DBT began as an application of the standard behavior therapy of the 1970s to treat suicidal individuals (Linehan, 1987a, 1987b). The basic premise of treatment was that individuals who wanted to be dead did not have the requisite skills to build a life worth living. However, in the process of developing the treatment, it quickly became apparent that a focus solely on change would not work. Many clients who attempted suicide were extremely sensitive to criticism and prone to emotion dysregulation. Efforts at helping such clients change led quickly to increased and at times overwhelming arousal. The result was often that the clients emotionally shut down—or, more rarely, stormed out of sessions or attacked their therapists. Dropping the emphasis on change, however, had equally problematic consequences. Clients interpreted this as their therapists’ ignoring their palpable suffering or treating it as of little consequence. Either extreme hopelessness or rage at the therapists for apparent insensitivity often occurred. From either therapeutic stance (i.e., an exclusive focus on change or on acceptance), clients experienced their therapists as invalidating not only specific behaviors but also themselves as a whole. Research by Swann, Stein-Seroussi, and Giesler (1992) may explain how such perceived invalidation leads to problematic behavior in therapy. Their research revealed that when an individual’s basic self-constructs are not verified, the individual’s arousal increases. The increased arousal then leads to cognitive dysregulation and the failure to process new information.
To keep both a client and a therapist in the room working effectively on the problems at hand, the therapist had to figure out how to hold both acceptance and change in the therapy simultaneously. This synthesis, when found, could engender both new client change and new acceptance. The wish to change every painful experience had to be balanced with a corresponding effort at learning to accept life’s inevitable pain. It was impossible to work on changing one set of problems if the client could not at least temporarily tolerate the pain of other problems. Without tolerance, at least for a short time, all problems converged and threatened to overwhelm both the client and the therapy. The inability to accept one’s own behavior prohibits any ability to change, because it leads either to withdrawal and avoidance, or to emotional responses such as rage or intense shame. Both interfere with the observation and self-understanding necessary for effective change. Therefore, it became clear that it was as necessary for the client to hold the synthesis of acceptance and change as it was for the therapist. Although treatment of severe disorders requires the synthesis of many dialectical polarities, that of acceptance and change is the most fundamental. It was the necessity of this synthesis that led to use of the term “dialectical” as a descriptor of the standard behavior therapy applied in the treatment.
A dialectical framework considers reality as continuous, dynamic, and holistic. Reality, from this perspective, is simultaneously both whole and consisting of bipolar opposites (e.g., an atom consisting of opposing positive and negative charges). Dialectical truth emerges through the combination (or “synthesis”) of elements from both opposing positions (the “thesis” and “antithesis”). The tension between the thesis and antithesis within each system—positive and negative, good and bad, children and parents, client and therapist, person and environment, and so forth—and their subsequent integration are what produce change. The new state following change through synthesis however, also consists of polar forces; thus change is continuous and constitutes the essential nature of life. A very important dialectical idea is that all propositions contain within them their own oppositions. As Goldberg (1980, pp. 295–296) put it, “I assume that truth is paradoxical, that each article of wisdom contains within it its own contradictions, that truths stand side by side. Contradictory truths do not necessarily cancel each other out or dominate each other, but stand side by side, inviting participation and experimentation.”
From the point of view of therapeutic dialogue and relationship, “dialectics” refers to change by persuasion and by making use of the oppositions inherent in the therapeutic relationship, rather than by formal impersonal logic. Through the therapeutic opposition of contradictory positions, both client and therapist can arrive at new meanings within old meanings, moving closer to the essence of the subject under consideration. The spirit of a dialectic point of view is never to accept a proposition as a final truth or an undisputable fact. Thus the question addressed by both client and therapist is “What is being left out of our understanding?” Dialectics as persuasion is represented in the specific dialectical strategies described a bit later in the chapter.
Dialectical assumptions influence case conceptualization in DBT in a number of ways. First, dialectics suggests that psychological disorders are best conceptualized as systemic dysfunctions. A systemic dysfunction is characterized by (1) defining disorder with respect to normal functioning, (2) assuming continuity between health and disorder, and (3) assuming that disorder results from multiple rather than single causes. Linehan’s biosocial theory of BPD, presented below, assumes that BPD represents a breakdown in normal functioning, and that this disorder is best conceptualized as a systemic dysfunction of the emotion regulation system. The biosocial theory proposes that the pathogenesis of BPD results from numerous factors; some of these are constitutional predispositions that create individual differences in susceptibility to emotion dysregulation, while others result from the individual’s interaction with the environment. Assuming a systemic view has the advantage of compelling the theorist to integrate work from a variety of fields and disciplines.
A second dialectical assumption underlying Linehan’s biosocial theory of BPD is that the relationship between the individual and the environment is a transactional process, the outcome of which at any given moment depends on the nature of the transaction. Within social learning theory, this is known as the principle of “reciprocal determinism.” Besides focusing on reciprocal influence, a transactional view also highlights the constant state of flux and change of the individual–environment system. Millon (1987) has made much the same point in discussing the etiology of BPD and the futility of locating the “cause” of the disorder in any single event or time period.
Both transactional and interactive models, such as the diathesis–stress model of psycho-pathology, call attention to the role of dysfunctional environments in bringing about disorder in the vulnerable individual. A transactional model, however, highlights a number of points that are easy to overlook in an interactive, diathesis-stress model. For example, a person (Person A) might act in a manner stressful to another individual (Person B) only because of the stress Person B is putting on Person A. For example, Person B could be a child who, due to an accident, requires most of the parents’ free time just to meet survival needs—or an inpatient who, due to the need for constant suicide precautions, uses up much of the unit’s nursing resources. Both of these environments are stretched in their ability to respond well to further stress. Both may invalidate Person B or temporarily “blame the victim” if any further demand on the system is made. Although the system (in these examples, the family and the therapeutic milieu) may have been predisposed to respond dysfunctionally in any case, such responses may have been avoided in the absence of exposure to the stress of that particular individual. A transactional, or dialectical, account of psychopathology may allow greater compassion because it is incompatible with the assignment of blame. This is particularly relevant with a label as stigmatized among mental health professionals as “borderline” (for examples of the misuse of the diagnosis, see Reiser & Levenson, 1984).
Thus DBT’s theoretical orientation to treatment is a blending of three theoretical positions: behavioral science, dialectical philosophy, and Zen practice. Behavioral science, the technology of behavior change, is countered by acceptance and tolerance of the client (with practices drawn both from Zen and from Western contemplative practice); these poles are balanced within the framework of a dialectical position. Although the term “dialectics” was first adopted as a description of this emphasis on balance, dialectics soon took on the status of guiding principles that have advanced the therapy in directions not originally anticipated. DBT is based within a consistent behaviorist theoretical position. However, the actual procedures and strategies overlap considerably with those of various alternative therapy orientations, including psychodynamic, client-centered, strategic, and cognitive therapies.
Core elements of DBT include the following:
Delineation of the functions that treatment must serve, and treatment modes to fulfill those functions (see Chapter 4, especially Table 4.1).
A biosocial theory of disorder that emphasizes reciprocal transactions over time between the individual and the individual’s environment.
A developmental framework of one pretreatment and four treatment stages, with Stage 1 designed for clients with the most severe and complex problems, and subsequent stages designed for progressively less troubled clients (see Table 3.1, below).
Within each stage, a hierarchical prioritizing of behavioral treatment targets (see Table 3.2, below).
Sets of acceptance strategies, change strategies, and dialectical strategies used to achieve the behavioral targets (see Figures 3.1 and 3.2, below).
A dialectical framework of therapy, which emphasizes the transactional influence of client and therapist upon each other, and the importance of balancing the influence of the client on the therapist with a corresponding influence of the treatment team on the therapist (DBT is a community of therapists treating a community of clients).
A comprehensive description of each of these aspects of the treatment can be found in the original DBT treatment manuals (Linehan, 1993a, 1993b). In this chapter we discuss each of these elements with attention to their application to adolescents. To begin, it is helpful to have an overview of how standard DBT is structured. This in turn is tied to the first core element above—a delineation of treatment functions and modes.
The overall program structure of DBT is dictated by five essential functions that a comprehensive treatment program must fulfill: improving client motivation to change; enhancing client capabilities; generalization of new behaviors; structuring the environment; and enhancing therapist capability and motivation. The responsibility for fulfilling these functions is spread among various treatment modes, with focus and attention varying according to the mode. DBT has typically used four modes: individual therapy, group skills training, telephone consultation, and therapist consultation meetings. It is important to realize that it is not a mode itself that is critical, but its ability to address a particular function. For example, ensuring that new capabilities are generalized from therapy to a client’s everyday life might be accomplished in various ways, depending on the setting. In a milieu setting, the entire staff might be taught to model, coach, and reinforce use of skills; in an outpatient setting, generalization usually occurs through telephone coaching. The individual therapist (who is always the primary therapist in DBT), together with the client, is responsible for organizing the treatment so that all functions are met. For a full discussion of functions and modes, see Chapter 4.
DBT theorizes that the behaviors of suicidal/self-injurious clients with BPD and multiple other problems stem from a combination of biological and environmental factors. Specifically, these factors are emotion dysregulation (which is most likely biological in origin), and invalidating environments (where inadequate emotion regulation coaching and dysfunctional learning take place)—hence the term “biosocial” theory. This theory appears highly relevant to adolescents who may not meet full criteria for BPD but have borderline features, who engage in suicidal behaviors, and who suffer from numerous other problems.
Linehan’s biosocial theory suggests that BPD criterion behaviors, and suicidal behaviors in particular, are primarily due to pervasive dysfunctions in the emotion regulation system. Although the mechanisms of the initial vulnerability to dysregulation remain unclear, it is probable that biological factors play a primary role. The etiology of this initial vulnerability may range from genetic influences, to prenatal factors, to traumatic childhood events affecting development of the brain and nervous system.
Borderline behavioral patterns are functionally related to, or are unavoidable consequences of, this fundamental dysregulation across several (perhaps all) emotions, including both positive and negative emotions. From the perspective of DBT, this emotional dysfunction is the core pathology, and thus is neither simply symptomatic or definitional. This systemic dysregulation is produced by emotional vulnerability combined with difficulties in modulating emotional reactions. “Emotional vulnerability” is conceptualized as high sensitivity to emotional stimuli, intense emotional responses, and a slow return to emotional baseline. Deficits in emotion modulation include difficulties in (1) inhibiting mood-dependent dysfunctional behaviors; (2) organizing behavior in the service of goals, independent of current mood; (3) increasing or decreasing physiological arousal as needed; (4) distracting attention from emotionally evocative stimuli; and/or (5) experiencing emotion without either immediately withdrawing or producing an extreme secondary negative emotion (for further discussion, see Linehan, 1993a; Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).
Most individuals with an initial temperamental vulnerability to intense emotionality do not develop BPD. Thus the theory further suggests that particular developmental environments are necessary. The crucial developmental circumstances in Linehan’s theory are “invalidating environments” (Linehan, 1987a, 1987b, 1989, 1993a). An invalidating environment is defined by the tendency to negate and/or respond erratically and inappropriately to private experiences, particularly to private experiences not accompanied by easily interpreted public accompaniments (e.g., feeling sick without having a high temperature). Private experiences, and especially emotional experiences and interpretations of events, are often not taken as valid responses to events; are punished, trivialized, dismissed, or disregarded; and/or are attributed to socially unacceptable characteristics, such as overreactivity, inability to see things realistically, lack of motivation, motivation to harm or manipulate, lack of discipline, or failure to adopt a positive (or, conversely, discriminating) attitude. Clients’ verbal descriptions are often viewed as inaccurate descriptions of their private experiences (e.g., “You are so angry but won’t admit it”). Invalidating environments emphasize controlling emotional expressiveness, oversimplify the ease of solving problems, and are intolerant of displays of negative affect. Emotional pain is attributed to lack of motivation, discipline, or effort. Individuals in an invalidating environment also tend to use punishment in their efforts to control behavior. Such a scenario exacerbates the emotional vulnerability and consequent emotion dysregulation of multiproblem individuals with BPD or borderline features, and their behavioral responses reciprocally influence their invalidating environments.
High rates of childhood abuse and trauma are reported among this population (Grilo, Sanislow, Fehon, Marino, & McGlashan, 1999; Sabo, 1997; Paris, 1997), suggesting that abuse, including sexual abuse, may be a prototypical invalidating experience for children. (Note also that research suggests a direct effect of early abusive experiences on emotion dysregulation, suggesting an additional pathway from childhood trauma to borderline personality features; see, e.g., Teicher, 2002.) More recent research, however, suggests that negative affect intensity/reactivity may be a stronger predictor of BPD symptoms than childhood sexual abuse, and that higher thought suppression may mediate the relationship between BPD symptoms and childhood sexual abuse (Rosenthal, Lynch, & Linehan, 2005). The transactional nature of the biosocial theory implies that individuals may develop borderline patterns of behavior via very different routes. Despite only moderate vulnerability to emotion dysregulation, a sufficiently invalidating environment may produce BPD patterns; conversely, even a “normal” level of invalidation may be sufficient to create BPD patterns for those who are highly vulnerable to emotion dysregulation (Koerner, & Linehan, 1997). Thus the relationship of early sexual abuse to BPD is still open to various interpretations (see, e.g., Silk, Lee, Hill, & Lohr, 1995; Fossati, Madeddu, & Maffei, 1999).
Although invalidating environments clearly prove maladaptive for children with extreme emotional sensitivity, it is noteworthy that such environments may arise despite the perfectly benign intentions of family members, or may even be present outside the family. Many factors can lead to invalidating family environments. For example, excessive and chronic stress on a family may simply tax the emotional resources of parents and leave them with little patience for attending to and seeking to understand a highly emotional child. Relatedly, the reciprocal interplay of biology and environment is continually operating, such that having a highly emotionally sensitive and reactive child in itself can place formidable stress on a “normal” family system, perhaps causing a “typically stressed” family to become “overstressed.” Another scenario is the “perfect family,” where children not only control their emotions effectively but also fit the mold of their parents’ expectations vis-à-vis behavioral styles, skills, interests, and gender role identity. When one of the children in such a setting breaks this mold and demonstrates unique interests, talents, temperament, or needs, otherwise well-meaning parents may become invalidating out of confusion, lack of understanding, or simply an effort to redirect the child onto the “proper” path. Yet another scenario involves parents who themselves received severe invalidation from caretakers and thus simply never learned to validate or even tolerate emotional displays. Such parents, though again perhaps well-meaning, often themselves lack the skills repertoire to help children modulate emotions effectively. Finally, there is the chaotic family: Parents themselves may misuse substances; experience severe depression or anxiety; engage in self-harming or suicidal behaviors; sexually abuse their children; and/or be unable to work, maintain adequate housing, or protect their children from abuse by others. The ability of such a family to provide the nurturing and learning environment an emotionally vulnerable child needs is compromised in the extreme. Understanding the manifold potential sources of invalidation is particularly important in DBT with adolescents and their family members, so that the therapist can hold onto the nonjudgmental assumption that all clients are doing their best and can avoid maligning the parents.
In addition, a pervasively invalidating environment can occur outside the family context. For example, characteristics of a school or neighborhood setting may prove a strong mismatch for the temperament of an emotionally sensitive child. Difficulties with acculturation may also play a role, as new immigrants or children of immigrants strive to adapt to a new cultural environment and community.
Regardless of its source, the overall results of the transactional pattern between emotion dysregulation and the invalidating environment are the emotional and behavioral patterns exhibited by the adult with BPD or borderline characteristics. Such an individual has never learned how to label and regulate emotional arousal, how to tolerate emotional distress, or when to trust his or her own emotional responses as reflections of valid interpretations of events (Linehan, 1993a). In more optimal environments, public validation of a person’s private, internal experiences results in the development of a stable identity. In an invalidating environment, however, an individual’s private experiences are responded to erratically and with insensitivity. The individual thus learns to mistrust his or her internal states, and instead scans the environment for cues about how to act, think, or feel. This general reliance on others results in the individual’s failure to develop a coherent sense of self. Emotion dysregulation also interferes with the development and maintenance of stable interpersonal relationships, which depend on both a stable sense of self and a capacity to self-regulate emotions. Moreover, the invalidating environment’s tendency to trivialize or ignore the expression of negative emotion shapes an expressive style later seen in the adult with BPD or borderline features—a style that vacillates between inhibition and suppression of emotional experience and extreme behavioral displays. Behaviors such as overdosing, cutting, and burning have important affect-regulating properties and are additionally quite effective in eliciting helping behaviors from an environment that otherwise ignores efforts to ameliorate intense emotional pain. From this perspective, the dysfunctional behaviors characteristic of BPD can be viewed as maladaptive solutions to overwhelming, intensely painful negative affect.
Linehan (1993a) has described behavioral patterns that often interfere with effective therapy as falling on three bipolar dimensions. Vacillation between the opposing extremes of these behavioral dimensions is commonly observed in therapy, often as a result of changes in emotional intensity. Suicidal behaviors can be understood at either end of these continua—reflecting, for example, self-directed hostility at one end or an escape from extreme despair at the other end. DBT defines these behavior patterns as “dialectical dilemmas” and identifies them as secondary targets of treatment (Linehan, 1993a). DBT seeks to move clients away from these behavioral extremes and toward more balanced, synthesized behavior. The three behavioral dimensions expressed as dialectical dilemmas are (1) unrelenting crisis versus inhibited grieving, (2) emotional vulnerability versus self-invalidation, and (3) active passivity versus apparent competence. These dialectical dilemmas can be seen as a framework within which the primary therapy targets (discussed next) are achieved. In Chapter 5 we discuss how these three behavioral patterns appear in therapy with adolescents. We also then describe three new dialectical dilemmas specific to adolescents and their families.
Linehan, and behaviorists in general, take “behavior” to mean anything an organism does involving action and responding to stimulation (Webster’s New Universal Unabridged Dictionary, 1983, p. 100). Conventionally, behaviorists categorize behavior as motor, cognitive/verbal, and physiological, all of which may be either public or private. There are several points to make here. First, the division of behavior into these three categories is arbitrary and is done here for conceptual clarity, rather than in response to evidence that these response modes actually are functionally separate systems. This point is especially relevant to understanding emotion regulation, given that basic research on emotions demonstrates that these response systems often overlap; they are somewhat, but definitely not wholly, independent. A related point here is that in contrast to biological and cognitive theories of BPD, biosocial theory suggests that there is no a priori reason for favoring explanations emphasizing one mode of behavior as intrinsically more important or compelling than others. Rather, from a biosocial perspective, the crucial question is under what conditions a given behavior–environment, behavior–behavior, or response system–response system relationship does hold, and under what conditions such a relationship enters causal pathways for the etiology and maintenance of BPD.
DBT is conceptualized as occurring in four stages that match levels of severity and complexity of problems. An additional pretreatment stage prepares the client and therapist for work together and elicits a commitment from each to work toward the various treatment goals. Stage 1 of therapy is designed for an individual at the most severe and complex levels of BPD. Its primary focus is on stabilizing the client and achieving behavioral control. The major studies of DBT for BPD to date have focused on the severely and multiply disordered client who enters treatment at Stage 1, and this book also focuses on Stage 1 treatment. As clients become more and more functional, DBT increasingly resembles standard behavior therapy. DBT Stages 2–4 have the following treatment goals: to replace “quiet desperation” with non-traumatic emotional experiencing (Stage 2); to achieve “ordinary” happiness and unhappiness, and reduce ongoing disorders and problems in living (Stage 3); and to resolve a sense of incompleteness and achieve freedom and capacity for joy (Stage 4) (see Table 3.1). In sum, the orientation of the treatment is first toward getting the client’s actions under control, then toward helping the client to feel better and to resolve problems in living, and finally toward helping the client to find joy and perhaps even a sense of transcendence.
The criteria for putting a client in Stage 1 are a high level of current disorder and the inability to realistically accomplish other goals before behavior and functioning come under better control. Level of disorder is determined by the severity and pervasiveness of problems, the disability or dysfunction that problems cause in daily activities, and the threat they pose to life (see Linehan, 1999). Individuals with both severe and pervasive problems that are either disabling (e.g., ones that keep the individuals out of school or necessary work; result in homelessness, loss of friends, and/or loss of close family members; and/or lead to treatment in emergency departments or inpatient units) or life-threatening (e.g., recent or current suicidality, life-threatening aggression toward others) are considered in need of Stage 1 treatment. Stage 1 DBT targets the reduction of out-of-control behavior patterns associated with severe and pervasive disorders, particularly behaviors associated with high risk of death. As Mintz (1968) suggested in discussing treatment of the suicidal client, all forms of psychotherapy are ineffective with a dead client. The same can be said of the individual who drops out of treatment. The adaptation of DBT for adolescents described in this book focuses primarily on Stage 1 targets.
In DBT, the specific tasks of the pretreatment stage are twofold. First, the client and therapist must arrive at a mutually informed decision to work together. Typically, the first session (or more if needed) is presented as an opportunity for the client and therapist to explore this possibility. Diagnostic interviewing, history taking, and formal behavioral analyses of high-priority targeted behaviors can be woven into these initial therapy sessions or conducted separately. Second, the client and therapist must negotiate a common set of expectancies to guide the initial steps of therapy.
TABLE 3.1. Hierarchy of Standard DBT Stages and Stage Targets
| Pretreatment stage | |
| Targets: | Orientation and commitment to treatment Agreement on goals |
| Stage 1 | |
| Targets: | 1. Decreasing life-threatening behaviors 2. Decreasing therapy-interfering behaviors 3. Decreasing quality-of-life interfering behaviors 4. Increasing behavioral skills |
| Stage 2 | |
| Target: | 5. Decreasing posttraumatic stress |
| Stage 3 | |
| Targets: | 6. Increasing respect for self 7. Achieving individual goals |
| Stage 4 | |
| Targets: | 8. Resolving a sense of incompleteness 9. Finding freedom and joy |
Note. Adapted by permission from Linehan (1993a). Copyright 1993 by The Guilford Press. Adapted by permission
Agreements outlining specifically what client and therapist can expect from each other are discussed and agreed to. If the client has dysfunctional beliefs regarding the process of therapy, the therapist attempts to modify these. Issues addressed include the goals of treatment and general treatment procedures, how long therapy may last, what outcomes can reasonably be expected, and various myths the client may have about the process of therapy in general. A dialectical/biosocial view of the client’s primary disorder is also presented.
Orientation covers several additional points. First, DBT is presented as a supportive therapy requiring a strong collaborative relationship between client and therapist. DBT is presented as a life enhancement program, where client and therapist function as a team to create a life worth living, rather than as a suicide prevention program. Second, DBT is described as a form of CBT with a primary emphasis on analyzing and replacing problematic behaviors with skillful behaviors. Third, the client is told that DBT is a skills-oriented therapy, with special emphasis on behavioral skill training. The commitment and orienting strategies, balanced by validation strategies (described later), are the most important strategies during this phase of treatment. In Chapter 7 we provide a detailed discussion of applying the pretreatment orientation and commitment strategies to adolescents and families. These pretreatment targets are an important part of DBT for adolescents.
The focus of Stage 1 of DBT is on attaining a life pattern that is reasonably functional and stable. In order for the client to attain such a life pattern, the therapist and client work toward four primary behavioral targets. “Targets” in DBT consist of making changes in sets of behaviors that are explicitly identified as needing such changes, typically through collaboration of therapist and client. These behaviors are prioritized for addressing in session, and are approached hierarchically and recursively as higher-priority behaviors reappear. Listed in order of importance, the four Stage 1 targets are (1) decreasing life-threatening behaviors, (2) decreasing therapy-interfering behaviors, (3) decreasing quality-of-life interfering behaviors, and (4) increasing behavioral skills.
DBT defines the four kinds of primary target behaviors very specifically. Clients are asked to monitor and record any occurrence of these primary target behaviors on DBT “diary cards,” and to bring the cards with them to individual and skills training sessions. Routine review of diary cards helps keep both client and therapist focused on the primary targets. The discussion that follows reviews the primary target behaviors in detail, and examines what those behaviors typically look like in adolescents. Table 3.2 provides an overview list of DBT pretreatment and Stage 1 goals with adolescent-oriented specifics.
Many adolescents with BPD or borderline personality features make repeated suicide attempts, engage in other behaviors that may pose a risk to life (e.g., participating in gang violence; failing to take essential life-sustaining medications), engage in repeated NSIB, communicate suicidal ideation, or report suicide-related expectancies or affect. A smaller subgroup may also engage in homicidal ideation and behavior. Everything discussed below regarding decreasing life-threatening behaviors is equally applicable to homicidality as it is to suicidality. As mentioned above, DBT targets specific categories of suicidal behavior that include both certain and ambivalent suicide attempts, NSIB, suicidal ideation and communication, or other cognitions and emotions related to suicide. Although not all life-threatening behaviors are accompanied by intent to die, they are nevertheless included in the category of life-threatening behaviors for reasons given below. In-depth discussions of the rationale for each of these categories appear in Linehan (1993a).
TABLE 3.2. Pretreatment and Stage 1 Treatment Targets Applied to Adolescents
Pretreatment stage
Targets: Informing adolescent about, and orienting adolescent to, DBT
Informing adolescent’s family about, and orienting family to, DBT
Securing adolescent’s commitment to treatment
Securing adolescent’s family’s commitment to treatment
Securing therapist’s commitment to treatment
Stage 1
Targets: Decreasing life-threatening behaviors
• Suicidal/homicidal crisis behaviors
• Suicide attempts
• Attempted murder
• NSIB
• Suicidal ideation or communication
• Suicide-related expectancies
• Homicide-related expectancies
• Suicide-related affect
• Homicide-related affect
Decreasing therapy-interfering behaviors
• By the adolescent
• By the therapist
• By participating family members
Decreasing behaviors that interfere with quality of life
• High-risk, impulsive behaviors (e.g., driving fast or while drunk, HIV-related behaviors)
• Dysfunctional interpersonal interactions
• Substance-abuse-related behaviors
• School problems (e.g., nonattendance, school failure)
• Antisocial behaviors
• Impulsive behaviors
• Problems maintaining physical health
Increasing behavioral skills
• Interpersonal skills
• Distress tolerance skills
• Emotion regulation skills
• Core mindfulness skills
• Walking the middle path skills
Suicide crisis behaviors are those behaviors that suggest imminent danger to the client. These include, but are not limited to, threats of imminent suicidal intent, attaining lethal means (e.g., access to a gun or large supply of medications), preparations for suicide (e.g., leaving a note, giving away possessions, saying goodbye to people), or indirect messages about suicidal intention (e.g., statements such as “I won’t be here then”). With new clients in particular, the therapist should always err on the conservative side in assessing and acting upon suicidal crisis behaviors. And with adolescents in particular, the therapist must remain vigilant to such signs—as teens sometimes have not brought themselves in for treatment, may not initially view their suicidal behaviors as a treatment target, and may not be forthright with this information.
The central reason for including all self-injurious acts under the category of life-threatening behaviors, even in the absence of suicidal intent, is that self-injury is one of the best predictors of eventual suicide. Risk of suicide increases 50–100 times within the first 12 months after an episode of self-injury, compared to the general population risk (Cooper et al., 2005). Approximately one-half of persons who die by suicide have a history of self-injury, and this proportion increases to two-thirds in younger age groups (Appleby et al., 1999).
Other reasons for targeting NSIB include the fact that any act of deliberate self-injury is simply antithetical to the most basic goal of any psychotherapy, which is to work toward helping rather than injuring the client. It would be hard for a therapist to convey true caring and compassion if the therapist is sending the message that acts of intentional self-injury need not be addressed. Finally, self-injurious acts such as self-cutting often leave the body permanently scarred and pose a risk of accidental death.
We have found at times that it is difficult to get commitment from adolescents to work on reducing self-injurious behaviors. Not only are many wedded to NSIB because of its functions (e.g., it is often negatively reinforcing by reducing emotional pain); we have also seen clients, particularly in our suburban middle-class population, who are embedded in a high school subculture in which various forms of self-mutilation are normative and even prized. For example, some teens who scar themselves with razors also get tattoos and have multiple body piercings. They may have friends who share these behaviors and thus become accustomed to practically wearing their scars as badges of honor, representing suffering, pain (or perhaps tolerance of pain), and bravery. One high school senior believed that her scars from self-cutting legitimized her emotional pain to her friends—proving that she was not just a crybaby or a whiner, but in the “big leagues” of sufferers. This same teen repeatedly begged her mother for a tattoo, which she believed would further mark her as belonging to a certain group of “cool” but long-suffering youth (she finally got herself a tattoo upon turning 18). At an age where peer approval is critically important, we have seen adolescents who are clearly reinforced for their self-injurious behavior with the acceptance, sympathy, or “oohs and ahs” of their friends. Thus, as part of behavioral analysis, it is crucial for the therapist to assess peer-related antecedents and consequences.
DBT also targets clients’ thoughts of suicide or communications about suicide, as these are reported either on the diary card, in session, on the telephone, or to friends, family members, or personnel. Suicidal thoughts might be related to planning, imagining, or expecting to commit suicide. Some clients have waxing and waning urges to die or to hurt themselves. These urges generally tend to be linked to the belief that these actions will supply a way out of their misery. Many threaten suicide repeatedly. Planning to commit, fantasizing about committing, expecting to commit, expressing the urge to commit, and threatening to commit suicide are all targeted directly by conducting behavioral analyses (see Chapter 8). Some teens may express extreme angst through listening to music that has self-harming, depressive, or apocalyptic themes. Thus adolescent self-report or parent report of such behavior must be taken seriously and assessed for its significance to the adolescent. (Fortunately, there is a recent trend for lyrics to attempt to alleviate adolescents’ alienation and despair, as in the hit song “Hold On” by the band Good Charlotte; see Azerrad, 2004.)
Suicidal ideation may or may not be targeted as a life-threatening behavior. When it is associated with suicidal intent or planning, when it increases or is new, when it relates to engaging in self-injurious behaviors, or when it inhibits adaptive coping, it is addressed directly. However, at times suicidal ideation becomes a habitual way of thinking, is low-level and stable, and is not linked to any self-injury or other risk behaviors or states of mind. If the adolescent experiences this type of suicidal ideation, it does not get treated as a primary target unless there is a significant increase from an ongoing stable pattern. Note that making such a determination necessitates ongoing assessment of suicidality, as well as familiarity with a client’s characteristic ideation regarding suicide and the triggers that commonly elicit suicidal ideation. Early in treatment, the therapist should err on the side of targeting such ideation directly.
Suicide-related expectancies are the beliefs clients hold about what suicide or self-injurious acts will do for them. Such expectancies often relate to escaping misery or eliminating one’s perceived role of being a burden to others. They also often involve notions about relief from intensely painful emotional states through distraction from chronic or transient difficult life circumstances; attaining temporary solace (e.g., going to sleep after overdosing); achieving desired responsiveness from others; hurting, upsetting, or “showing” others; being taken seriously by others; or gaining a desired admission to a hospital. Adolescents may be socially isolated and believe that a suicidal act will gain the attention of peers, or may be feeling rejected by a peer group or boyfriend/girlfriend and believe that suicide will gain the attention of these others or teach them a lesson.
As with suicidal ideation and communication, the therapist targets suicide-related expectancies when they relate to suicidal risk behaviors or impede skillful problem solving. Useful areas to assess include the client’s expectancies about positive and negative outcomes of suicide or self-injury, as well as beliefs about the utility of alternative, adaptive coping options. For example, one intermittently suicidal adolescent expressed the belief that killing herself would devastate important people in her life (her parents, boyfriend, and certain close friends). In contrast to adolescents for whom upsetting others is a motivating factor in suicide, this girl believed that the extent of pain she would inflict on others by killing herself was reason enough not to do it. Thus focusing on these relationships became an important strategy in coping with her suicidal thinking.
Like suicidal thoughts, communications, and expectancies, suicide-related affect is targeted directly only when it intensifies or when it is linked to suicidal crisis behaviors, self-injurious behaviors, or impairment in effective problem solving. Affective states are generally linked to suicidal behaviors/NSIB in one of two ways. First, acts of self-injury (or even plans to commit or images of committing such acts) often bring relief or escape from painful emotions, such as anger, depression, shame, or anxiety. Second, NSIB may be accompanied by positive affective states, such as feelings of calm, relaxation, eager anticipation, and pleasure. Such affective links to NSIB thus serve as one mechanism by which such acts get negatively or positively reinforced.
Suicidal adolescents with BPD or borderline characteristics share with their adult counterparts a tendency to experience repeated therapy failures, mostly because of their tendency to drop out of treatment prematurely (Trautman et al., 1993). Dropout, noncompliance, and other treatment-interfering behaviors by clients are seen often in the beginning stages of therapy with teens, as often they are brought in unwillingly by parents rather than having decided themselves to initiate therapy. In addition, they may be reluctant to share their therapy with family members (inclusion of family members is important in treating adolescents; we discuss it in detail later). Treatment-interfering behaviors also include motivational difficulties that impede progress; relational or other behavioral difficulties that burn out the therapist or the client and reduce the therapist’s motivation to treat or the client’s motivation to participate in therapy; a client’s acting in ways that punish effective therapist behaviors and reinforce ineffective therapist behaviors; or a therapist’s acting in ways that punish effective client behaviors and reinforce ineffective client behaviors.
Thus, second only to life-threatening behaviors, DBT places paramount emphasis on client and therapist behaviors that interfere with the success or continuation of therapy. (In DBT for adolescents, family members’ therapy-interfering behaviors are also targeted as necessary; see below.) The target of decreasing therapy-interfering behaviors supersedes targets related to the client’s quality of life, since if therapy is failing or on the brink of termination, discussion of these other issues becomes irrelevant. Put simply, a client who is not receiving therapy can obviously no longer benefit from therapy.
Client behaviors that interfere with therapy include (1) behaviors that interfere with receiving therapy, (2) behaviors that interfere with other clients, and (3) behaviors that burn out the therapist.
Client behaviors that interfere with receiving therapy include behaviors that interfere with attending therapy, behaviors that interfere with being attentive in the therapy session, noncollaborative behaviors, and noncompliant behaviors. Examples of behaviors that interfere with attending therapy include repeated or prolonged hospitalizations (this also constitutes a quality-of-life-interfering behavior), canceling sessions, experiencing crises that disrupt therapy, or arriving to sessions late or leaving early. With adolescents, behaviors that interfere with therapy attendance can be complicated by parental factors. For example, some adolescents may need to come late, leave early, or miss sessions altogether because of parents’ busy schedules or unreliability. Yet it is important to remember that, regardless of what caused a therapy-interfering behavior, it is still therapy-interfering behavior. Thus, in cases in which family or caregiver factors played a role, adolescents are neither blamed nor “let off the hook.” Instead, problem-solving strategies are applied that emphasize ways to get to therapy even if a family member is unavailable. That is, part of coping effectively, particularly for adolescents living in chaotic home environments, entails flexible and advanced planning for attending therapy sessions. This might involve coaching an adolescent on effectively communicating to a parent about the importance of arriving to therapy on time, developing alternative transportation plans, or knowing when not to rely on an unreliable caretaker.
Examples of behaviors that interfere with being attentive in the therapy session include coming to a session under the influence of drugs or alcohol, being excessively tired in session, dissociating in session, or experiencing a panic attack or other extreme emotional states that interfere with participating in the session. We have noticed that adolescents in particular display behaviors that interfere with being attentive during group skills training sessions. Teenagers are highly distractible; easily engage with rather than ignore disruptive peer behaviors; and are prone to passing notes, doodling, giggling, flirting, and impulsively shouting out comments. Such behaviors are typically handled by skills trainers, but if they persist, they can also be addressed with a behavioral analysis by the primary therapist in the individual session. Chapter 10 details these issues.
Noncollaborative behaviors also interfere with receiving therapy; these involve breaches in the agreement on the goals, strategies, or procedures of therapy. They include such behaviors as not working or talking in therapy, arguing with or challenging the therapist repeatedly, failing to stick to the therapy targets, lying to the therapist, minimizing ratings on the diary card, or giving repeatedly vague or evasive answers to therapist questions. Adolescents who repeatedly respond with “I don’t know,” “I don’t care,” or “You got me” fall into this last category. Client behaviors that interfere with receiving therapy also include noncompliant behaviors. These include not bringing in or filling out diary cards, not completing homework assignments, not keeping agreements with the therapist, not engaging in session or group activities (e.g., role-playing new skills), or otherwise not participating in the treatment process. A common example is not calling the therapist before engaging in self-injurious behavior or not calling the therapist at times scheduled for phone consultation contacts.
Behaviors that interfere with other clients also fall under the rubric of client therapy-interfering behaviors. These behaviors may occur in connection with either individual or group sessions. In the context of an individual session, they may include engaging in behaviors that keep other clients from beginning their sessions on time, behaving loudly or explosively in session so that other clients hear the disturbance, or behaving in or around the clinic in ways that disturb other clients (e.g., some of our more rambunctious adolescents have been known to run down the clinic hallway shrieking and laughing loudly on their way out for their break). Such behaviors may also occur in group. These may involve threatening other group members or making hostile remarks to them; being disrespectful or openly judgmental of group members as they participate in group; inducing other clients to engage in destructive behaviors or behaviors incompatible with DBT agreements; or otherwise interfering with other clients’ sense of comfort in, progress in, or compliance with therapy. The issue of inducing other clients to engage in destructive or non-DBT behaviors applies particularly to adolescents, who respond strongly to peer pressure. For example, the adolescents in our suburban population typically disperse during break time to use the restroom, get snacks, or smoke cigarettes just outside the clinic door. One evening the adolescents were nowhere to be found at the end of the group break. When one therapist went to search for them, she found them in the clinic parking lot—crowded into the car of one of the adolescents, blasting music, and smoking. The adolescent who drove the car had encouraged the others to spend the break there, which violated two agreements: (1) where the adolescents were expected to spend their break (i.e., in safe proximity to the group room), and (2) when they were supposed to return. As a therapy-interfering behavior, such a digression would typically be handled in two ways. The first would be for the skills trainers to address it immediately, by clarifying expectations about how and where to spend break, and obtaining a commitment to abide by these expectations. Depending on the overall context, group leaders might also skillfully express their feelings about the problematic behavior and make a request for specific behavior change (modeling interpersonal effectiveness skills taught in the skills group), or they might conduct a miniature behavioral analysis of the digression, with a rapid move to generating solutions and obtaining commitment. The second way would be for it to be addressed as a therapy-interfering behavior by a behavioral analysis within the next individual therapy session, provided that there was no target higher on the hierarchy to address during that session (the individual therapist would be informed of the problem during team consultation; see Chapter 8 on conducting a behavioral analysis).
Finally, behaviors that burn out the therapist are addressed within the category of client therapy-interfering behaviors. These include behaviors that exceed the therapist’s personal limits (e.g., calling too frequently, repeatedly demanding extra session time); behaviors that push organizational limits (e.g., behaviors that threaten the program’s existence in a particular setting); behaviors that decrease the therapist’s motivation (e.g., hostile insults to the therapist, lack of progress toward goals); and behaviors that reduce milieu staff members’ or group members’ motivation (i.e., behaviors that reduce the motivation of others in the client’s environment to care for the client).
When working with adolescents, we include family members in treatment (see Chapter 9). Thus situations sometimes arise in which family members themselves engage in therapy-interfering behaviors. This provides a challenge, since the parents are not the clients per se and do not have the ongoing individual therapy format in which this might be addressed. The remaining chapters have woven through them discussions of how to handle family members’ therapy-interfering behaviors as they pertain to orientation and commitment, individual therapy and family sessions, skills training sessions, and crisis situations. As a general rule, however, when a family member’s therapy-interfering behavior also becomes therapy-interfering for the adolescent (e.g., not driving the teen to session, not permitting the teen to use the phone for in vivo coaching), the behavior also becomes a target for the adolescent’s own session. This is because regardless of the fact that the adolescent may not have caused the behavior, problem solving must nevertheless occur to preserve the adolescent’s participation in effective therapy.
Therapist behaviors that interfere with therapy are just as important as client behaviors that interfere with therapy. The two main classes of therapist behaviors that can impede therapy are becoming nondialectical and engaging in behaviors that convey a lack of respect for the client. Examples of becoming nondialectical involve becoming imbalanced, such as being too acceptance- or too change-focused, or being too flexible or too rigid. Examples of showing disrespect to adolescents are talking in a condescending manner (e.g., using a formal or authoritarian “doctor-to-client” air), or releasing information and getting the “necessary” consent from parent but not “sufficient” consent from the adolescent.
Usually, becoming imbalanced or failing to convey respect to the client results from understandable conditions within the therapy or within the therapist’s life outside the therapy. It is the role of the therapist consultation team to validate and support the therapist while helping him or her problem-solve to regain the balance needed for DBT. In DBT, clients are encouraged to bring up in session any behaviors on the part of the therapist that they experience as therapy-interfering. For adolescents, granting such permission is especially empowering and rewarding, and conveys a level of respect that they may perceive as rarely coming from adults.
Suicidal clients often engage in a host of behaviors that, although not directly life-threatening, relate to maintaining a life of misery and interfere with building a life worth living. For adolescents, these behaviors may include the following: dysfunctional interpersonal relationship interactions (e.g., staying in abusive relationships, alienating caregivers); school-or work-related dysfunctional behaviors (e.g., cutting classes, failing exams or courses, being fired from an after-school job); impulsive behaviors (e.g., anger outbursts, promiscuous or unprotected sex); substance-abuse-related behaviors (e.g., driving while intoxicated); antisocial behaviors (e.g., violence, gang membership); mental-health-related dysfunctional behaviors (e.g., repeated hospitalizations, emergency room visits); other Axis I or Axis II diagnostic features (e.g., depression, social phobia); problems in maintaining physical health (e.g., not following medication regimens, such as insulin for clients with diabetes); and behaviors that interfere with long-term goals (e.g., extreme behavioral passivity, dropping out of high school, getting pregnant).
For a therapist working with an adolescent, targeting quality-of-life-interfering behaviors often requires a judgment call. For example, marijuana or alcohol use can clearly interfere with a teen’s quality of life and relate to a pattern of risk behavior or other dysfunction. On the other hand, it is developmentally normative for adolescents to experiment with drugs and alcohol (see Chapter 5). Thus, with ambiguous behavior patterns, the therapist will need to assess whether the behavior seems extreme (e.g., addiction to heroin and selling drugs in high school to support the habit, as opposed to trying marijuana at a party); whether it relates to other risk patterns (e.g., getting drunk and then driving); whether it interferes with therapy (e.g., causing the teen to miss many therapy sessions in a row); or whether it threatens life (e.g., predictably precipitating a suicide attempt). Thus the therapist’s task becomes both determining whether a behavior merits analysis as a target or not, and determining where in the hierarchy of targets a behavior falls. For example, a therapist might target a high-risk sexual practice (e.g., sex without using a condom, sex with multiple partners) as a behavior that threatens quality of life (e.g., it may result in an unwanted pregnancy or contraction of a nonfatal sexually transmitted disease), or may be tempted to target it as a behavior that threatens life itself (e.g., it may lead to contracting HIV). Note, however, that generally the classification of life-threatening behaviors is limited to those risk behaviors that involve intentional self-injury or that have realistic, imminent threat to life (thus behavior with risk of contracting HIV would not qualify).
Therefore, even though behaviors such as drunk driving and promiscuous sex could prove fatal, they would usually still be categorized under quality-of-life-interfering behaviors. In work with adolescents, therapists sometimes tend to move up the priority of such targets in response to the parents’ urgings to do so. In addition, the therapist’s own values will inevitably have some influence on the degree to which he or she will address certain behaviors, and may influence where he or she will place certain behaviors within the target hierarchy. It will be beneficial for the therapist to try to be aware of the role his or her values are playing in identifying behavioral targets, and to attempt to find the middle way between an overly lax and an overly conservative position. When in doubt, the therapist should bring these questions to the therapist consultation group. In addition, for ambiguous behavior patterns, the therapist will want to work collaboratively with the client to determine where these behaviors should be placed on the hierarchy. In general, the therapist will need to remember to assess carefully whether the behavior in question actually interferes with the adolescent’s life quality, interferes with therapy, or threatens life, rather than blithely making assumptions. Behaviors deemed less harmful or serious (e.g., ordinary relationship conflict, ambivalence over career choice) are treated in later stages of DBT.
As part of the aim of building a life worth living by reducing the aforementioned target behaviors, DBT simultaneously targets increasing behavioral skills. The skills training group provides the main forum for the acquisition and strengthening of these skills, while individual therapy helps clients to generalize the skills to the situations they encounter in their lives.
The skills taught in DBT correspond directly to the DBT conceptualization of the DSM-IV-TR BPD criteria. According to this conceptualization, these criteria fall into areas of dysregulation across several domains. DBT for adolescents maintains this conceptualization, even if an adolescent does not meet full criteria for BPD. The areas of dysregulation and the corresponding skills modules follow:
Interpersonal dysregulation: Interpersonal Effectiveness Skills
Behavioral and cognitive dysregulation: Distress Tolerance Skills
Emotion dysregulation: Emotion Regulation Skills
Self dysregulation: Core Mindfulness Skills
For adolescents and their families, in addition to these specific skills, we have developed a fifth module (Walking the Middle Path Skills) to address unbalanced thinking and behaviors. (This is discussed in Chapter 10; see also Appendices B and C.)
In the Chapter 4 we take a more detailed look at each treatment mode, including skills training, and discuss how it addresses Stage 1 treatment targets. As we will see, each mode addresses Stage 1 targets, but the hierarchy of those targets shifts according to the mode’s function. The following section describes the various treatment strategies employed in DBT.
‘Treatment strategies” in DBT are coordinated sets of procedures used to achieve specific treatment goals. Although DBT strategies usually consist of a number of steps, use of a strategy does not necessarily require the application of every step. It is considerably more important that the therapist apply the intent of the strategy, rather than inflexibly leading the client through a series of prescribed maneuvers.
DBT employs five sets of treatment strategies to achieve the previously described behavioral targets: (1) dialectical strategies, (2) validation strategies, and (3) problem-solving strategies; (4) stylistic strategies; and (5) case management strategies. DBT strategies are illustrated in Figure 3.1. Within an individual session and with a given client, certain strategies may be used more than others, and not all strategies may be necessary or appropriate. Validation and problem-solving strategies, together with dialectical strategies, make up the core of DBT and form the heart of the treatment. DBT core strategies are listed in Figure 3.2. An abbreviated discussion of the DBT treatment strategies follows. For greater detail, the reader is referred to the treatment manual (Linehan, 1993a).
Dialectical strategies permeate the entire therapy. There are three types of dialectical strategies. The first has to do with how the therapist structures interactions within the therapy relationship; the second involves how the therapist defines skillful behaviors; and the third consists of certain specific strategies used during the conduct of treatment.
FIGURE 3.1. Treatment strategies in DBT.
From Linehan (1993a). Copyright 1993 by The Guilford Press. Reprinted by permission.
FIGURE 3.2. DBT core strategies.
From Linehan, Cochran, and Kehrer (2001). Copyright 2001 by The Guilford Press. Reprinted by permission.
Dialectical strategies in the most general sense of the word have to do with how the therapist balances the dialectical tensions within the therapy relationship. As noted above, the fundamental dialectic within any psychotherapy, including that with clients who have BPD, is between acceptance and change. A dialectical therapeutic position is one of constantly combining acceptance with change, flexibility with stability, nurturing with challenging, and a focus on capabilities with a focus on deficits. The goal is to bring out the opposites, both in therapy and the client’s life, and to provide conditions for syntheses. The presumption is that change may be facilitated by emphasizing acceptance, and acceptance by emphasizing change. The emphasis upon opposites sometimes takes place over time (i.e., over the whole of an interaction), rather than simultaneously or in each part of an interaction. Although many if not all psychotherapies, including cognitive and behavioral treatment, attend to these issues of balance, placing the concept of balance at the center of the treatment assures that the therapist remains attentive to its importance.
Strategies emphasizing acceptance are very similar to (or in some cases identical to) strategies used in client-centered therapy, as well as the case management outreach strategies emphasized in community psychiatry. Those emphasizing change are drawn primarily from cognitive and behavioral therapies. The categorization is artificial, however, since in many ways every strategy comprises both acceptance and change. Indeed, the best strategies are those that combine acceptance and change in one move. The overall emphasis on balance (both within and outside of therapy) is similar to that in gestalt and systems therapies.
Behavioral extremes and rigidity—whether these are cognitive, emotional, or overtly behavioral—are signals that synthesis has not been achieved, and thus can be considered non-dialectical. Instead, a middle path similar to that advocated in Zen Buddhism is advocated and modeled. “The middle way is not halfway between extremes, but a completely new path” (Aitken, 2003). This emphasis on balance is similar to the approach advocated in the relapse prevention model proposed by Marlatt and his colleagues (e.g., Marlatt & Donovan, 2005) for treating addictive behaviors. Thus the therapist helps the client move from “either-or” to “both-and.” The key here is not to invalidate the first idea or polarity when asserting the second.
here are eight specific dialectical treatment strategies: (1) entering the paradox, (2) using metaphor, (3) playing the devil’s advocate, (4) extending, (5) activating the client’s “wise mind,” (6) making lemonade out of lemons (turning negatives into positives), (7) allowing natural change (and inconsistencies even within the therapeutic milieu), and (8) assessing dialectically by always asking the question “What is being left out here?” We describe a selection of these strategies below. For a complete review, the interested reader is referred to the DBT treatment manual (Linehan, 1993a).
Entering the paradox is a powerful strategy because it contains the element of surprise. The therapist presents the paradox without explaining it and highlights the paradoxical contradictions within the behavior, the therapeutic process, and reality in general. The essence of the strategy is the therapist’s refusal to step in with rational explanation; the client’s attempts at logic are met with silence, a question, or a story designed to shed a small amount of light on the puzzle to be solved. The client is pushed to achieve understanding, move towards synthesis of the polarities, and resolve the dilemma him- or herself.
Linehan (1993a) has highlighted a number of typical paradoxes and their corresponding dialectical tensions encountered over the course of therapy. For example, clients are free to choose their own behavior, but can’t stay in therapy if they do not work at changing their behavior. Clients are taught to achieve greater independence by becoming more skilled at asking for help from others. Clients have a right to kill themselves, but if they ever convince the therapist that suicide is imminent, they may be locked up. Clients are not responsible for being the way they are, but they are responsible for what they become. In highlighting these paradoxical realities, both client and therapist struggle with confronting and letting go of rigid patterns of thought, emotion, and behavior, so that more spontaneous and flexible patterns may emerge.
The use of metaphor, stories, parables, and myth is extremely important in DBT and provides an alternative means of teaching dialectical thinking. Stories are usually more interesting than didactic teaching approaches, are easier to remember, and encourage the search for different meanings of events under scrutiny. In general, the idea of metaphor is to take something the client does understand, and compare it to something the client does not understand. Used creatively, metaphors can aid understanding, suggest solutions to problems, and reframe both the problems of clients and those of the therapeutic process.
The devil’s advocate strategy is quite similar to the argumentative approach used in rational–emotive and cognitive restructuring therapies as a method of addressing a client’s dysfunctional beliefs or problematic rules. In this strategy, the therapist presents a propositional statement that is an extreme version of one of the client’s own dysfunctional beliefs, and then plays the role of devil’s advocate to counter the client’s attempts to disprove the extreme statement or rule. For example, a client may state, “Because I’m overweight, I’d be better off dead.” The therapist argues in favor of the dysfunctional belief, perhaps by suggesting that since this is true for her, the client, it must be true for others as well; hence all overweight people would be better off dead. The therapist might continue along these lines as follows: “And since the definition of what constitutes being overweight varies so much among individuals, there must be an awful lot of people who would be considered overweight by someone. That must mean they’d all be better off dead!” And “Gosh, I’m about 5 pounds overweight. I guess that means I’d be better off dead, too.” Any reservations the client proposes can be countered by further exaggeration until the self-defeating nature of the belief becomes apparent.
The therapist often plays devil’s advocate the first several sessions to elicit a strong commitment from the client. When the strategy is used in this manner, the therapist argues that since the therapy will be painful and difficult, it is not clear how making such a commitment (and therefore being accepted into treatment) could possibly be a good idea. This usually has the effect of moving the client to take the opposite position in favor of therapeutic change. For this use of the strategy to be successful, it is important that the therapist’s argument seem reasonable enough to invite counterargument by the client, and that the argument be delivered with a straight face, in a naive but offbeat manner.
The term “extending” has been borrowed from aikido, a Japanese form of self-defense. In that context, extending occurs when the aikido practitioner waits for a challenger’s movements to reach their natural completion, and then extends their endpoint slightly further than what would naturally occur, leaving the challenger vulnerable and off balance. In DBT, extending occurs when the therapist takes the severity or gravity of what the client is communicating more seriously than the client intends, or responds to a part of the client’s communication that is not the part the client intends to be taken seriously. This strategy is the emotional equivalent of the devil’s advocate strategy. It is particularly effective when the client is threatening dire consequences of an event or problem. Take the following interaction with a client, who is threatening suicide if an extra appointment time for the next day is not scheduled. The interchange occurs after attempts to find a mutually acceptable time have failed.
CLIENT: I’ve got to see you tomorrow, or I’m sure I will end up killing myself. I just can’t keep it together by myself any longer.
THERAPIST: Hmm, I didn’t realize you were so upset! We’ve got to do something immediately if you are so distressed that you might kill yourself. What about hospitalization? Maybe that is needed. Should I call your parents?
CLIENT: I’m not going to the hospital! And you can’t call my parents. Why won’t you just give me an appointment?
THERAPIST: How can we discuss such a mundane topic as session scheduling when your life is in danger? How are you planning to kill yourself?
CLIENT: You know how. Why can’t you cancel someone or move an appointment around? You could put an appointment with one of your students off until another time. I can’t stand it any more.
THERAPIST: I’m really concerned about you. Do you think I should call an ambulance?
The aspect of the communication that the therapist takes seriously (suicide as a possible consequence of not getting an appointment) is not the aspect (needing an extra appointment the next day) that the client wants taken seriously. The therapist takes the consequences seriously and extends the seriousness even further. The client wants the problem taken seriously, and indeed is extending the seriousness of the problem. What typically occurs when the therapist uses this strategy is that the client then deescalates the extreme communication (e.g., “No, don’t bother calling an ambulance—I’m not going to do anything. I just really want to see you tomorrow!”) The therapist can then attend directly to problem solving in regard to the client’s request, thereby reinforcing the deescalated and direct communication (minus the threat) about the problem.
Making lemonade out of lemons is similar to the notion in psychodynamic therapy of utilizing a client’s resistances; therapeutic problems are seen as opportunities for the therapist to help the client. The strategy involves taking something that is apparently problematic and turning it into an asset. Problems become opportunities to practice skills; suffering allows others to express empathy; weaknesses become strengths. The danger in using this strategy is that it is easily confused with the invalidating refrains repeatedly heard by clients with BPD or borderline features. The therapist should avoid the tendency to oversimplify the client’s problems, and refrain from implying that the lemons in his or her life are really lemonade. While recognizing that the cloud is indeed black, the therapist assists the client in finding the positive characteristics of a situation and thus the silver lining.
As noted earlier, validation and problem-solving strategies, along with dialectical strategies, constitute the core of DBT and the heart of the treatment. Validation strategies are the most obvious acceptance strategies, while problem-solving strategies are the most obvious change strategies. Both validation and problem-solving strategies are used in every interaction with the client, although the relative frequency of each depends on the particular client and the current situation and vulnerabilities of that client. Many treatment impasses are due to an imbalance of one strategy over the other.
Clients with BPD or borderline features present themselves clinically as individuals in extreme emotional pain. They plead, and at times demand, that the therapist do something to change this state of affairs. It is very tempting to focus the energy of therapy on changing the client by modifying irrational thoughts, assumptions, or schemas; critiquing interpersonal behaviors or motives contributing to interpersonal problems; giving medication to change abnormal biology; reducing emotional overreactivity and intensity; and so on. In many respects, this focus recapitulates the invalidating environment by confirming the client’s worst fears: The client is the problem, and indeed cannot trust his or her own reactions to events. Mistrust and invalidation of a person’s response to events, however, is extremely aversive and can elicit intense fear, anger, shame, or a combination of all three. Thus the entire focus of change-based therapy can be aversive, since by necessity the focus contributes to and elicits self-invalidation.
“Validation” (according to the online version of the Oxford English Dictionary; Simpson & Weiner, 1989) means “a strengthening, reinforcement, confirming; an establishing or ratifying.” It includes activities such as confirming, corroborating, substantiating, verifying, and authenticating. The act of validating is “to support or corroborate on a sound or authoritative basis…to attest to the truth or validity of something.” To communicate that a response is valid is to say that it is “well-grounded or justifiable: being at once relevant and meaningful…logically correct…appropriate to the end in view [or effective]…having such force as to compel serious attention and [usually] acceptance.” These are precisely the meanings associated with the term when used in the context of psychotherapy in DBT.
The essence of validation is this: The therapist communicates to the client that her [sic] responses make sense and are understandable within her [sic] current life context or situation. The therapist actively accepts the client and communicates this acceptance to the client. The therapist takes the client’s responses seriously and does not discount or trivialize them. Validation strategies require the therapist to search for, recognize, and reflect to the client the validity inherent in her [sic] response to events. With unruly children, parents have to catch them while they’re good in order to reinforce their behavior; similarly, the therapist has to uncover the validity within the client’s response, sometimes amplify it, and then reinforce it. (Linehan, 1993a, pp. 222–223; emphasis in original)
Two things are important to note here. First, validation means the acknowledgment of that which is valid. It does not mean “making” valid. Nor does it mean validating that which is invalid. The therapist observes, experiences, and affirms, but does not create validity. Second, “valid” and “scientific” are not synonyms. Science may be one way to determine what is valid, but the following are also bases for claiming validity: logic, sound principles, generally accepted authority or normative knowledge, and experience or apprehension of private events (at least when these are similar to the same experiences of others or are in accord with other, more observable events).
Validation can be considered at any one of six levels. Each level is correspondingly more complete than the preceding one, and each level depends on one or more of the previous levels. The first two levels of validation encompass activities usually defined as empathic, and the third and fourth levels are similar to empathic interpretations as those terms are used in the general psychotherapy literature. Although surely most therapists use and support Levels 5 and 6 of validation, they are much less often discussed in the literature. They are, however, definitional of DBT and are required in every interaction with the client. These levels are described most fully in Linehan (1997), and the following definitions are taken from her discussion.1
[At Level 1], validation requires listening to and observing what the client is saying, feeling, and doing as well as a corresponding active effort to understand what is being said and observed. The essence of this step is that the therapist is interested in the client. The therapist pays attention to what the client says and does. The therapist notices the nuances of response in the interaction. Validation at [Level 1] communicates that the client per se, as well as the client’s presence, words, and responses in the session have “such force as to compel serious attention and [usually] acceptance” [see definitions of “validation” above]. (pp. 360-361; emphasis in original)
The second level of validation is the accurate reflection back to the client of the client’s own feelings, thoughts, assumptions, and behaviors. The therapist conveys an understanding of the client, a hearing of what the client has said, and a seeing of what the client does, how he or she responds. Validation at [Level 2] sanctions, empowers, or authenticates that the individual is who he or she actually is. (p. 362)
[At Level 3] of validation, the therapist communicates to the client understanding of aspects of the client’s experience and response to events that have not been communicated directly by the client. At [this] level…the therapist “reads” the client’s behavior and figures out how the client feels and what the client is wishing for, thinking, or doing just by knowing what has happened to the client. It is when one person can make the link between precipitating event and behavior without being given any information about the behavior itself. Emotions and meanings the client has not expressed are articulated by the therapist.” (p. 364)
[At Level 4], behavior is validated in terms of its causes. Validation here is based on the notion that all behavior is caused by events occurring in time and, thus, in principle is understandable. Behavior is justified by showing that it is caused. Even though information may not be available to know all the relevant causes, the client’s feelings, thoughts, and actions make perfect sense in the context of the person’s current experience, physiology, and life to date. At a minimum, what is can always be justified in terms of sufficient causes. That is, what is “should be” in that whatever was necessary for it to occur had to have happened. (p. 367)
[At Level 5], the therapist communicates that behavior is justifiable, reasonable, well-grounded, meaningful, and/or efficacious in terms of current events, normative biological functioning, and/or the client’s ultimate life goals. The therapist looks for and reflects the wisdom or validity of [the] client’s response and communicates that the response is understandable. The therapist finds the relevant facts in the current environment that support the client’s behavior. The therapist is not blinded by the dysfunctionality of some of the client’s response patterns to those aspects of a response pattern that may be either reasonable or appropriate to the context. Thus, the therapist searches the client’s responses for their inherent accuracy or appropriateness, or reasonableness (as well as commenting on the inherent dysfunctionality of much of the response if necessary). (pp. 370-371; emphasis in original)
[At Level 6], the task is to recognize the person as he or she is, seeing and responding to the strengths and capacities of the individual while keeping a firm empathic understanding of the client’s actual difficulties and incapacities. The therapist believes in the individual and his or her capacity to change and move towards ultimate life goals. The client is responded to as a person of equal status, due equal respect. Validation at the highest level is the validation of the individual as “is.” The therapist sees more than the role, more than a “client,” or “disorder.” [This level of] validation is the opposite of treating the client in a condescending manner or as overly fragile. It is responding to the individual as capable of effective and reasonable behavior rather than assuming that he or she is an invalid. Whereas [Levels 1-5] represent sequential steps in validation of a kind, [Level 6] represents both change in level as well as kind. (p. 377)
Cheerleading strategies are another form of validation, and are the principal strategies for combating clients’ active passivity and tendencies to hopelessness. In cheerleading, therapists communicate the belief that clients are doing their best and validate their ability to eventually overcome their difficulties (a type of validation that, if not handled carefully, can simultaneously invalidate clients’ perceptions of their helplessness). In addition, the therapists express a belief in the therapy relationship, offer reassurance, and highlight any evidence of improvement. Within DBT, cheerleading is used in every therapeutic interaction. Although active cheerleading by therapists should be reduced as clients learn to trust and validate themselves, cheerleading strategies always remain an essential ingredient of a strong therapeutic alliance.
We have previously discussed how therapies with a primary focus on client change are typically experienced as invalidating by highly emotionally dysregulated clients. However, therapies that focus exclusively on validation can prove equally problematic. Exhortation to accept one’s current situation by itself offers little solace to an individual who experiences life as painfully unendurable. Within DBT, problem-solving strategies are the core change strategies, designed to foster an active problem-solving style. With emotionally dysregulated clients who have BPD or borderline features, however, the application of these strategies is fraught with difficulties. The therapist must keep in mind that the process will be more difficult than with many other client populations. In work with emotionally dysregulated clients, the need for sympathetic understanding and interventions aimed at enhancing current positive mood can be extremely important. The validation strategies just described, as well as the irreverent communication strategy to be described below, can be tremendously useful here.
Within DBT, problem solving is a two-stage process that concentrates first on understanding and accepting a selected problem, and second on generating and implementing alternative solutions. The first stage employs behavioral analysis, which also involves insight into recurrent behavioral context patterns, and the giving of didactic information about principles of behaviors, norms, and so on. The second stage specifically targets change by employing solution analysis, which also involves orienting the client to the specific therapeutic change procedures likely to bring about desired changes, and strategies designed to elicit and strengthen commitment to these procedures. The following discussion specifically addresses behavioral and solution analyses. (See also Chapter 8 for an illustration of how to conduct behavioral analysis and solution analysis with a client.)
Behavioral analysis is one of the most important strategies in DBT. It is also the most difficult. The purpose of a behavioral analysis is to select a problem and to determine empirically what is causing it, what is preventing its resolution, and what aids are available for solving it. Behavioral analysis addresses four primary issues:
Are ineffective behaviors being reinforced, are effective behaviors followed by aversive outcomes, or are rewarding outcomes delayed?
Does the client have the requisite behavioral skills to regulate emotions, respond skillfully to conflict, and manage his or her own behavior?
Are there patterns of avoidance, or are effective behaviors inhibited by unwarranted fears or guilt?
Is the client unaware of the contingencies operating in the environment, or are effective behaviors inhibited by faulty beliefs or assumptions?
Answers to these questions will guide the therapist in the selection of appropriate change procedures, such as contingency management, behavioral skill training, exposure, or cognitive modification. Thus the value of a behavioral analysis is in helping the therapist assess and understand a problem fully enough in order to guide effective therapeutic response.
The first step in conducting a behavioral analysis is to help the client identify the problem to be analyzed and describe it in behavioral terms. Problem definition usually evolves from a discussion of the previous week’s events, often in the context of reviewing diary cards. The assumption of facts not in evidence is perhaps the most common mistake at this point. Defining the problem is followed by conducting a chain analysis—an exhaustive, blow-by-blow description of the chain of events leading up to and following the behavior (i.e., antecedents and consequences).
In a chain analysis, the therapist constructs a general road map of how the client arrives at dysfunctional responses, including where the road actually starts, notated with possible alternative adaptive pathways or junctions along the way. Additional goals are to identify events that automatically elicit maladaptive behavior, behavioral deficits that are instrumental in maintaining problematic responses, and environmental and behavioral events that may be interfering with more appropriate behaviors. The overall goal is to determine the function of the behavior, or, from another perspective, what problem the behavior was instrumental in solving.
Chain analysis always begins with a specific environmental event. Pinpointing such an event may be difficult, as clients are frequently unable to identify anything in the environment that set off a problematic response. Nevertheless, it is important to obtain a description of the events co-occurring with the onset of the problem. The therapist then attempts to identify both environmental and behavioral events for each subsequent link in the chain. Here the therapist must play the part of a very keen observer, thinking in terms of very small chunks of behavior. The therapist asks the client, “What happened next?” or “How did you get from there to there?” Although from the client’s point of view such links may be self-evident, the therapist must be careful not to make assumptions. For example, a client who had frequently attempted suicide stated once that she tried to kill herself because her life was too painful to live any longer. From the client’s point of view, this was an adequate explanation for her suicide attempts. For the therapist, however, taking one’s life because life was too painful was only one possible solution. One could decide life was too painful, then decide to change one’s life. Or one could believe that death might be even more painful and decide to tolerate life despite its pain. In this instance, careful questioning revealed that the client actually assumed she would be happier dead than alive. Challenging this assumption then became a key to ending her persistent suicide attempts.
It is equally important to pinpoint exactly what consequences are maintaining the problematic response. Similarly, the therapist should also search for consequences that serve to weaken the problem behavior. As with antecedent events, the therapist probes for both environmental and behavioral consequences, obtaining detailed descriptions of emotions, somatic sensations, actions, thoughts, and assumptions. A rudimentary knowledge of the rules of learning and principles of reinforcement is crucial.
The final step in behavioral analysis is to construct and test hypotheses about events that are relevant to generating and maintaining the problem behavior. The biosocial theory of BPD suggests several factors of primary importance. For example, DBT focuses most closely on intense or aversive emotional states; the amelioration of negative affect is always suspected as among the primary motivational variables in dysfunctional behavior. The theory also suggests typical behavioral patterns, such as deficits in dialectical thinking or behavioral skills, that are likely to be instrumental in producing and maintaining problematic responses.
Once the problem has been identified and analyzed, problem solving proceeds with an active attempt at finding and identifying alternative solutions. Sometimes solutions will be suggested during the conduct of the behavioral analysis, and pointing to these alternative solutions may be all that is required. At other times a more complete solution analysis will be necessary. Here the first task is to “brainstorm” or generate as many alternative solutions as possible. Solutions should then be evaluated in terms of the various outcomes expected. The final step in solution analysis is choosing a solution that will somehow be effective. Throughout the evaluation, the therapist guides the client in choosing a particular behavioral solution. Here it is preferable for the therapist to pay particular attention to long-term gain rather than short-term gain, and for solutions to be chosen that render maximum benefit to the client rather than benefit to others.
DBT employs four sets of change procedures taken directly from the cognitive and behavioral treatment literature:
Skills training: Teaching the client new skills.
Contingency procedures: Providing a consequence that influences the probability of preceding client behaviors’ occurring again.
Exposure: Providing nonreinforced exposure to cues associated previously but not currently with a threat.
Cognitive modification: Changing the client’s dysfunctional assumptions or beliefs.
These four areas are viewed as primary vehicles of change, since they influence the direction that client changes take. Although they are discussed as distinct procedures by Linehan (1993a), it is not clear that they can in fact be differentiated in every case in clinical practice. The same therapeutic sequence may be effective because it teaches the client new skills (skills training), provides a consequence that influences the probability of preceding client behaviors’ occurring again (contingency procedures), provides nonreinforced exposure to cues associated previously but not currently with threat (exposure), and/or changes the client’s dysfunctional assumptions or schematic processing of events (cognitive modification). In contrast to many cognitive and behavioral treatment programs in the literature, these procedures (with some exceptions noted below) are employed in an unstructured manner, interwoven throughout all therapeutic interactions. Thus, although the therapist must be well aware of the principles governing the effectiveness of each procedure, the use of each is usually an immediate response to events unfolding in a particular session. The exceptions are in skills training, where skills training procedures predominate, and Stage 2, where exposure procedures predominate.
An emphasis on skill building is pervasive throughout DBT. In both individual and group therapy, the therapist insists at every opportunity that the client actively engage in the acquisition and practice of behavioral skills. The term “skill” is used synonymously with “ability,” and includes in its broadest sense cognitive, emotional, and overt behavioral skills, as well as their integration (which is necessary for effective performance). Skill training is called for when a solution requires skills not currently in the individual’s behavioral repertoire, or when the individual has the component behaviors but cannot integrate and use them effectively. As listed earlier, skills training in standard DBT includes training in mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. The training process incorporates three types of procedures: (1) skill acquisition (modeling, instructing, advising); (2) skill strengthening (encouraging in vivo and within-session practice, role playing, feedback); and (3) skill generalization (phone calls to work on applying skills, taping therapy sessions to listen to between sessions, homework assignments). In working with adolescents, we find it useful to include family members in skills training as well, since they can provide coaching for the adolescent and often themselves have important skills deficits.
Every response within an interpersonal interaction is a potential reinforcement, punishment, or withholding/removal of reinforcement. Contingency management requires therapists to organize their own behaviors so that client behaviors that represent progress are reinforced, while unskillful or maladaptive behaviors are extinguished or lead to aversive consequences. The most important contingencies with most clients are therapists’ interpersonal behaviors with the clients. The ability of a therapist to influence a client’s behavior is directly tied to the strength of the relationship between the two. Thus contingency procedures are less useful in the very beginning stages of treatment (except possibly in cases where the therapist is the “only game in town”). A first requirement for effective contingency management is that therapists attend to their clients’ behaviors and reinforce those behaviors that represent progress toward the clients’ treatment goals. Equally important is that therapists take care not to reinforce behaviors targeted for extinction. In theory this may seem obvious, but in practice it can be quite difficult. The problematic behaviors of emotionally dysregulated clients are often followed by positive increases in desired outcomes or cessation of painful events. Indeed, the very behaviors targeted for extinction have been intermittently reinforced by mental health professionals, family members, and friends. Note that contingencies operate no differently with family members involved in an adolescent’s treatment, and that family sessions and skills training sessions can at times highlight these contingencies (e.g., a parent may be reinforcing a teen’s maladaptive behaviors and ignoring adaptive behavior attempts). In fact, in the new Walking the Middle Path module of skills training, learning principles are taught explicitly to adolescents and family members, to help facilitate awareness of the contingencies operating in their interactions.
Contingency management will at times require the use of aversive consequences, similar to “setting limits” in other treatment modalities. Three guidelines are important here. First, punishment should “fit the crime,” and the client should have some way of terminating its application. For example, in DBT a detailed behavioral analysis follows a self-injurious act, and this analysis is an aversive procedure for most clients. Once it has been completed, however, the client’s ability to pursue other topics is restored. Second, it is crucial that therapists use punishment with great care, in low doses, and very briefly, and that a positive interpersonal atmosphere be restored following any client improvement. Third, punishment should be just strong enough to work. Although the ultimate punishment is termination of therapy, a preferable fall-back strategy is putting clients on “vacations from therapy.” This approach is considered when all other contingencies have failed, or when a situation is so serious that a therapist’s therapeutic or personal limits have been crossed. When utilizing this strategy, the therapist clearly identifies what behaviors must be changed, and clarifies that once the conditions have been met, the client can return. The therapist maintains intermittent contact by phone or letter, and provides a referral or backup while the client is on vacation. (In colloquial terms, the therapist kicks the client out and then pines for his or her return.)
Observing limits constitutes a special case of contingency management involving the application of problem-solving strategies to client behaviors that threaten or cross a therapist’s personal limits. Such behaviors interfere with the therapist’s ability or willingness to conduct the therapy, and thus constitute a special type of therapy-interfering behavior. Therapists must take responsibility for monitoring their own personal limits, and clearly communicate to their clients which behaviors are tolerable and which are not. Therapists who do not do this will eventually burn out, terminate therapy, or otherwise harm clients.
DBT favors natural over arbitrary limits. Thus limits will vary between therapists and within the same therapist over time and circumstances. Limits should also be presented as for the good of a therapist or treatment agency, not for the good of a client. The effect of this is that while clients may argue about what is in their own best interests, they do not have ultimate say over what is good for their therapists. Also, for adolescents this approach is often refreshing, compared to hearing parents’ requests of them as being “for their own good.”
All of the change procedures in DBT can be reconceptualized as exposure strategies. Many of the principles of exposure as applied to DBT have been developed by researchers in exposure techniques (see Foa & Kozak, 1986; Foa, Steketee, & Grayson, 1985). These strategies work by reconditioning dysfunctional associations that develop between stimuli (e.g., an aversive stimulus, hospitalization, may become associated with a positive stimulus, nurturing in the hospital; the client may later work to be hospitalized) or between a response and a stimulus (e.g., an adaptive response, healthy expression of emotions, is met with aversive consequent stimuli, rejection by a loved one; the client may then try to suppress emotions). As noted earlier, the DBT therapist conducts a chain analysis of the eliciting cue, the problem behavior (including emotions), and the consequences of the behavior. Working within a behavior therapy framework, the therapist operates according to three guidelines for exposure in DBT: (1) Exposure to the cue that precedes the problem behavior must be nonreinforced (e.g., if a client is fearful that discussing suicidal behavior will lead to being rejected, the therapist must not reinforce the fear by ostracizing the client); (2) dysfunctional responses are blocked, in the order of the primary and secondary targets of treatment (e.g., self-injurious behavior related to shame is blocked by getting the client’s cooperation to throw away hoarded medications); and (3) actions opposite to the dysfunctional behavior are reinforced (e.g., the therapist reinforces the client for talking about painful, shame-related self-injurious behavior).
Therapeutic exposure procedures are used informally throughout the whole of DBT and may be formally implemented when clients have suicidal behaviors under control and can cooperate in therapy. These procedures involve first orienting the client to the techniques and to the fact that exposure to cues is often experienced as painful or frightening. Generally, the therapist encourages the client to stay in contact with the cue—particularly when the cue is an image, an emotion, or a topic under discussion. The therapist does not remove the cue to emotional arousal, and at the same time helps the client block the action tendencies (including escape responses) associated with the problem emotion. In addition, the therapist works to assist the client in achieving enhanced control over the aversive event. A crucial step of exposure procedures is that the client be taught how to control the event. It is critical for the client to have some means of titrating or ending exposure when emotions become unendurable. The therapist and client should collaborate in developing positive, adaptive ways for the client to end exposure voluntarily. At a minimum, however, the client should be encouraged to continue exposure until some habituation occurs, marked by a noticeable reduction in the problem emotion (see Linehan, 1993a).
The fundamental message given to clients in DBT is that cognitive distortions are just as likely to be caused by emotional arousal as to be the cause of the arousal in the first place. The overall message is that for the most part, the source of a client’s distress is the extremely stressful events of his or her life, rather than a distortion of events that are actually benign. Although direct cognitive restructuring procedures, such as those advocated by Beck and by Ellis (Beck, Rush, Shaw, & Emery, 1979; Beck, Freeman, Davis, & Associates, 2003; Ellis, 1962, 1973) are used, they do not hold a dominant place in DBT. In contrast, contingency clarification strategies are used relentlessly, highlighting contingent relationships operating in the here and now. Emphasis is placed on highlighting both immediate and long-term effects of clients’ behavior, both on themselves and on others; clarifying the effects of certain situations on the clients’ own responses; and examining future contingencies the clients are likely to encounter. An example here is orienting clients to DBT as a whole and to treatment procedures as these are implemented.
Stylistic strategies have to do with the style and form of therapist communication—the “how” rather than the “what” of therapy. DBT balances two quite different styles of communication. The first, “reciprocal” communication, is similar to the communication style advocated in client-centered therapy. The second, “irreverent” communication, is quite similar to the style advocated by Whitaker (1975) in his writings on strategic therapy. Reciprocal communication strategies are designed to reduce a perceived power differential by making the therapist more vulnerable to the client. In addition, they serve as a model for appropriate but equal interactions within an important interpersonal relationship. Irreverent communication, in contrast, is designed to push the often rigid client off track so that new learning can take place. Irreverence by definition is an unexpected, somewhat “off-the-wall” response to a client. It can facilitate problem solving or produce a breakthrough after long periods when progress has seemed glacial. To be used effectively, irreverent communication must balance reciprocal communication, and the two must be woven into a single stylistic fabric. Without such balancing, neither strategy represents DBT.
Responsiveness, self-disclosure, and genuineness are the basic guidelines of reciprocal communication. Responsiveness requires taking the client’s agenda and wishes seriously. It is a friendly, affectionate style reflecting warmth and engagement in the therapeutic interaction. Both self-involving and personal self-disclosure, used in the interest of the client, are encouraged. Disclosure of immediate, personal reactions to the client and his or her behavior is frequent. For example, a therapist whose client complained about his coolness said, “When you demand warmth from me, it pushes me away and makes it harder to be warm.” Similarly, when a client repeatedly failed to fill out diary cards but nevertheless pleaded with her therapist to help her, the therapist responded, “You keep asking me for help, but you won’t do the things I believe are necessary to help you. I feel frustrated, because I want to help you but feel you won’t let me.” Such statements serve both to validate and to challenge a client. They are also instances of contingency management (because therapist statements about the client are typically experienced as either reinforcing or punishing) and of contingency clarification (because the client’s attention is directed to the consequences of his or her interpersonal behavior). Self-disclosure of professional or personal information is used to validate and model coping and normative responses.
Irreverent communication is used to push the client “off balance,” get the client’s attention, present an alternative viewpoint, or shift affective response. It is a highly useful strategy when the client is immovable, or when therapist and client are “stuck.” It has an “offbeat” flavor and uses logic to weave a web the client cannot get out of. Although it is responsive to the client, irreverent communication is almost never the response the client expects. The therapist highlights some unintended aspect of the client’s communication, or “reframes” it in an unorthodox manner. For example, if the client says, “I am going to kill myself, the therapist might say, “I thought you agreed not to drop out of therapy.” Irreverent communication has a matter-of-fact, almost deadpan style, which is in sharp contrast to the warm responsiveness of reciprocal communication. Humor, a certain naiveté, and guilelessness are also characteristic of the style. A confrontational tone is irreverent as well, communicating “bullshit” to responses other than the targeted adaptive response. For example, the therapist might say, “Are you out of your mind?” or “You weren’t for a minute actually believing I would think that was a good idea, were you?” The irreverent therapist also calls the client’s bluff. For the client who says, “I’m quitting therapy,” the therapist might respond, “Would you like a referral?” The trick here is to time the bluff carefully, with the simultaneous provision of a safety net; it is important to leave the client a way out.
Although all clients can benefit from this approach, the irreverent communication style works particularly well with adolescents. It helps command their respect and strengthens the alliance, and often differs greatly from the responses they are accustomed to from parents, teachers, doctors, or other authority figures. It is essential, however, never to use it in a mean-spirited way; the therapist must be mindful of his or her intentions and attitudes while using irreverence.
When there are problems in the client’s environment that interfere with the client’s functioning or progress, the therapist moves to the case management strategies. Although not new, case management strategies direct the application of core strategies around case management problems. There are three case management strategy groups: the consultation-to-the-patient 2strategy, environmental intervention, and the consultation team meeting.
The consultation-to-the-patient strategy is deceptively simple in theory and extremely difficult in practice. As its name indicates, the strategy requires the therapist to be a consultant to the client rather than to the client’s network. The overriding implications of this are that in general, a DBT therapist does not intervene to adjust environments for the sake of the client, and does not consult with other professionals about how to treat the client unless the client is present. According to this philosophy, the client, not the therapist, is the intermediary between the therapist and other professionals. The therapist’s job is to consult with the client on how to interact effectively with his or her environment, rather than to consult with the environment on how to interact effectively with the client. The consultation-to-the-patient strategy is the preferred case management strategy and perhaps the most innovative aspect of DBT.
This strategy was developed with three objectives in mind. First, clients must learn how to manage their own lives and care for themselves by interacting effectively with other individuals in the environment, including healthcare professionals. The consultant strategy expresses belief in clients’ capacities and targets their ability to take care of themselves. By doing too much for an adolescent client in particular, a therapist inadvertently interferes in the teen’s capacity to build mastery—a necessary ingredient in the treatment of depression. Second, the consultation-to-the-patient strategy was designed to decrease instances of so-called “splitting” between a DBT therapist and other individuals interacting with a client. Splitting occurs when different individuals in the person’s network hold differing opinions on how to treat the client. By remaining in the role of a consultant to the client, the therapist stays out of such arguments. Table 3.3 lists key corollaries to the consultation-to-the-patient strategy. Finally, this strategy promotes respect for clients by imparting the message that they are credible and capable of performing interventions on their own behalf.
With an adolescent, a practitioner might be tempted to alter the balance of consultation to the client versus consultation to the client’s network, believing that since the client is a minor, more consultation on his or her behalf is needed. Although this may be true at times, it is also beneficial to serve as consultant directly to the adolescent whenever possible. Adolescents can themselves benefit from enhancing their effective interactions with others, from reductions in “splitting,” and from the message that they are capable of advocating for themselves. For example, the therapist can consult with an adolescent regarding how to speak effectively with family members, other care providers, teachers, or bosses.
TABLE 3.3. Corollaries to the Consultation-to-the-Patient Strategy
1. Give other professionals general information about the treatment program.
2. Outside of the treatment team, do not discuss the client or his or her treatment without the client present.
3. Within the treatment team, share information, but keep the spirit of the strategy (i.e., let go of attachment to what other team members do with the client).
4. Do not tell other professionals how to treat the client.
5. Teach the client to act as his or her own agent in obtaining appropriate help.
6. Do not intervene or solve problems for the client with other professionals before giving the client a chance to solve the problem.
7. Do not defend other professionals.
Note. For further details, see Linehan (1993a, pp. 412–416).
Traditionally, health care professionals routinely exchange information helpful to whichever professional is currently treating the client. Thus routine use of the consultation-to-the-patient strategy will ordinarily require attention to orienting professionals in one’s own community to the strategy. Although consultation between professionals is actually encouraged, not discouraged, the requirement that the client be present (and, preferably, arrange the consultation) is almost always going to be different and require expenditure of some extra time. In our experience, however, once the community is oriented, the strategy works well and actually can save time in the long run. With adolescents, the idea of orienting professionals in the community to this strategy would apply when a therapist interacts regularly with school or healthcare professionals regarding teen clients. Orienting the community helps to ensure that the adolescents will be taken seriously rather than punished for direct communication and appropriate self-advocacy (e.g., when an adolescent assertively discusses troubling side effects of a medication with a treating physician).
As outlined above, the bias in DBT is toward teaching the client how to interact effectively with his or her environment. The consultation-to-the-patient strategy is thus the dominant case management strategy and is used whenever possible. There are times, however, when intervention by the therapist is needed. In general, the environmental intervention strategy is used over the consultation-to-the-patient strategy when substantial harm may befall a client if a therapist does not intervene. The general rule for environmental intervention is that when clients lack abilities that they need to learn, are impossible to obtain, or are not reasonable or necessary, the therapist may intervene.
Consultation with therapists is integral, rather than ancillary, to DBT. Consultation to the therapist, as a treatment strategy, balances the consultation-to-the-patient strategy discussed above. DBT, from this perspective, is defined as a treatment system in which (1) therapists apply DBT to the clients and (2) the consultation team applies DBT to the therapists. Thus the team actually “treats” the therapist, and in doing so it provides a dialectical balance for therapists in their interactions with clients.
There are three primary functions of consultation to the therapist in DBT. First, the consultation team helps to keep each individual therapist in the therapeutic relationship. The role here is to cheerlead and support the therapist. Second, the team balances the therapist in his or her interactions with the client. In providing balance, consultants may move close to the therapist, helping him or her maintain a strong position. Or consultants may move back from the therapist, requiring the therapist to move closer to the client to maintain balance. With adolescents and family members, the team will often help the therapist maintain balanced allegiances (e.g., helping with such struggles as seeing the parents as entirely to blame). Third, within programmatic applications of DBT, the team provides the context for the treatment. At its purest, DBT is a transactional relationship between and among a community of clients and a community of therapists.
This chapter is adapted from Linehan, Cochran, and Kehrer (2001). Copyright 2001 by The Guilford Press. Adapted by permission.
1All quotations are from Linehan (1997). Copyright 1997 by the American Psychological Association. Reprinted by permission.
2Although we prefer to use the term “client,” the strategy outlined in Linehan (1993a) is “consultation to the patient,” and we will use that term here to avoid confusion.