Dialectical Behaviour Therapy: Description, research and future directions.

Abstract

Theoretical and Philosophical Foundations of DBT. A central dialectic between acceptance and change lies at the heart of DBT. In developing DBT, Linehan initially attempted to apply behavioural theory and change strategies to clients presenting with BPD and suicidal behaviour. She experienced several difficulties in these early stages of treatment development. Clients' were frequently non-collaborative in-session, did not practise agreed homework assignments and often did not return for subsequent treatment sessions at all. Linehan hypothesised that these 'therapy-interfering behaviours' arose because the clients experienced the strong focus on changing emotions, thoughts and behaviours as invalidating. Indeed, as clients often believe they are incapable of change, the whole notion of a treatment based on change is fundamentally invalidating. In response to these concerns, she searched for a philosophy / theoretical approach that strongly emphasised acceptance. Zen principles and practise underpin the acceptance-based components of DBT. To house these two contrasting approaches, Linehan uses dialectical philosophy. The following sections of this paper discuss these three foundations of the treatment in more detail. Pushing for Change: Behavioural Theory & Problem-Solving DBT like 'first wave' cognitive -behavioural treatments emphasises behavioural theory, rather than cognitive theory common to second wave treatments such as Cognitive Therapy for depression (Hayes, Follette & Linehan, 2004). Like 'first wave' therapies 'third wave' therapies, of which DBT was perhaps one of the first, take a radical behaviourist perspective to mental phenomenon. Thus, any response of an organism, such as thinking, emoting, sensing, as well as overt motor behaviour constitutes behaviour. The emphasis on behavioural theory in DBT influences the treatments approach to diagnosis and case conceptualisation. Consistent with a radical behaviourist stance, DBT views the diagnostic criteria of BPD (DSM-IV, 2000, p. 710) as simply descriptions of the overt and covert behaviours of the client and, crucially, that when these behaviours stop the diagnosis ceases to exist. Indeed, to a radical behaviourist: 'A self or personality is at best a repertoire of behaviour imparted by an organized set of contingencies' (Skinner, 1974, p. 167). This approach contrasts with other theoretical models of personality and personality disorder that consider the diagnostic criteria as symptoms of an underlying 'borderline personality' organisation. A behavioural approach to diagnosis provides a more hopeful perspective to clients. In pre-treatment, DBT therapists describe the behavioural understanding of the diagnosis, identify behavioural targets for treatment and describe and demonstrate how DBT delivers behavioural change. Outlining that changing both their overt and covert behaviours removes the diagnosis orients clients towards recovery. DBT emphasises classical and operant conditioning in case conceptualisation. DBT therapists conduct behavioural analyses to comprehend both the classically conditioned links in the chain of events leading up to problematic behaviour and the functional (operant) consequences of the behaviour. For example, a client with a history of childhood sexual abuse frequently experienced increases in guilt and suicidal ideation whilst preparing for bed. Analysis of the increases in ideation revealed a classically conditioned association between going to bed and thoughts of suicide. The client learnt this association in childhood as the perpetrator would tell her she deserved to die during the abusive episodes, which occurred in her bed, for which she experienced intense guilt. In the present, following the increases in suicidal ideation, the client would search for self-harm implements. As she began to search, she experienced relief from guilt as she now believed that she was doing 'the right thing'. …