Capstone: Dialectical Behavior Therapy Skills in Individual Therapy
November 9, 2020
Dialectical Behavior Therapy Skills in Individual Therapy
Borderline personality disorder (BPD) is a complex and severe mental illness that is marked by patterns of instability with interpersonal relationships, affect, self-image, and dysregulation with behavior (Fassbinder et al., 2018). Individuals with BPD may have increased levels of undifferentiated and negative affect, decreased emotional regulation, high reactivity and sensitivity to emotions, and a longer affective activation (Kramer, 2017). It has been thought that BPD is difficult to treat with it having increased suicide attempts, self-harm, hospitalizations, and rates of failure of treatment (Little et al., 2018). Borderline personality disorder has been estimated to affect 2-6% of the general population, 8-11% of those receiving outpatient treatment, and 15-20% of those who are in psychiatric inpatient care (Carson-Wong et al., 2018; Rizvi et al., 2013). Among those diagnosed with BPD, rates of self-harm are higher with 69% to 80% who engage in nonsuicidal self-injury, an estimated 75% have attempted suicide at least once, and up to 10% who have died by suicide compared to just 1.9-8.7% of the general population (Carson-Wong et al., 2018; Rizvi et al., 2013). Individuals with BPD also have used more psychiatric and treatment services compared to individuals with other personality disorders and major depressive disorders (Carson-Wong et al., 2018).
Individuals who are diagnosed from BPD are also at risk of comorbidities with other mental disorders due to BPD affecting all aspects of life and being associated with impairments in quality of life in mental, social, and physical dimensions, difficulties with social functioning and participation, as well as high societal costs (Fassbinder et al., 2018). Feigenbaum (2007) reported that it is hypothesized that those who have BPD have heightened emotional response systems which can be due to biological vulnerabilities or trauma and neglect from early childhood experiences that could have resulted in changes to the development of neural structures associated with emotional regulation, behavioral dyscontrol, social cognitive deficits, and affect dysregulation. These changes can then lead to an emotional system that responds with increased speed and strength to environmental stimuli and causing increased behavioral and cognitive dysregulation. This heightened emotional arousal can reduce the effectiveness of cognitive processing systems and result in decreased problem solving, ability to recall coping strategies, and ability to consider consequences of actions (Feigenbaum, 2007). Cognitive confusion and emotional arousal can lead individuals to act impulsively in order to reduce the feelings of emotional intensity, but long-term consequences may include additional emotional arousal like shame or self-disgust (Feigenbaum, 2007).
According to Feigenbaum (2007), BPD is a dysfunction of the emotion regulation system that is linked to systems involving cognition, behavior, interpersonal communication, and self-identity. Areas of dysregulation in BPD include affective dysregulation, behavioral dysregulation, interpersonal dysregulation, self-dysregulation, and cognitive dysregulation. Affective dysregulation involves instability due to mood reactivity, intense and appropriate anger, and difficulty with controlling anger. Interpersonal dysregulation includes efforts to avoid rejection or abandonment and a pattern of intense and unstable relationships characterized by both devaluation and idealization of the partner. Self-dysregulation consists of disturbances in identity, unstable sense of self or self-image, and chronic emptiness. Cognitive dysregulation involves dissociative symptoms or stress-related paranoid ideation. Dysfunction in any one of these systems can exacerbate problems in other systems.
The biopsychosocial model of BPD posits that borderline personality disorder is a lasting disorder in one’s emotion regulation system and the behaviors in the BPD criterion are a means to regulate emotions and can be seen as a natural consequence of the dysregulation (Linehan & Wilks, 2015). Feigenbaum (2007) adds that invalidating environments, especially in early life, can result in distrust in one’s own emotional reactions to events and foster self-invalidation. An individual may feel that they are alone and are unable to manage or understand their own experiences and can lead to decreased self-efficacy, dependency, or increased help-seeking behaviors.
Due to the high prevalence rates and the associated stress of working with those that are diagnosed with BPD, there is a need for effective interventions for this population (Rizvi et al., 2013). Borderline personality disorder was viewed as being untreatable in the past, but treatments today have been shown to be effective for treating BPD (Fassbinder et al., 2018). Transference-focused therapy, schema-focused therapy, mentalization-based therapy, cognitive-analytical therapy, interpersonal-analytical therapy, and dialectical behavior therapy have been shown to be effective in the treatment of borderline personality disorder (Andión et al., 2012). Out of these treatment modalities, dialectical behavior therapy (DBT) has the most comprehensive and strongest empirical support and is widely used in clinical practice (Andión et al., 2012; Little et al., 2018).
Dialectical Behavior Therapy
Dialectical behavior therapy was initially developed for individuals with high-risk, complex, and multi-diagnostic disorders (Linehan & Wilks, 2015), and it is structured and manualized based on the cognitive-behavioral approach (Andión et al., 2012). DBT’s success with BPD and suicidal behavior has led to adaptations and extensions for treatment with other conditions that involve emotion dysregulation (Bedics et al., 2013). This treatment modality has elements of behavioral techniques, cognitive, restructuring, mindfulness practice, validation, and dialectical philosophy principles (Andión et al., 2012). BPD is grounded on behaviorism with elements from the principles of Zen and dialectical philosophy (Bedics et al., 2013). Therapists are trained to provide skills for helping clients increase awareness of emotions, tolerance and management of intense emotions effectively, and prevention of emotions from escalating to uncontrollable intensities (King et al., 2019).
Dialectical behavior therapy is grounded on the biopsychosocial theory of BPD and posits that the disorder is developed when an emotionally sensitive individual ignores, suppresses, or punishes their emotions due to invalidating environments. This cycle of invalidation and dysfunctional reactions increases emotional sensitivity further and hinders the development of skills required to regulate one’s emotions (Barnicot et al., 2015). In the DBT model, individuals who are diagnosed with BPD are assumed to lack interpersonal and self-regulation skills, and personal and environmental factors play a role in frequently limiting the use of behavioral skills or reinforcing maladaptive behaviors. Through treatment, DBT then promotes the learning of new skills and the application of them across different contexts (Feigenbaum, 2007).
Dialectical philosophy in DBT is rooted in the principles of acceptance and change. Problem-solving strategies and validation strategies are based on this dialectic where therapists help clients accept their circumstances but also promote ways in which the client can change (Swales, 2009). Problem-solving strategies include skills training where clients learn new and effective coping styles, contingency management, exposure procedures, and cognitive modification (Bedics et al., 2013). Validation in DBT helps to foster the relationship between therapist and client and helps the client start to see themself from a different view (Bedics et al., 2013). It helps the client take a nonjudgmental stance toward themself and help them gain the capacity to self-validate. Validation in DBT has six stages and the higher stages have shown to be effective in increasing positive affect while decreasing negative affect (Carson-Wong et al., 2018). Levels 1 through 3 merely communicate to the client that the therapist hears what they are saying, and levels 4-6 help normalize the client’s thoughts, behaviors, or feelings (Carson-Wong et al., 2018). Level 1 includes listening and observing; level 2 includes accurate reflection; level 3 involves articulating the unverbalized; level 4 validates the client in terms of past events; level 5 validates the client through terms of their current circumstances; and level 6 is radical genuineness where the therapist treats the client as capable, effective, not fragile, and reasonable much like one would talk to an equal or a friend (Feigenbaum, 2007). The use of validation is present in most therapies, but DBT explicitly includes validation strategies and is considered important in treatment (Carson-Wong et al., 2018).
Dialectical behavior therapy has shown to be effective in multiple randomized controlled studies, and is one of the leading treatments recommended by the American Psychological Association and the U.K. Department of Health (Feigenbaum, 2007) . There are statistically significant improvements compared to treatment as usual (TAU), reductions in severity and frequency of self-harm, suicidality, anger, anxiety, depression, length and frequency of hospitalizations, increased treatment retention, improved global functioning (Andión et al., 2012; Barnicot et al., 2015; Little et al., 2018; Panepinto et al., 2015; Rizvi et al., 2013); reduction in impulsive BPD behaviors, sustained improvements at end of treatment and 18-month follow-up (Andión et al., 2012); and reductions in hopelessness, violence, anger, and improved social adjustment (Panepinto et al., 2105). DBT has also shown to be effective in short term inpatient programs (Feigenbaum, 2007) and 6-month courses to reduce self-harm behaviors, hopelessness, depression, and number of hospitalizations (Rizvi et al., 2013). According to Little et al. (2018), the positive outcomes of DBT are influenced by increased hope, learning and using of the new skills, taking responsibility for change, and effecting change by the therapeutic relationship. They also reported that clients who participated in DBT perceived therapy as changing their lives progressing from hopelessness to having hope for the future.
The focus of DBT is to help clients attain a “life worth living” (Linehan & Wilks, 2015) and has five key aims which include (1) increasing motivation for change and using skills; (2) teaching skills for effective behavior and emotion regulation; (3) supporting clients to be able to generalize the skills to a variety of environments and contexts; (4) helping create an environment that reinforces usage of the skills; and (5) increasing the therapist’s own skills and their motivation to continue working with clients (Little et al., 2018). By increasing coping strategies, DBT targets four key problem areas including confusion about one’s self, emotion dysregulation, impulsivity, and interpersonal chaos (Panepinto et al., 2015).
Rizvi et al. (2013) state that DBT’s popularity may be due to strong empirical support, and the integration of biological, social-environmental, spiritual, and behavioral domains in one treatment appeals to different backgrounds. Its synthesis of both acceptance and change strategies and practical and sophisticated theoretical strategies support both the client and the therapist, and thus increases satisfaction with the program and effectiveness. According to Linehan & Wilks (2015), in order for DBT to be effective, treatment had to be based on principles and be flexible rather than complying with highly structured protocols. The modularities in DBT can be separated into independent modules that can be catered to differences in client needs. DBT has been adapted into treatment for substance abuse, eating disorders, depression, ADHD, other personality disorders, suicidal and aggressive behaviors, adolescents, the elderly, correctional settings, and many others (Rizvi et al., 2013).
Skills Training
Skills are the primary emphasis to help clients replace ineffective or maladaptive behaviors with effective coping strategies and responses (Linehan & Wilks, 2015). The four skills modules are mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. Change skills are emphasized in the interpersonal effectiveness and emotion regulation modules while acceptance skills are emphasized in the mindfulness and distress tolerance modules (Linehan & Wilks, 2015). These DBT skills were developed from social psychology, spiritual teachings, or adaptations based on evidence-based treatments. New skills are developed and modified based on clinical need or advancement in research; skills in DBT will adapt to address novel challenges and improve treatment outcomes as new research comes (Linehan & Wilks, 2015).
Mindfulness. The mindfulness module is the most important skill as all other modules are grounded in this practice. It has been reported as the most frequently used skill among patients with BPD and is associated with changes in the activation of areas in the brain involved with emotion regulation (Feliu et al., 2014). Mindfulness is based on Zen and other contemplative practices and adapted into behavioral skills that could be used in therapy (Linehan & Wilks, 2015). In DBT, clients are taught three what and three how skills of mindfulness. What you do when practicing mindfulness include observing, describing, and participating. How you practice mindfulness is being nonjudgmental, one-mindful, and effective (Linehan & Wilks, 2015). Practicing mindfulness has been linked to improvements in emotion regulation and helps the client take a non-judgmental stance, focusing on one thing in the present, and being capable to identify what is effective (Feigenbaum, 2007).
Distress Tolerance. The distress tolerance module also rests on acceptance strategies. Instead of placing focus on changing one’s behaviors, this teaches clients to be able to accept, find meaning, and tolerate the distress that they may feel. Techniques in this module include delayed gratification strategies and self-soothing techniques with a focus on surviving the present moment without making the situation worse (Linehan & Wilks, 2015).
Emotion Regulation. Increasing clients’ ability to manage their emotions effectively is a possible central mechanism of change in DBT (Kramer, 2017). Training in emotion regulation offers clients a variety of behavioral and cognitive strategies to decrease ineffective emotional responses and increase wanted emotions (Linehan & Wilks, 2015). Emotion regulation skills training identifies emotional vulnerability, prompting events, appraisal and interpretation of cues, neurochemical, physiological, experiential response tendencies and action urges, nonverbal and verbal actions and responses, and the consequences of the initial emotion including secondary emotions (Linehan & Wilks, 2015). Clients are able to withstand their emotional pain and have the opportunity to choose different responses to emotions and events that are more in line with their goals through awareness (King et al., 2019).
Interpersonal Effectiveness. Training in interpersonal effectiveness teaches clients how to better manage interpersonal conflicts, develop friendships, end destructive relationships, and reinforce their environment effectively. The skills in interpersonal effectiveness are grounded from research in assertiveness training and equips clients with better behaviors and responses to manage relationships with others (Linehan & Wilks, 2015). The module helps clients clarify their priorities, be effective in asserting their rights and wishes, and behave in ways to maintain positive relationships that make others feel valued yet keeping one’s own self-respect.
DBT Skills in Individual Therapy
DBT has been shown to be effective by numerous studies, but the application of standard DBT, which includes individual therapy, group skills training, telephone coaching, and consultation, can be a financial burden to many institutions. Studies have also shown that DBT can be adapted to where a single therapist can provide both skills training and individual therapy and can be a well structured and more cost effective therapeutic option for places where standard DBT is not feasible (Andión et al., 2012). DBT skills alone have been shown to reduce suicidality and gains in skills acquisition among college students (Panepinto et al., 2015) and has shown to build resilience across work or school settings (Linehan & Wilks, 2015). The mindfulness module alone also decreased depressive symptomatology and psychiatric severity after intervention (Feliu et al., 2014). Rizvi et al. (2017) also concluded that even novice DBT clinicians can be effective in providing treatment while it is being learned. The structure, function, and degree of flexibility of DBT in adapting treatment to different circumstances is promising in its potential efficacy in individual therapy.
Application of DBT Skills Training in Individual Therapy
The present client is a 29-year-old female who has been diagnosed with borderline personality disorder. The client has shown a pervasive pattern of instability in their interpersonal relationships, self-image, and affect and impulsive behaviors in different contexts from a young age. The client grew up with abusive parents and little social and financial support. The client experiences trauma from their invalidating and abusive childhood and is reluctant to speak about the past. The client presently lives with their 8-year-old daughter and is a single mother. The client is dependent on government assistance due to not being able to keep a job because of BPD. The present client has received their GED and is now in the process of pursuing an Associate’s Degree.
The client does not have any underlying physical conditions but has been in mental health treatment since adolescence. The client has had numerous inpatient admissions for self-harm but has been generally stable for the past year. The client exhibits preoccupation with abandonment among people in their life including significant others and friends. The client alternates between idealization and devaluation of their typically intense relationships. The client has an unstable sense of self and is constantly second-guessing their feelings and actions. The client exhibits occasional impulsivity in regards to spending, binge eating, and other potentially self-damaging behaviors. The client exhibits affective instability due to mood reactivity and chronic feelings of emptiness. The client sometimes displays inappropriate, intense, and uncontrollable anger towards others and exhibits transient, stress-related paranoid ideations.
Client’s functional impairments include inadequate work functioning; chronic, uncontrolled, and severe mood instability; impulsiveness; and frequent poor choices, along with depressive symptoms when mood is significantly low. Client’s subjective impairment alternates between feeling like there is nothing they can do for their situation and feeling like they are able to overcome any obstacle they may encounter. The problem complexity of the present client is dynamic, continuous, and episodic. The reluctance of the client to process negative feelings in the past may hinder growth. Due to the client’s diagnosis, their readiness to change can cycle between all the stages, from precontemplation through maintenance but is often in the contemplation stage. The client may at times resist therapeutic influence due to feelings of abandonment, but the therapist may overcome this by providing high levels of validation and radical acceptance combined with an irreverent view of the problem, with irreverence in DBT meaning matter-of-fact, straightforward and clear manner of discussion which can elicit change. The client’s social support includes their significant other and a few close friends with whom they interact on a daily basis. The client’s coping styles include humor, distancing, escape-avoidance, self-distraction, venting, and impulsivity with self-harming and/or destructive behaviors. The client’s current mental status is normal with blunted affect and mood; normal speech and thought; no perceptual disturbances; oriented to place, time, and person; normal memory and intelligence; and normal appearance. The client currently does not pose a risk of harm to self or others.
Goals
The three initial goals that client and internship student agreed upon were based on time-limited, measurable, and behaviorally specific goals. These goals were (1) replace negative thoughts about self with positive affirmations at least three times a day for one week; (2) identify and interrupt the progression of ruminative thinking at least once a day for a week with distracting but healthy and self-enriching activities; and (3) practicing a mindfulness technique for at least five minutes once a day for a week.
Interventions
During the sessions, the internship student conveyed high levels of validation and radical acceptance to the client and took an irreverent stance to problems that the client faced. Acceptance of the client’s situation but at the same time helping the client with problem-solving strategies helped to elicit change. Mindfulness practices were introduced to the client including the what and how of mindful practice, breathing exercises, body scan meditation, and being in the present moment using the five senses. Distress tolerance skills were discussed including The Stop Skill (stop, take a step back, observe, proceed mindfully), paired muscle relaxation (tensing and relaxing each part of the body), listing distracting yet healthy activities, and sensory awareness. Emotion regulation was also introduced through an emotion wheel and using the Identifying and Describing Emotions Worksheet which helps the client identify the exact emotion they are feeling, the prompting event, the reactions that they had, and what would be a more effective reaction or behavior to replace with any self-destructive responses.
Outcome
The internship student was able to create a positive therapeutic alliance with the client through validation and acceptance strategies. The client was open and excited to try DBT skills therapy and was eager to try the new skills learned in the sessions. In subsequent sessions, the client reported feeling more empowered with having more effective and healthy coping styles to use in response to uncontrollable, intense feelings. The client also feels that the contingency management factor helps prevent making situations worse. The client understands that it takes time to develop the skills and continuous practice in order to master them, but feels that the DBT skills are a needed and useful contribution to their repertoire of coping strategies. Unfortunately, the length of time the internship student had with the client was insufficient to gather more qualitative data, but it is promising and hopeful that DBT skills training can be effectively applied in individual therapy in a mental health community setting.
References
Andión, Ó., Ferrer, M., Matali, J., Gancedo, B., Calvo, N., Barral, C., Valero, S., Di Genova, A., Diener, M. J., Torrubia, R., & Casas, M. (2012). Effectiveness of combined individual and group dialectical behavior therapy compared to only individual dialectical behavior therapy: A preliminary study. Psychotherapy, 49(2), 241–250. https://doi.org/10.1037/a0027401.supp (Supplemental)
Barnicot, K., Couldrey, L., Sandhu, S., & Priebe, S. (2015). Overcoming barriers to skills training in borderline personality disorder: A qualitative interview study. PLoS ONE, 10(10). https://doi.org/10.1371/journal.pone.0140635
Bedics, J. D., Korslund, K. E., Sayrs, J. H. R., & McFarr, L. M. (2013). The observation of essential clinical strategies during an individual session of dialectical behavior therapy. Psychotherapy, 50(3), 454–457. https://doi.org/10.1037/a0032418
Carson-Wong, A., Hughes, C. D., & Rizvi, S. L. (2018). The effect of therapist use of validation strategies on change in client emotion in individual dbt treatment sessions. Personality Disorders: Theory, Research, and Treatment, 9(2), 165–171. https://doi.org/10.1037/per0000229
Fassbinder, E., Assmann, N., Schaich, A., Heinecke, K., Wagner, T., Sipos, V., Jauch-Chara, K., Hüppe, M., Arntz, A., & Schweiger, U. (2018). PROBPD: Effectiveness of outpatient treatment programs for borderline personality disorder: A comparison of schema therapy and dialectical behavior therapy: study protocol for a randomized trial. BMC Psychiatry, 18. https://doi.org/10.1186/s12888-018-1905-6
Feigenbaum, J. (2007). Dialectical behaviour therapy: An increasing evidence base. Journal of Mental Health, 16(1), 51–68. https://doi.org/10.1080/09638230601182094
Feliu, S. A., Pascual, J. C., Borràs, X., Portella, M. J., Martín, B. A., Armario, A., Alvarez, E., Pérez, V., & Soler, J. (2014). Effects of dialectical behaviour therapy‐mindfulness training on emotional reactivity in borderline personality disorder: Preliminary results. Clinical Psychology & Psychotherapy, 21(4), 363–370. https://doi.org/10.1002/cpp.1837
King, A. M., Rizvi, S. L., & Selby, E. A. (2019). Emotional experiences of clients with borderline personality disorder in dialectical behavior therapy: An empirical investigation of in-session affect. Personality Disorders: Theory, Research, and Treatment, 10(5), 468–472. https://doi.org/10.1037/per0000343
Kramer, U. (2017). The role of coping change in borderline personality disorder: A process‐outcome analysis on dialectical‐behaviour skills training. Clinical Psychology & Psychotherapy, 24(2), 302–311. https://doi.org/10.1002/cpp.2017
Linehan, M. M., & Wilks, C. R. (2015). The course and evolution of dialectical behavior therapy. American Journal of Psychotherapy, 69(2), 97. https://doi.org/10.1176/appi.psychotherapy.2015.69.2.97
Little, H., Tickle, A., & das Nair, R. (2018). Process and impact of dialectical behaviour therapy: A systematic review of perceptions of clients with a diagnosis of borderline personality disorder. Psychology and Psychotherapy: Theory, Research and Practice, 91(3), 278–301. https://doi.org/10.1111/papt.12156
Panepinto, A. R., Uschold, C. C., Olandese, M., & Linn, B. K. (2015). Beyond borderline personality disorder: dialectical behavior therapy in a college counseling center. Journal of College Student Psychotherapy, 29(3), 211–226. https://doi.org/10.1080/87568225.2015.1045782
Rizvi, S. L., Hughes, C. D., Hittman, A. D., & Vieira Oliveira, P. (2017). Can trainees effectively deliver dialectical behavior therapy for individuals with borderline personality disorder? Outcomes from a training clinic. Journal of Clinical Psychology, 73(12), 1599–1611. https://doi.org/10.1002/jclp.22467
Rizvi, S. L., Steffel, L. M., & Carson-Wong, A. (2013). An overview of dialectical behavior therapy for professional psychologists. Professional Psychology: Research and Practice, 44(2), 73–80. https://doi.org/10.1037/a0029808
Swales, M. A. (2009). Dialectical behaviour therapy: Description, research and future directions. International Journal of Behavioral Consultation and Therapy, 5(2), 164–177.