the approach—acceptance and change (e.g., embracing opposites that exist simultaneously in a “both-and” model” rather than an “either-or” stance!) (Vaughn).
A life Worth Living
Who Does DBT Help?
Individuals with pervasive emotion dysregulation, impulse control, instability in relationships and self-image, as well as those engaging in non-suicidal self-injury (NSSI), and /or suicidal ideation.
Linehan’s (1993) original skills training manual was specifically and entirely focused on treating clients with high risk for suicide and those who met the criteria for borderline personality disorder (BPD). However, since the first edition in 1993, DBT has been empirically researched, adapted, implemented, and shown effective with a variety of disorders including (1) borderline personality disorder with co-occurring: suicidal and self-harming behavior, substance use disorder, post-traumatic stress disorder (PTSD), and high irritability, (2) cluster B personality disorders, (3) suicidal and self-harming adolescents, (4) pre-adolescent children with severe emotional and behavioral dysregulation (e.g., ages 7-12), (5) PTSD related to childhood sexual abuse, (6) transdiagnostic emotion dysregulation, (7) bipolar disorder, (8) attention deficit hyperactivity disorder (ADHD), (9) eating disorders (e.g., binge-eating disorder, Bulimia Nervosa), and (10) Major Depression: treatment-resistant major depression, and older adults with chronic depression and one or more personality disorders (The Linehan Institute, 2021).
Borderline Personality Disorder (BPD)
BPD is a complex and serious mental disorder characterized by a pervasive pattern of difficulties with emotional regulation and impulse control, as well as instability both in relationships and in self-image, where individuals frequently engage in non-suicidal self-injury (NSSI) (e.g., cutting, burning) (Bateman & Fonagy, 2013). Unfortunately, 69-80% of borderline clients present with recurrent suicidal behavior (Bateman & Fonagy). The associated suicide rate is tragically high and estimated at nearly 10% (Prada et al., 2018). The creator of DBT, Marsha Linehan (2017h), describes BPD as "being in hell" and the daily relational battle being the equivalent of "trying to get out of the infernal flames with only a metal ladder." Often times, individuals with BPD are highly stigmatized and struggle to maintain a consistent therapeutic relationship (Linehan, 2017j). Interestingly, Linehan (2017j), the developer of DBT advocates re-naming BPD with the less stigmatizing title of "pervasive emotion dysregulation disorder." However, as of yet this change has not been accepted by the American Psychological Association.
Additionally, borderline individuals frequently struggle with mentalization. Malda-Castillo (2019) describe mentalizing as an “ability to help make sense of one’s own and others’ states of mind regarding desires, intentions, thoughts, feelings and behaviors” (p. 466). An inability to mentalize effectively is often illustrated when an individual becomes upset about someone else’s behavior and makes quick assumptions about their thoughts and intentions without thoughtful consideration (Malda-Castillo). This inability to mentalize effectively creates significant emotional distress and tremendous instability in the individual's relationships (Bateman & Fonagy, 2013). These challenges associated with BPD are illustrated in the video below.
Additionally, borderline individuals frequently struggle with mentalization. Malda-Castillo (2019) describe mentalizing as an “ability to help make sense of one’s own and others’ states of mind regarding desires, intentions, thoughts, feelings and behaviors” (p. 466). An inability to mentalize effectively is often illustrated when an individual becomes upset about someone else’s behavior and makes quick assumptions about their thoughts and intentions without thoughtful consideration (Malda-Castillo). This inability to mentalize effectively creates significant emotional distress and tremendous instability in the individual's relationships (Bateman & Fonagy, 2013). These challenges associated with BPD are illustrated in the video below.
Cultural Sensitivity
DBT is a culturally-sensitive model and is effective amongst individuals of diverse backgrounds in terms of age, gender, sexual orientation, and race/ethnicity (Behavioral Tech, 2021c).
Although Linehan’s DBT model was originally researched and implemented in the United States, DBT is cross-culturally effective and has been scientifically researched in RCTs in Australia, Brazil, Canada, Germany, Great Britain, Italy, The Netherlands, Norway, Spain, Sweden, and Taiwan (Behavior Tech, 2021c). Additionally, DBT has expanded training opportunities into 30 countries; more recently, in Latin America.
Behavioral Tech (2021d), which is the research, dissemination, and training entity of the Linehan Institute has also provided training to diverse community mental health systems including, US Veterans Administration teams, criminal justice systems, school systems, and other systems that treat persons at high risk for suicide.
Although Linehan’s DBT model was originally researched and implemented in the United States, DBT is cross-culturally effective and has been scientifically researched in RCTs in Australia, Brazil, Canada, Germany, Great Britain, Italy, The Netherlands, Norway, Spain, Sweden, and Taiwan (Behavior Tech, 2021c). Additionally, DBT has expanded training opportunities into 30 countries; more recently, in Latin America.
Behavioral Tech (2021d), which is the research, dissemination, and training entity of the Linehan Institute has also provided training to diverse community mental health systems including, US Veterans Administration teams, criminal justice systems, school systems, and other systems that treat persons at high risk for suicide.
DBT's Biosocial Theory
DBT’s biosocial model is a theory of how symptoms arise and are maintained. It is a NO-BLAME model.
The biosocial theory in DBT explains how symptoms arise and problems continue, this applies to BPD as well as a variety of psychopathologies (Vaughn, 2018). The bio piece of this theory essentially proposes individuals are inborn (i.e., born with) certain sensitivities (Daros et al., 2018; Vaughn). For instance, these sensitivities might be related to one’s skin (e.g., how one’s skin reacts to perfumes, textures, detergents) or digestive sensitivities (e.g., what one can eat or what causes more difficulties). This same idea is applied to emotions. According to biosocial theory emotion dysregulation develops from a biological predisposition for an “over-sensitivity” as well as an overreactive emotional response system. This predisposition and overreactive response system is frequently called “emotional vulnerability” (Daros et al.). This component is not something that can necessarily be changed as it is considered a part of one’s genetic make-up (Vaughn). However, emotional vulnerability alone, is not enough to cause severe difficulties. When emotional vulnerability is coupled with aversive childhood experiences (ACEs) (e.g., emotional neglect, social rejection, interpersonal violence, and/or invalidation), it may result in biological and psychological changes in the development of effective emotion regulation (Daros et al.).
In DBT, the social piece of the theory refers to problematic transactions over time for the individual in an invalidating environment that causes the problem (e.g., distress, emotion dysregulation, distorted self-image, challenging interpersonal issues, and dysfunctional self-harming or risk-taking behaviors) (Daros et al., 2018; Vaughn, 2018). An invalidating environment is an environment in which the individual does not fit, it may be or may not be abusive. For instance, the individual with the heightened emotional sensitivity may feel somewhat like a lion cub born into a family of house cats and the invalidating/mismatched transactions over time lead to pervasive emotion dysregulation (Sheller, 2015).The core issue in DBT is pervasive emotion dysregulation.
That being said, DBT holds to a no-blame model (i.e., no one is at fault) (Linehan, 2015); rather it is the transactions between the individual and the invalidating environment that causes the problem. Thus, the biological sensitivity paired with the negative transactions in an invalidating environment causes the emotion dysregulation and tends to exacerbate symptoms which leads to negative patterns of maladaptive coping (Daros et al. 2018; Linehan; Vaughn, 2018). DBT seeks to identify these patterns and change them (Linehan).
In DBT, the social piece of the theory refers to problematic transactions over time for the individual in an invalidating environment that causes the problem (e.g., distress, emotion dysregulation, distorted self-image, challenging interpersonal issues, and dysfunctional self-harming or risk-taking behaviors) (Daros et al., 2018; Vaughn, 2018). An invalidating environment is an environment in which the individual does not fit, it may be or may not be abusive. For instance, the individual with the heightened emotional sensitivity may feel somewhat like a lion cub born into a family of house cats and the invalidating/mismatched transactions over time lead to pervasive emotion dysregulation (Sheller, 2015).The core issue in DBT is pervasive emotion dysregulation.
That being said, DBT holds to a no-blame model (i.e., no one is at fault) (Linehan, 2015); rather it is the transactions between the individual and the invalidating environment that causes the problem. Thus, the biological sensitivity paired with the negative transactions in an invalidating environment causes the emotion dysregulation and tends to exacerbate symptoms which leads to negative patterns of maladaptive coping (Daros et al. 2018; Linehan; Vaughn, 2018). DBT seeks to identify these patterns and change them (Linehan).
Meaning of Dialectics
ACCEPTANCE and CHANGE
"Dialectics" is a philosophical term that essentially means two things that seem like opposites can in fact both be true at the same time (Shaller, 2015). Dialectics is also a way of looking at reality (Linehan, 2015). Kress et al. (2021) define dialectics as the art of investigating the relative truth of principles, opinions, and guidelines. This is the theoretical premise or view from which DBT operates. Therefore, DBT relies on the idea that balance exists between acceptance and change (Kress et al.).
For example, in DBT, it is assumed that (1) everyone is doing the best they can, and (2) they also need to try harder, combined with the reality that (3) this really is how life is right now and (4) with change you really do have to try different things and be motivated to go after the life you want: Essentially, DBT it is a giant scale swaying back and forth trying to find this balance (Shaller, 2015).
DBT involves arriving at the truth by examining the argument and resolving the two contradictory beliefs into a rational synthesis in which the opposing concepts work together (Kress et al., 2021). Balancing dialectical dilemmas is a task of therapy. Dialectical dilemmas are behavorial patterns involving both over-regulation and under-regulation of emotional expression that need to be resolved: These dilemmas are recognized in therapy as consistent and common challenges for both borderline and other individuals who fluctuate between each end of the dilemma (Linehan, 2015, Vaughn, 2018).
For example, in DBT, it is assumed that (1) everyone is doing the best they can, and (2) they also need to try harder, combined with the reality that (3) this really is how life is right now and (4) with change you really do have to try different things and be motivated to go after the life you want: Essentially, DBT it is a giant scale swaying back and forth trying to find this balance (Shaller, 2015).
DBT involves arriving at the truth by examining the argument and resolving the two contradictory beliefs into a rational synthesis in which the opposing concepts work together (Kress et al., 2021). Balancing dialectical dilemmas is a task of therapy. Dialectical dilemmas are behavorial patterns involving both over-regulation and under-regulation of emotional expression that need to be resolved: These dilemmas are recognized in therapy as consistent and common challenges for both borderline and other individuals who fluctuate between each end of the dilemma (Linehan, 2015, Vaughn, 2018).
The Use of Dialectics in DBT
The use of dialectics in DBT helps the client to: (1) develop a broader perspective of their problem; (2) learn to look for the dialectic pole; (3) consider more options and possibilities; and (4) get “unstuck” and develop a sense of efficacy and competence (Kress et al., 2021).
For the DBT therapist, it is essential to recognize when they, themselves, also gets stuck in dialectical dilemmas. For instance, when working with suicidal clients, it is critical to recognize and understand that the client can want to both die and live simultaneously (dialectic poles); they are not mutually exclusive. The therapist needs to try to resist getting stuck focusing on one end or the other and balance their approach to help the client avoid suicidal behavior and yet simultaneously pursue a life worth living (Vaughn, 2018).
For the DBT therapist, it is essential to recognize when they, themselves, also gets stuck in dialectical dilemmas. For instance, when working with suicidal clients, it is critical to recognize and understand that the client can want to both die and live simultaneously (dialectic poles); they are not mutually exclusive. The therapist needs to try to resist getting stuck focusing on one end or the other and balance their approach to help the client avoid suicidal behavior and yet simultaneously pursue a life worth living (Vaughn, 2018).
DBT Assumptions
Are beliefs— about the Client, the Therapist, and Treatment (Linehan, 2015).
01
The client is doing the best they can and wants to improve
02
Clients need to do better, try harder, and be motivated to change
They may have not have caused all their problems but they need to solve them anyway.
03
The lives of suicidal borderline individuals are unbearable
Every day.
04
Clients must learn new behaviors in all relevant contexts and they cannot fail in therapy
If the client has come to therapy and tried—and the therapy is ineffective—then it may not be the right therapeutic approach, but the client has not failed!
05
Therapists need support
DBT is demanding and requires an empathic and genuinely understanding therapeutic relationship which may be quite challenging when treating chronically suicidal or self-harming individuals.
DBT Functions
Linehan (2015) articulates that DBT functions of treatment are designed to:
1
Enhance
an individual's capabilities by increasing skillful behavior.
2
Improve and Maintain
the client's motivation to change and to engage in treatment.
3
Ensure
that generalization of change occurs throughout treatment.
4
Enhance
a therapist's motivation to deliver effective treatment.
5
Assist
the individual in restructuring or changing his or her environment in such a way that it supports and maintains progress and advancement toward goals.
DBT Structure
A year long—weekly Format
Dbt's 3 Paradigms
DBT'S Acceptance, Change, and Dialectical Paradigms—are all based in behaviorism, mindfulness, and dialectical philosophy—to alter entrenched behavioral patterns and "get the patient out of hell" (Swenson & Linehan, 2016, p. 23).
RECOMMENDATIONS FOR THERAPIST'S UTILZING DBT'S 3 PARADIGMS
Swenson & Linehan (2016) recommend when shifting between acceptance, change, and dialectics in a session, the therapist should:
1
Stay focused
on the primary target which provides the overall agenda and shift to secondary targets (i.e., instrumental targets), as needed in order to accomplish the primary target.
2
Remain alert
for the presence of currently active emotions in the client, especially those emotions that are poorly regulated, emotional dysregulation is the core construct for understanding, and treating clients in DBT.
3
Keep interventions
consistent with guidelines found in: (a) biosocial theory, (b) therapist’s agreements, (c) assumptions about clients, (d) assumptions about therapy, and (e) the current stage of treatment.
4
Use
the structural strategies for structuring the sessions (e.g., beginning a session, targeting, a diary card, etc.).
5
Implement
the suicide crisis protocol if suicidal behavior is increased or imminent.
Goals of DBT
The overarching goal of DBT is to help the client create a “life worth living” rather than ending their life or bearing their unbearable existence (Linehan, 2015). Therefore, the day-to-day goal of DBT is to develop dialectical thinking and practice skills that result in emotion regulation, reduced suffering, and improved relationships (Kress et al., 2021). Linehan (2015) describes this as helping the client get out of hell. DBT helps the client to recognize how their attempts to avoid, deny, or escape strong emotions paradoxically makes those emotions more intense (Kress et al.). By helping clients accept their feelings, providing tools for emotion regulation, and decreasing emotional avoidance—through psychoeducation and exposure to upsetting situations and triggers—DBT empowers clients to increase their tolerance of distress and use coping skills such as meditation and mindfulness to regulate their emotions (Kress et al.).
THERAPIST's TARGETS FOR CLIENT'S IN STAGE 1
As the therapist helps the client eliminate and reduce problematic behaviors as well as learn new skills, these skills are reinforced in individual sessions and through inter-session contact (Vaughn, 2018).
Eliminate Life-Threatening Behaviors
Life-threatening behaviors includes suicidal thoughts, urges, and attempts, as well as self-harm. A behavior is life-threatening if it imminently threatens the client’s life (Linehan, 2015).
Learn More
Reduce Therapy-Interfering Behaviors
Therapy-interfering behavior is anything that gets in the way of the patient receiving therapy or makes it likely the treatment will end prior to completion (Linehan, 2015). Examples of these behaviors might include being late to sessions, missing sessions, not completing homework, failing to follow treatment recommendations, calling a therapist too frequently, or pushing or challenging the therapist limits (Vaughn, 2018).
Learn More
Reduce Quality-of-Life Interfering Behaviors
Quality-of-Life interfering behaviors are anything that interferes with the client creating their life worth living plan. Examples of this behavior include substance abuse, impulsive sexual behavior, impulsive spending, reckless activities or driving, and eating disorder behavior.
Learn More
Keep clients in the environment they are in
Therapist attempt to help the client use new skills in the environment they are in rather then sending them to a structured environment that does not exist in the outside world, such as a hospital or residential facility.
Increase Skills
through psycho-educational skills group, the client will learn how to self-validate, communicate effectively, ways in which they can regulate their emotions, how they can tolerate distress, and the formal practice of mindfulness. For example, Dr. Linehan (2019) recommends paced breathing as a holisitic anti-anxiety and emotion regulation technique for any client beginning DBT as well as continuous long-term use.
Learn MoreStages: The House of DBT
The client has the potential to progress through 4 stages in DBT (Reddy & Vijay, 2017).
Stage 1: May take anywhere from 3-12 months, but generally takes at least a year. The focus is on reducing suicidal, therapy-interfering, and quality-of-life-interfering behaviors, and improving behavioral skills.
Stage 2: Treating issues related with past trauma. For example, exposure techniques for post-traumatic stress disorder.
Stage 3: Development of self-esteem, reclaiming ordinary happiness, and improving day-to-day behavioral skills.
Stage 4: Development of capacity for optimum experiencing and finding a higher purpose.
Stage 2: Treating issues related with past trauma. For example, exposure techniques for post-traumatic stress disorder.
Stage 3: Development of self-esteem, reclaiming ordinary happiness, and improving day-to-day behavioral skills.
Stage 4: Development of capacity for optimum experiencing and finding a higher purpose.
DBT IN Action—Dr. Fruzzetti
Case Example 1—Dr. Fuzzetti (2016) demonstrates DBT with a client who is self-harming.
DBT in Action—Dr. Linehan
Case Example—Dr. Linehan (2017) works with a client who is self-harming when angry.
DBT in Action—alice's CAse
Case Example—A full session with Dr. Fruzzetti (2012) and Alice—a client with BPD
Regulation Versus Dysregulation
However, certain circumstances or experiences can negatively impact this developmental process, for instance: punitive or controlling parents, overwhelming childhood stress or trauma, emotional invalidation, a lack of secure attachment to parents, and differences in brain structure (Salter-Pedneault, 2021; Sutton, 2021). Disruption to the development of emotion regulation results in a reduced inability to understand, label, regulate, and tolerate emotional responses (Daros et al., 2018).
Individual’s experiencing emotion dysregulation often experience significant distress in emotional situations as they struggle with understanding their feelings and responding in healthy ways to challenging life events (Salter-Pedneault). According to DBT, emotions precede the development of thoughts, and once those neural networks associated with emotions begin to fire, they light up other neural networks and incite even stronger emotions (Kress et al., 2021). Once a pattern has been established, similar events may set off a “trigger” that results in repeated incidents of (1) intense emotion, (2) feelings of abandonment, and (3) a need to take action to stop the distressing emotions (Kress et al.).
Additionally, individuals with pervasive emotion dysregulation present with impaired adaptation to environmental demands and increased risk-taking behaviors (Huben et al., 2020). Huben et al. define risk-taking as a decision to engage in behavior for which there is uncertainty about its outcome and potential benefits or costs (e.g., reckless driving, risky sexual behaviors, compulsive gambling). Problematic behaviors may also emerge in the form of maladaptive coping mechanisms in an attempt to provide temporary relief that is ineffective in the long-term (e.g., binge-eating, self-injury, suicidal behavior) (Behavioral Tech, 2021a). Thus, weekly skills training in healthy coping strategies is a critical component of DBT in order to help the client build a life worth living (The Linehan Institute, 2021).
Mindfulness
Distress Tolerance
DBT distress tolerance refers to a set of skills for coping with uncomfortable emotions (Linehan, 2015).
Distress Tolerance
Distress Tolerance Skills help an individual navigate uncomfortable or painful situations and manage urges to engage in harmful behaviors. Linehan (2015) divides distress tolerance skills into three categories: crisis survival techniques, sensory body awareness, and reality acceptance.
Learn MoreDistress Tolerance Strategies
Impulsive and suicidal behaviors in DBT are considered maladaptive coping mechanisms resulting from the individual’s inability to tolerate distress long enough to pursue potentially more effective solutions. To counter these maladaptive behaviors, distress tolerance skills seek to aid the individual in coping with a crisis, through acceptance, distracting, and self-soothing strategies (Linehan, 2015).
Learn MoreDistress Tolerance Media
Click on the videos to learn more about self-soothing techniques, radical acceptance, and fighting impulsive urges.
Learn MoreEmotion Regulation
Understanding Emotion Regulation
Emotion regulation skills help one understand and reduce vulnerability to emotions as well as how to change emotions that an individual wants to change (Linehan, 2015).
Learn More
The Impact of Challenges with Emotion Regulation for Clients and their Families
Difficulties with emotion regulation include problems with recognizing emotions, with labeling and describing emotions, with avoidance of emotions, with what to do when an emotion is on the scene, and with managing rapidly shifting, volatile, or extremely intense emotions (Linehan, 2015). These challenges create a significant burden for clients and their families.
Learn More
Emotion Regulation Strategies
Emotion regulation skills (i.e., strategies) seek to help the client understand and name emotions and change emotional responses by (1) checking the facts, (2) doing the opposite action, and (3) problem solving as well as learning to be mindful of emotions of current emotions, and managing extreme emotions (Linehan, 2015).
Learn MoreInterpersonal Effectiveness
What Drew you to dbt?
Therapist's Roles
A DBT therapist is constantly dancing: Trying to make sure they really understand and ACCEPT where you are coming from whilst also pushing you to CHANGE when they can!
The DBT therapist is an equal partner with the client as a co-collaborator, in a transactional, reciprocal relationship, where the client learns from the therapist and vice versa, the therapist learns from the client (Kress et al., 2021; Tan, 2011; Vaughn, 2018).
Additionally, the therapist plays an active and directive role in therapy, often acting as coach, teacher, motivator/cheerleader, juggler, validator as well as a coping model (Tan, 2011). Therapy to some degree should always include an encouragement component (Kress et al., 2021), which is integral to DBT.
Although, a positive, warm, genuine, and collaborative therapeutic alliance is essential to DBT; the therapeutic relationship alone, is not considered sufficient for effective treatment to occur (Tan, 2011). Thus, structured and systematic interventions are implemented through a strong therapeutic relationship (Linehan, 2015).
The therapist engages in appropriate levels of self-disclosure (Shaller, 2015), openly provide instructions, suggestions, and constructive feedback (Tan, 2011), as well as offers positive reinforcements and verbal praise to the client whilst continuing to encourage the client to actively participate in goal-setting (i.e., what makes their life worth living) (e.g., perhaps, a more stable, happier romantic relationship, having one’s own residence or a pet, learning an instrument, maintaining employment) (Vaughn, 2018).
This will look different for each client and may change significantly over the course of treatment. Throughout therapy, the therapist emphasizes focusing on the immediate experience in the present moment, with acceptance— an open, curious, or receptive attitude— minus judgment, criticism, or an evaluative attitude (Linehan, 2015; Tan, 2011).
Ultimately, the therapist can positively influence the therapeutic process by believing that clients are motivated and capable of change and using that belief to instill hope and optimism during the process, as well as promoting an environment where clients feel safe discussing their struggles and new ways of being (Kress et al., 2021).
Additionally, the therapist plays an active and directive role in therapy, often acting as coach, teacher, motivator/cheerleader, juggler, validator as well as a coping model (Tan, 2011). Therapy to some degree should always include an encouragement component (Kress et al., 2021), which is integral to DBT.
Although, a positive, warm, genuine, and collaborative therapeutic alliance is essential to DBT; the therapeutic relationship alone, is not considered sufficient for effective treatment to occur (Tan, 2011). Thus, structured and systematic interventions are implemented through a strong therapeutic relationship (Linehan, 2015).
The therapist engages in appropriate levels of self-disclosure (Shaller, 2015), openly provide instructions, suggestions, and constructive feedback (Tan, 2011), as well as offers positive reinforcements and verbal praise to the client whilst continuing to encourage the client to actively participate in goal-setting (i.e., what makes their life worth living) (e.g., perhaps, a more stable, happier romantic relationship, having one’s own residence or a pet, learning an instrument, maintaining employment) (Vaughn, 2018).
This will look different for each client and may change significantly over the course of treatment. Throughout therapy, the therapist emphasizes focusing on the immediate experience in the present moment, with acceptance— an open, curious, or receptive attitude— minus judgment, criticism, or an evaluative attitude (Linehan, 2015; Tan, 2011).
Ultimately, the therapist can positively influence the therapeutic process by believing that clients are motivated and capable of change and using that belief to instill hope and optimism during the process, as well as promoting an environment where clients feel safe discussing their struggles and new ways of being (Kress et al., 2021).
DBT Behavior Chain Analysis
DBT chain analysis is utilized consistently throughout treatment to map out and assess instances of the client’s problematic behavior over a chronological continuum (Swenson, 2020).
For instance, a client’s dog is sick, the client worries that her dog might die, the client becomes fearful, the client then engages in a self-harming behavior. Or the client’s partner argues with her, the client worries her partner may leave, the client becomes consumed by fear, the client engages in a self- harming behavior.
With this information regarding patterns of behavior and identification of dysfunction, the client can begin to break the chain of destructive habits by replacing the dysfunctional links in the chain with DBT skills from the four main components of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness in order to make wiser choices, and have greater peace (Swenson, 2020).
Six Key Components to DBT CHain
(Swenson, 2020).
1
Vulnerability Factors
(i.e., what makes you vulnerable to the prompting event) (e.g., stress).
2
Prompting Event
(i.e., the event that sparked the chain that led to the target behavior) (e.g., sick dog).
3
Links
(i.e., behaviors and events between the prompting event and the target behavior, such as thoughts or emotions), (e.g., frustration, anger, anxiety, fear, panic, grief).
4
Target Behavior
(i.e., a specific dysfunctional behavior the client wants to change) (e.g., cutting, substance abuse, traumatic responses, dissociation).
5
Consequences
(i.e., the short-term and long-term consequences of the target behavior).
6
Solutions
(i.e., solutions you can use to change the behavior in the future.) (e.g., creating a functional replacement chain with the client and putting it into practice).
Formal ASsessment
Motivational Interviewing (MI) during the pre-treatment phase is a directive, client-centered counseling approach that may help a client assess and explore their ambivalence toward making change (Miller & Rollnick, 2012). MI may be particularly helpful for clients with co-occurring substance abuse or eating disorders (Kress et al., 2021).
Additionally, DBT utilizes a Demographic Data Scale (DDS) as a self-reporting questionnaire to gather extensive demographic information on the client that will impact implementation of culturally-appropriate adaptations or emphasis (Linehan, 1982 as cited in University of Washington: Center for Behavioral Technology [UWA], 2021).
The Treatment History Interview (THI) gathers detailed information about a client’s psychiatric and medical treatment over a desired period of time (Linehan & Heard, 1987as cited in UWA, 2021).
Next, the therapist will utilize the Suicidal Behavior Questionnaire (SBQ), which is a self-report questionnaire designed to assess suicidal ideation, suicide expectancies, suicide threats and communications, and suicidal behavior (Addis & Linehan, 1989 as cited in UWA, 2021).
The Lifetime-Suicide-Attempt Self-Injury Count (L-SASI) is an interview to obtain a detailed lifetime history of non-suicidal self-injury and suicidal behavior (Linehan & Comtois, 1996 as cited in UWA, 2021).
The Substance Abuse History Interview (SAHI) is an interview to assess periods of drug use (by drug), alcohol use, and abstinence in a client’s life over a desired period of time (McLellan et al, 1980; Sobbell et al., 1987 as cited in UWA, 2021).
The Social History Interview (SHI) is an interview to gather information about a client’s significant life events over a desired period of time. It was developed by adapting and modifying the psychosocial functioning portion of both the Social Adjustment Scale-Self Report (SAS-SR) and the Longitudinal Interview Follow-up Evaluation Base Schedule (LIFE) to assess a variety of events (e.g., jobs, moves, relationship endings, jail) during the target timeframe. Using the LIFE, functioning is rated in each of 10 areas (e.g., work, household, social interpersonal relations, global social adjustment) for the worst week in each of the preceding four months and for the best week overall. Self-report ratings using the SAS-SR are used to corroborate interview ratings (Weismann & Bothwell, 1976; Keller et al., 1987 as cited in UWA, 2021).
The Linehan Risk Assessment & Management Protocol (LRAMP) is utilized throughout therapy in an on-going manner whenever the client presents with increased suicidality (Linehan, 2009 as cited in UWA, 2021).
Diary cards also play an integral role in the client self-assessing urges, moods, behaviors, and usage of skills which aids the client and therapist in identifying patterns of maladaptive functioning in order to generate targets and make adjustments toward weekly and long-term goals (Linehan, 2015).
Additionally, DBT utilizes a Demographic Data Scale (DDS) as a self-reporting questionnaire to gather extensive demographic information on the client that will impact implementation of culturally-appropriate adaptations or emphasis (Linehan, 1982 as cited in University of Washington: Center for Behavioral Technology [UWA], 2021).
The Treatment History Interview (THI) gathers detailed information about a client’s psychiatric and medical treatment over a desired period of time (Linehan & Heard, 1987as cited in UWA, 2021).
Next, the therapist will utilize the Suicidal Behavior Questionnaire (SBQ), which is a self-report questionnaire designed to assess suicidal ideation, suicide expectancies, suicide threats and communications, and suicidal behavior (Addis & Linehan, 1989 as cited in UWA, 2021).
The Lifetime-Suicide-Attempt Self-Injury Count (L-SASI) is an interview to obtain a detailed lifetime history of non-suicidal self-injury and suicidal behavior (Linehan & Comtois, 1996 as cited in UWA, 2021).
The Substance Abuse History Interview (SAHI) is an interview to assess periods of drug use (by drug), alcohol use, and abstinence in a client’s life over a desired period of time (McLellan et al, 1980; Sobbell et al., 1987 as cited in UWA, 2021).
The Social History Interview (SHI) is an interview to gather information about a client’s significant life events over a desired period of time. It was developed by adapting and modifying the psychosocial functioning portion of both the Social Adjustment Scale-Self Report (SAS-SR) and the Longitudinal Interview Follow-up Evaluation Base Schedule (LIFE) to assess a variety of events (e.g., jobs, moves, relationship endings, jail) during the target timeframe. Using the LIFE, functioning is rated in each of 10 areas (e.g., work, household, social interpersonal relations, global social adjustment) for the worst week in each of the preceding four months and for the best week overall. Self-report ratings using the SAS-SR are used to corroborate interview ratings (Weismann & Bothwell, 1976; Keller et al., 1987 as cited in UWA, 2021).
The Linehan Risk Assessment & Management Protocol (LRAMP) is utilized throughout therapy in an on-going manner whenever the client presents with increased suicidality (Linehan, 2009 as cited in UWA, 2021).
Diary cards also play an integral role in the client self-assessing urges, moods, behaviors, and usage of skills which aids the client and therapist in identifying patterns of maladaptive functioning in order to generate targets and make adjustments toward weekly and long-term goals (Linehan, 2015).
Links to Formal DBT Assessments
Formal Assessments Made Available to DBT Therapists Through the University of Washington's Center for Behavioral Technology and Research (2021).
(1) Linehan Risk Assessment & Management Protocol (LRAMP)
(2) BORDERLINE SYMPTOM LIST (BSL) | Scoring Instructions
(3) DBT-WCCL SCALE AND SCORING | Scoring Values
(4) Demographic Data Scale (DDS)
(5) NIMH S-DBT Diary Card (includes instructions)
(6) NIDA Diary Card (includes instructions)
(7) CARES Diary Card
(8) Imminent Risk and Action Plan
(9) Lifetime Suicide Attempt Self-Injury | Instructions | Scoring
(2) BORDERLINE SYMPTOM LIST (BSL) | Scoring Instructions
(3) DBT-WCCL SCALE AND SCORING | Scoring Values
(4) Demographic Data Scale (DDS)
(5) NIMH S-DBT Diary Card (includes instructions)
(6) NIDA Diary Card (includes instructions)
(7) CARES Diary Card
(8) Imminent Risk and Action Plan
(9) Lifetime Suicide Attempt Self-Injury | Instructions | Scoring
