Dialectical Behaviour Therapy - Research Paper Example

? Dialectical Behaviour Therapy Even though there are many treatment options for treating psychological disorders, none of them found to be 100% effective. Psychotherapy or cognitive behaviour therapy has its own limitations in treating people with chronic mental problems. Dialectical Behavioural Therapy (DBT) was evolved during the late 1970’s by combining cognitive behavioural therapy with Buddhist meditation practice and Eastern meditation practice. Dialectical behavioural therapy believes that the thoughts of a person is controlled by two opposing forces; one towards the negative direction and the other towards the positive direction. When these opposite forces are balancing each other, the person may behave normally. In all the other cases the person may behave abnormally which is the reasons for most of the psychological problems. In order to treat such psychological problems, the dominating force should be regulated or controlled in such a way that both the negative force and the positive force are equal in magnitude, which is the core principle of DBT. DBT found to be effective in the treatment of borderline personality disorders (BPD), bipolar disorders such as substance abuse, suicide tendency etc. Moreover it is easy to treat even chronic patients with the help of DBT. This paper analyses the history, development and major characteristics of DBT as the prominent psychotherapy for treating patients with severe mental problems like BPD, substance abuse, suicide tendency etc. Dialectical Behavioural Therapy “Dialectic behaviour therapy (DBT) is cognitive behavioural treatment originally designed by Marsha Linehan (1993) as an outpatient treatment for people diagnosed with borderline personality disorder” (Sakdalan et al, 2010, p.568). It is developed in conjunction with the Buddhist meditative practice. Marsha M. Linehan, a Washington University psychologist, developed this most modern therapy for many of the psychological disorders by combining the positive elements of Cognitive Behavioral Therapy (CBT) with the Buddhist meditative practice. DBT is found to be most effective in the treatment of Bipolar disorders. The drawbacks of Cognitive behavioral therapy in treating BPD patients haves been corrected in DBT with the help of the principles of Buddhist meditative practice to make it the number one treatment for BPD’s at present. In fact DBT is the first psychotherapy found to be effective in the case of patients with bipolar disorder. Mood disorders, causing self-injury, sexual abuse, substance abuse etc are some other behavioral problems which can be treated with the help of DBT. Even though DBT involves most of the elements of CBT, there are certain differences in the approach. In CBT, the therapist behaves like an adversary whereas in DBT, the therapist acts as an ally. In other words, patients feel much more confidence while undergoing DBT. CBT involves both individual and group components. Individual sessions with the therapist, group skill development training phone coaching etc are some of the major characteristics of DBT. History and development of DBT During the late 1970’s psychologists like Marsha M. Linehan tried to develop a new treatment option for borderline personality disorders as they found that the existing CBT has certain limitations in treating BPD’s. They heard about the Buddhist meditative practice during this period and tried to incorporate the positive elements of it with CBT. Buddhist meditative practice believes that everything is constructed by opposing forces or dialectics. “Dialectics is the method of reasoning which aims to understand things concretely in all their movement, change and interconnection, with their opposite and contradictory sides in unity”(Di, n. d). In other words, the balancing of two opposing forces is making a person in the normal or neutral state. If any of the force happens be stronger, the person’s mind tends to travel in that direction. In order to bring the person back to the normal state, the dominating force should be brought back to its original state. Linehan and his colleagues found the above philosophy of dialectics attractive and effective in treating patients with mental disorders and they succeeded in developing a new stream of treatment called DBT in treating mental problems. In DBT, the therapists try to identify the dominating force and try to reduce it to its original level. Major concepts of DBT Conceptualized as a comprehensive and multicomponent approach for problems related to pervasive emotion dysregulation, DBT, unlike many treatments in the cognitive-behavioural tradition, does not provide a session-by-session protocol for the delivery of treatment. Instead, it is principle driven, which utilizes some protocols. The functions of treatment are broad and help maximize the versatility of its application across a wide range of clinical settings and for patients with varying degrees and types of psychopathology (Wheelis, 2010, p. 327) In cognitive behavior therapy, the therapist conducts several counseling sessions or free associations with the patient in order to know the causes of the disease and also to educate the patient about the remedial measures. In other words, the treatment develops session by session in cognitive behavior therapy. On the other hand in DBT, the therapist tries to modify the behavior and thinking process of the patient with the help of certain protocols. When a person thinks about something, he analyzes both pros and cons of that thing before making any conclusion. If no biasing or prejudices are there, he will analyze the matter in a neutral manner and will take the correct decisions. In the case of mental patients, negative thinking will override the positive thinking process. In other words, they will think more about the negative aspects of a thing and forget about thinking about the positive sides of that thing. Thus, they will always be directed by negative energy which will be reflected in their behaviors will reflect it. DBT tries to bring back the equilibrium state or the normal state of the person by encouraging the person to think more about positive things. According to Dimef & Linehan (2001), “DBT enhances behavioral capabilities, improve motivation to change, assures that new capabilities generalize to the natural environment, structures the natural environment and enhances therapist capabilities and motivation to treat clients effectively” (Dimef & Linehan, 2001, p.1). Most of the mental patients live in their own world, a world filled with negative energy. They will make a strong barrier or wall around their negative world in order to protect it from the intrusion of positive energy. Breaking of this barrier is necessary for the effective treatment of mental patients and DBT accomplishes that with the help of suitable protocols. DBT not only motivates the patient to break the barrier, but also it helps the therapist to formulate suitable strategies to each patient based on the nature of the disease. “DBT is designed to treat clients at all levels of severity and complexity of their disorders” (Dimef & Linehan, 2001, p.2). Unlike CBT, DBT can be used in all cases of mental disorders irrespective of the complexity of the disease. CBT cannot be applied to a patient if he is in a violent mood or his disease is in chronic state. In an excited state, no mental patient will show readiness either to speak or to listen. Speaking and listening or the bi-directional communication is the core of CBT. The therapist will seek the assistance of a psychiatrist in order to calm down the patient first with the help of medications or sedations. Only after the patient shows some readiness to speak or listen, the therapist will start the CBT session. As mentioned earlier, DBT is the combinational treatment of CBT and Buddhist mindfulness mediation. It also includes the Easter meditative traditions. In the case of DBT, the therapist establishes a strong relationship with the patient first in order to force acceptance and changes in the minds of the patient later. “The DBT program is an adult outpatient treatment program that offers individual therapy and skills training groups. Primary care doctors, psychiatrists, social workers, and psychologists within the hospital system refer patients to this program” (Jacobo et al, 2007, p.76). As mentioned earlier, DBT contains both individual and group component. In the individual component, the therapist and the patient give priority to the aggressive behaviors such as suicidal tendency, violence etc first and discusses the ways to avoid it. After settling such behaviors, the therapist then focuses his attention to the behaviors of the patient which causes problems to others. During the last stages of therapy, the therapist focuses more on improving the skills needed to lead a quality life by the patient. In short, during the individual therapy, the therapist and the patient discuss the problems one by one and analyses the ways to solve it. Moreover individual therapy give more emphasize to reduce the suicidal tendencies and uncontrolled emotions. Group therapy sessions normally conduct once in a week to improve the skills like mindfulness, emotion regulation, distress regulation, social skills etc. Mindfulness is a term borrowed from Buddhist meditation practices by DBT. Mindfulness is a practice of bringing the complete attention of a person to a particular present activity. Mindfulness practice helps a person to focus his thoughts only on the present activities. It should be noted that mental patients normally worried about the past and future. Mindfulness helps them to avoid thoughts about past and future and concentrate only on present. Unlike psychoanalysis, DBT does not recognize unconscious meanings or motivations and instead focuses on sequences of measurable behaviour and the contingencies that reinforce them. The treatment protocol emphasizes a deficit model and is structured around specific targets and goals combined with “skills” training (i.e., specific skill sets to help with emotional, cognitive, and behaviour dysregulation) Combining an overarching dialectical philosophy, emphasis on the therapeutic relationship and mindfulness, DBT offers a comprehensive therapeutic approach including individual sessions and group work (Wheelis, 2010, p. 325) In short, “DBT treatment targets emotion dysregulation and its aftereffects by enhancing motivation and teaching skills aimed at areas of deficit” (Neacsiu et al, 2010, p.564) Major applications of DBT DBT for treating bipolar disorders Bipolar disorders are increasing day by day in all parts of the world because of various reasons and DBT found to be the most effective treatment for that. Bipolar disorders are mostly found among the teenagers. The symptoms of bipolar disorders such as suicide tendency, substance abuse, unprotected sex, and other risky or aggressive behaviours can be seen among teenagers. No therapy found to be 100% effective in the treatment of bipolar disorders. However, DBT found to be the most effective treatment for bipolar disorders. Skills training, individual therapy and group therapy are used extensively as part of DBT while providing treatment for people with bipolar disorders. Different sessions of one hour duration for 24 weeks will be administered as part of the group and individual therapies and skills development. DBT for treating suicide tendency “DBT is a treatment adopted for treating suicidal tendency among adolescents (Apter, 2010, p.272)”. “The central theory of suicide tendency and suicide prevention that has shaped suicide prevention research to date contends that suicide is a symptom of mental disease” (Linehan, 2008, p. 483). Many people have the belief that suicide tendency is caused by some kind of environmental factors. However, it should be noted that different people respond to same problems differently. For example, some teenagers try to commit suicide while their love affairs break. On the other hand many other teenagers handle such situations without any problems. Those who are trying to commit suicide for the breaking of love affairs definitely have some mental problems or suicide tendency. “Individuals with posttraumatic stress disorder (PTSD) have been found to be at heightened risk for both suicidal behaviour and nonsuicidal self-injury. Dialectical behavior therapy is the most empirically supported treatment available for suicidal behaviours and nonsuicidal self-injury (Harned et al, 2010, p.421). It is found that DBT can help reduce suicide tendency to a minimum level. DBT helps patients with suicide tendency to accept realities and control their emotions. It educate the patients how to manage stressful situations. DBT for treating substance abuse Substance abuse is another mental disorder which can be treated with the help of DBT. Drug addiction, alcohol addiction etc are considered as a habit rather than a disease earlier. However modern studies proved that these problems are mental diseases rather than a habit. Several modifications and additions were added to standard DBT for use with this substance abusing population. A new set of “attachment” strategies were added to DBT. These strategies consisted of a set of organized interventions designed to increase the positive valance of the therapy and the therapist, as well as to reach out to and bring back “lost” patients. A dialectical stance on drug use was developed in recognition that, on the one hand, cognitive-behavioral relapse prevention approaches are effective in reducing the frequency and intensity of drug use following a period of abstinence from drug use, and, on the other, “absolute abstinence” approaches are effective in lengthening the interval between periods of use. “Dialectical abstinence,” i.e., a synthesis of unrelenting insistence on total abstinence before any illicit drug abuse with an emphasis on radical acceptance, on judgmental problem-solving, and effective relapse prevention after any drug use, followed by a quick return to the unrelenting insistence on abstinence, seeks to balance these two positions (Linehan et al, 1999, p.282) Most of the conventional treatment therapies of substance abuse focus more on increasing the period between two successive substance abuse incidents. Such therapies believe that when patients fail to get opportunities for substance abuse on a regular basis, they will try to modify their behaviour. In other words, the core of such therapies is to increase the gap between two successive substance abuse incidents and thereby decrease the tendency to abuse substance quiet regularly. However, in many cases, these therapies found to be ineffective since the tendency for substance abuse may not be gone completely out of the mind of the patient. Whenever he gets an opportunity in the future, he may get back to his old habits. While treating substance abuse with the help of DBT, the patient forced to modify his behaviour. In other words, DBT not only educates the patient about the consequences of a particular behaviour, but also helps the patient to come out of such behaviour. For example, mindfulness is a strategy used in DBT to concentrate more on the present and avoid thought about past and future. Thus the past experiences will never encourage the patient to restart his substance abuse behaviour once he succeeded in practicing mindfulness. DBT for treating BPD BPD results from a transaction over time that can follow several different pathways, with the initial degree of disorder more on the biological side in some cases and more on the environmental side in others. The main point is that the final result, BPD, is due to a transaction where both the individual and the environment co-create each other over time with the individual becoming progressively more emotionally unregulated and the environment becoming progressively more invalidating (Linehan, 2003). Borderline personality disorder is one of the most complicated psychological problems. No therapies found to be effective in treating BPD’s. It is already proved that more than 10% of the patients with BPD commit suicide. Feelings of anger, frustrations, depressions and anxiety are some of the common symptoms of borderline personality disorders. Patients with BPD live in an imaginary world in which the world of reality has no significance. They consider their own world as the real one and the other world as the imaginary one. Normal therapies cannot penetrate into this imaginary world whereas DBT can helps therapists in penetrating into the imaginary world of the patients with BPD. Relationship building between the patient and the therapist is the core of DBT. Establishing strong relations with the patient will help the therapist to explore the inner thoughts of the patient properly and to cultivate positive energy into the minds of the patient. DBT is based on a combined capability deficit and motivational model of BPD which states that (1) people with BPD lack important interpersonal self-regulation including emotional regulation and distress tolerance skills and (2) personal and environmental factors often both block and/or inhibit the use of behavioral skills that clients do have and reinforce dysfunctional behavior (Dimef & Linehan, 2001, p.1). DBT believes that both environmental factors and the hereditary factors are relevant in the case of patients with BPD. Emotion regulation system of the people is normally controlled by the genetic factors. Moreover traumatic experiences at early ages can cause problems in the behaviour of a person later in his life. Conclusions Dialectical behavioural therapy is the most advanced therapy for treating many of the psychological disorders like bipolar diseases, substance abuse, suicide tendency, borderline personality disorders etc. It is developed with the help of the principles of cognitive behavioural therapy and Buddhist meditation practice. One of the major advantages of DBT is that it can be used to treat mental diseases at any stages. Cognitive behaviour therapy has limitations in treating patients with chronic mental disorders whereas DBT has treatment options for all types of mental disorders at any stage. DBT consists of both individual and group components. At the beginning of the treatment procedure, the therapist meets the patient separately and tries to build relationships with him. After few sessions of one hour duration, the therapist may succeed in acquiring the trust of the patient. The initial duty of the therapist is to control the self-damaging, suicide or violent tendency of the patient. Then the therapist give more focus to the building of social skills, emotion regulation and controlling skills, proper behavioural skills etc with the help of group therapy. Mindfulness or the ability to concentrate fully on present things will be developed in the minds of the patient with the help of suitable techniques by the therapist. The patient will gain the ability to forget about the past and future after the successful DBT. In short, since DBT combines all the good elements of the other available psychotherapies, it can be considered as the best treatment option for patients with any kind of mental disorders. References Apter A. MD (2010). Suicidal behaviour in adolescence. The Canadian journal of psychiatry. May 2010; 55, 5; ProQuest Central. Dimeff L & Linehan MM (2001). Dialectical Behaviour Therapy in Nutshell. The California Psychologist 34, 10-13. Di (n.d). Retrieved from http://www.marxists.org/glossary/terms/d/i.htm#dialectics Harned MS, Jackson SC, Comtois KA and Linehan MM (2010). Dialectical Behavior Therapy as a Precursor to PTSD Treatment for Suicidal and/or Self-Injuring Women With Borderline Personality Disorder. Journal of Traumatic Stress, Vol. 23, No. 4, August 2010, pp. 421–429 Jacobo MC, Blais MA, Baity MR and Harley R (2007). Concurrent Validity of the Personality Assessment Inventory Borderline Scales in Patients Seeking Dialectical Behaviour Therapy. Journal Of Personality Assessment, 88(1), 74–80 Lawrence Erlbaum Associates, Inc. Linehan MM Ph.D (2003). Dialectical Behaviour Therapy (DBT) for Borderline Personality Disorder. Retrieved from http://www.dbtselfhelp.com/html/linehan_dbt.html Linehan MM Ph.D.(2008). Suicide Intervention Research: A Field in Desperate Need of Development Suicide & Life - Threatening Behavior; Oct 2008; 38, 5; ProQuest Central. 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Mending the Mind Psychoanalytic Dialogues, 20:325–336, 2010 Taylor & Francis Group, DOI: 10.1080/10481885.2010.483958 Read More