DIALECTICAL BEHAVIOUR THERAPY

ASSIGNMENT
Vanshika Garg
MACLP 4B
(148)
Bipolar Disorder – Case Study
Karen’s Case
Karen was admitted to the intensive care unit of West Raymond medical Center
after she knowingly took an overdose of sedatives in addition to alcohol in a
suicide attempt following a disagreement with her man.
Consequently, the 32-year old single, unemployed woman lost consciousness
which meant that she had to inevitably spend three days in the hospital. While
still in the hospital the doctors never wanted to discharge her until they were
convinced that she was under the care of a psychotherapist. Karen’s
psychotherapist was, however, reluctant to respond to Karen’s calls concerning
her discharge citing that Karen, in a span of two years, had a record of three
suicide attempts.
Karen wanted to take away her life because three months her boyfriend, Gary,
had dumped her. Karen first met Gary, a 32-year-old construction worker in a
bar where a horrendous love affair between the two blossomed to the extent that
Karen started imagining spending the rest of her life with Gary. Karen was so
into Gary that she constantly wanted to hear from him. She never noticed that
the frequency with which she was meeting Gary was undergoing a temporal but
constant decrement. Ultimately, Karen realized the evasive nature of Gary and
started to suspect that Gary was gradually leaving her. One day while out with
Gary an argument ensued and they ended up breaking up. Borderline
Personality Disorder Case Study
Karen had been involved with other men before meeting Gary. For instance,
prior to meeting Gary, Karen was dating Eric. According to Karen’s roommate,
Karen had barely met Eric for a week before they started dating. Just like their
affair with Gary, their affair with Eric was short-lived. Similar stories can be
told about her alleged relationships with Ahmad, James, and Stefan who came
after Eric before she finally met Gary. Worth noting is the fact that immediately
after graduating from high school, Karen was married to George who was
overprotective to Karen and demanded that she only leave the house in his
company. Sadly George died in a car accident leaving Karen so much
devastated. These occurrences in Karen’s life made her excessively afraid of
being abandoned to the extent that she constantly would want to kill herself
whenever anyone abandons her- perhaps the reason why she constantly
complained that her roommate was leaving her even after they had spent a
whole day together. Borderline Personality Disorder Case Study
The doctors at West Raymond medical Center had to discharge Karen after her
psychiatrist refused to continue working with her. She was discharged to the
local mentor who continued giving her mentorship for some time before she
was recommended by one of the mentors to a Dialectical Behavior Therapist
called Dr. Banks. According to Dr. Banks, Karen met the requirements for
DSM-IV therapy for Borderline Personality Disorder. This is because one of her
greatest fears was abandonment. Again, her personal interpersonal relationship
was unstable together with an unstable self-image. Moreover, she had attempted
to commit suicide more than three times together with constant infliction of pain
to herself. Just like her sense of self, her moods were tremendously unstable
with constant feelings of emptiness which she displayed in undeserved anger.
To top it off, Karen’s life was profoundly marked with impulsiveness and
separation. All this was enough reason to render Karen one of the Dialectical
Behavior Therapy patients. Just like another dialectical behavior therapist, Dr.
Bank intended to address Karen’s condition from two perspectives; he wanted
Karen to participate in behavioral skills training groups that could enable her to
develop her behavioral skills. The doctor also intended to hold individual
psychotherapy sessions with Karen as a way of soothing her as well as offer
guidance on the application of the behavioral skills. Borderline Personality
Disorder Case Study
Diagnostic and statistical manual of mental disorders (DSM-IV-TR) describes
Borderline Personality Disorder as a “pattern of instability in interpersonal
relationships, self-image, and marked impulsivity” (American Psychiatric
Association, 2000). Adolph Stern was the first person to use the term borderline
in 1938 to describe patients who with disturbed neurotics (Wirth-Cauchon,
2001); the same characteristics that were being exhibited by Karen. Dialectical
Behavior Therapy (DBT) was developed by Marsha Linehan in 1993 with the
aim of helping people with overwhelming emotional shutdowns (Mckay, Wood
& Brantley, 2007). The therapy enjoys international accolades because of its
effectiveness in helping people with suicidal instincts; people like Karen. BPD
is caused by biological, psychological as well as social factors. Biologically,
BPD traits can be inherited from parents and can be carried until early
adulthood before it starts showing signs (Paris, 2005). Psychological and social
factors on the other hand do not influence this condition directly. Borderline
Personality Disorder Case Study
DBT considers reality to be dynamic and holistic and is carried out in stages
with the success of these stages being profoundly dependent on an individual
theoretical orientation. The theoretical orientations in this light are behavioral
science, dialectical philosophy, and Zen practice all balanced in balance by
dialectical frameworks. The therapy has four fundamental stages all of which
have pre-treatment activities and exercises before the beginning of each stage
(Freeman & Power, 2007). The first stage is a one-year-long stage that
underscores the pertinence of getting the patients’ behavior under control
(Freeman & Power, 2007). Like in Karen’s case, Dr. Bank had to first get Karen
to conform to the dictates of the treatment. The doctor urged Karen to stick to
therapy and avoid terminating the therapy while still underway by quitting or
trying to commit suicide again. Karen was also discouraged from using suicide
as a means of solving her life problems The second stage involves dealing with
the patient’s past trauma that according to Freeman & Power (2007) may lead to
the patient reverting to stage one behavior. Dr. Bank by all means tried to help
Karen forget the past incidences. Karen was also equipped with the ability to
soothe herself in case she remembers her past traumas. Then Karen on being
able to forget her past tribulations, the doctor moved with her to the next stage
that serves to deal with the long-term effects that Borderline Personality
Disorder might face their lives after the therapy is done. Linehan (1993) attests
that it is imperative that the therapist addresses the needs of each step before
moving to a higher stage. Further, Linehan (1993) asserts that how a session
with a borderline personality disorder patient ends is extremely valuable as it
determines whether the patient will move to the next stage. Linehan (1993) even
goes ahead to give strategies that therapists can use in ending a session. The
strategies involve issues like an opening discussion with the patient at the
beginning of a session, active planning before a session, to making referrals
(Linehan, 1993). As asserted by Freeman & Power (2007), there exist times
when a patient might be taken to a fourth stage in which the patient will be
under the care of a therapist, a spiritual advisor, or a teacher. This stage serves
to ameliorate the sense of incompleteness as well as enable the individual to
find lasting happiness (Miller, Rathus, and Linehan, 2006). As highlighted in
the last topic of Karen’s case, the therapy which lasted for over eighteen months
was successful. She stopped hurting herself and has since stopped taking
alcohol. Borderline Personality Disorder Case Study
DBT Therapy
There are underlying core elements that are unique to this therapeutic practice.
First, the therapy should start by articulating its purpose (Miller, Rathus, and
Linehan, 2006). The entire period of the therapy is regulated by these set
objectives. Secondly, the therapist must decide on a biosocial theory of the
disorder before considering the third element that involves the designing of a
developmental framework of the treatment stages with provisions of the
pretreatment. sessions (Miller, Rathus and Linehan, 2006). Fourthly, the
therapist should clearly highlight the behavior that he or she wants to tackle
within each stage (Miller, Rathus, and Linehan, 2006). Elements five and six
help the therapist formulate some key strategies of the therapy and decide on a
dialectical framework of the therapy respectively (Miller, Rathus, and Linehan,
2006). Notably, BPD has no medication that cures except for medication that
can only lower some of the effects that come along with it; effects like
depression.
Conversely, there are some behaviors by the patients that are known to interfere
with effective DBT administration. Linehan (1993a) describes these patterns to
be falling in three dimensions (as cited in Miller, Rathus, and Linehan, 2007).
Linehan (1993a) identifies the four patterns as; unrelenting crisis versus
inhibited grieving, emotional vulnerability versus self-invalidation, and lastly
active passivity versus apparent competence (as cited in Miller, Rathus, and
Linehan, 2006). Borderline Personality Disorder Case Study
Researches indicate that victims of BPD also experience some co-morbid
disorders (Clarkin, Marziali, and Munroe-Blum, 1992). The research of Axis 1
Co-morbidity and diagnostic overlap with BPD carried out by various
researchers by use of varied assessment tools show how BPD patients stand a
risk of suffering from other ailments that are connected to BPD. The findings
depicted that BPD patients were more impulsive, self-destructive, angry, and
showed signs of depression most of the time. 
Therapy Plan
DBT can be thought of as a “program”, given the different tools, modalities, and
resources it uses.
Teaching skills is one of the main objectives and requires time and practice.
Therefore, DBT will typically last for a year at a minimum. The four
components of DBT include:

 Individual therapy
 Group skills training
 Intersession contact
 Peer consultation
The 4 Stages and Targets of DBT
There are 4 stages of treatment in DBT, defined by the severity of the patient’s
behaviors. Therapists use this framework to support patients in achieving
certain goals.

 Stage I: behavioral
 Stage II: emotional and cognitive
 Stage III: interpersonal
 Stage IV: sense of self

There is no specific time frame designed for each one of the stages. The amount
of time spent within each stage will be determined by these goals.
Stage I: Behavioral
At this stage, a behavior is out of control: patients may try to kill themselves,
engage in self-harming behaviors, or use drugs and alcohol excessively. Self-
destructive behaviors can also occur at this stage, and mental illness could be
described as “being in hell”.
The goal is to achieve behavioral control.
Stage II: Emotional and Cognitive
Leaving life-threatening behaviors behind, patients may feel as living in quiet
desperation. Past trauma and invalidation may make suffering continuous for
them, this can cause the patient to inhibit emotion experiencing. Post-traumatic
stress disorder (PTSD) is addressed at this stage.
The goal is to move from quiet desperation to normative emotional
experiencing and expression.

Stage III: Interpersonal

Stage III is aimed at rebuilding a life and achieving skills generalization in
relationships and working environments. Life goals should be defined and self-
respect has to be built. Finding peace and happiness becomes the main focus.
The goal is to achieve ordinary happiness and unhappiness. LPR

Stage IV: Sense of self

This stage is optional and is often used with those patients who seek further
spiritual fulfillment or a sense of connection to a greater whole. Those patients
usually cannot stay with just a life of ordinary happiness and unhappiness from
the previous stage. LPR
Goal: Moving from a sense of incompleteness towards a life that involves an
ongoing capacity to experience joy and freedom.
DBT patients usually do not have just one problem that needs to be addressed,
but several ones. They may present multiple problematic behaviors that do not
fall under one specific diagnosis.
Where does the therapist start?
DBT uses a target hierarchy to determine the order in which problems should be
addressed:

1. Life-threatening behaviors. These behaviors, like with fire, should be

extinguished first due to the extreme risk to the patient’s life they entail.
They can include all forms of suicidal and non-suicidal self-harm,
suicidal ideation and communication, as well as other behaviors the
patient engages in for the purpose of causing him/herself physical harm.
2. Therapy-interfering behaviors.  They interfere with the client receiving
effective treatment. These behaviors can be on the therapist’s or the
client’s end and include arriving late or even missing sessions and a non-
collaborative stance in working towards treatment goals.
 3. Quality-of-life-interfering behaviors. These are other types of behavior
that prevent the patients from having a reasonable quality of life, such as
problematic relationships, mental illness, or housing crises.
4. Skills acquisition. This category refers to the need for patients to learn
new skill-full behaviors in order to replace ineffective ones and, in
consequence, achieve their goals. These skills are aimed at assisting in
building relationships, managing emotions and effectively dealing with
different life problems. 

All these should be addressed at Stage I.

PTSD should be addressed at Stage II, where the goal is to end the continuous
suffering and move to normative emotional experiencing.
In a typical session, many of the above-mentioned problems can be present. For
example, the patient may talk about a recent breakup and how he or she self-
injured to alleviate the emotional pain. In that case, the therapist will first target
self-harm (life-threatening behavior) and then the breakup (quality-of-life-
interfering behavior).
The underlying notion is that DBT will be ineffective if the patient is dead or
does not attend sessions.   
What are the goals of DBT?
Standard DBT focuses on the following 5 essential functions:

1. Improving behavioral capabilities by increasing skillful behavior

2. Increasing motivation to change through contingency management 
3. Confirming generalization of skillful behavior to the natural environment
4. Structuring the treatment environment so that it reinforces functional
rather than dysfunctional behaviors
5. Enhancing therapist capabilities and motivation to treat patients
effectively.
Enhancing Skills: The 4 Modules in DBT skills training

Mindfulness module
Mindfulness refers to putting one’s mind in a state of fullness. In other words, it
is the ability to live being intentionally aware of the present moment, without
judging and or staying attached to a particular moment.
There are 3 ways to practice mindfulness:

 Participate
 Observe
 Describe

Participate
Participating refers to doing only one thing at a time. The idea is to allow the
client to let go of self-consciousness, judgments, and fears; and to fully
concentrate on a particular activity.
Examples for clients:

o “Participating in only one activity might be different depending on

which activity you are doing.”
o “For example: If you are eating a piece of chocolate cake, you are
just eating a piece of chocolate cake. You shouldn’t be watching
TV, sending messages to your friends, and listening to music while
you eat the cake.”

Observe
Observing means directly noticing the sensory experience. It is composed of
what a person feels, tastes, sees, touches and hears without putting any labels on
it, reacting to it or judging it.
Examples for clients:

o “At first, it can be challenging for our minds, because they try to
label what is happening rather than just being with the bare
sensations of an experience.”
o “One example of observing is when you are listening to music,
imagine that your body is permeable to sounds and observe each
one of those sounds. You can also experience observing while
breathing gently and focusing your attention on the movement and
pauses of your belly, how it rises and falls during your breath.”
o “You can practice Observing by doing this activity of
mindful breathing.”

Describe
Describe is based on observing. To describe is to put words to what you are
observing, whether it is a thought, a sensation or an emotion.
This is a powerful tool to help clients identify and distinguish thoughts and
feelings from real facts. Highly sensitive clients can use this skill to reduce their
reactivity. When someone is describing, facts need to be checked to avoid
jumping into wrong conclusions about oneself or others.
Examples for clients:

o “Your own interpretations or assumptions shouldn’t be considered

to describe what you observe. Just stick to the facts.”
o “For example: imagine that your mind is a railroad and your
thoughts and emotions are wagons of a train that circulates on it,
describe them and label them as they pass by.”
o “Imagine that your mind is a river, thoughts and emotions are
ships that sail through it. You are sitting in front of it on the grass,
you can describe them while they pass.”

Interpersonal effectiveness module

One of the greatest struggles of borderline or emotionally dysregulated patients
is related to the difficulty in asking for what they want. Therefore, the
interpersonal effectiveness module focuses on setting clear goals (Objective
effectiveness), maintaining self-respect (Self-respect effectiveness), and, having
conflict-free relationships (Relationship effectiveness).
Dialectical behavior therapy uses acronyms to help clients remember the skills
tied to each type of effectiveness.

Objective effectiveness: DEAR MAN

“Be effective in maintaining your rights and wishes”

 D – Describe the situation

 E – Express how you feel about it
 A – Ask for what you want
 R – Reinforce the other person
 M – Be Mindful
 A – Appear confident
 N- Be willing to Negotiate

Relationship effectiveness: GIVE

“Act in such a way that you can maintain good relationships, that others feel
comfortable with you and with themselves”
G – Be Gentle, avoiding attacks and judgmental statements.
I – Act Interested by listening to the other person and not interrupting
V- Validate and acknowledge the other person’s wishes, feelings, and opinions
E- Easy manner, smiling and using humour
 
Self-respect effectiveness: FAST
“Act in such a way that you can maintain self-respect”
F- Be Fair to yourself and to the other party
A- Apologize less
S- Stick to your values
T- Be Truthful and avoid exaggerating
3. Distress tolerance module
Distress tolerance is geared toward increasing a person’s tolerance of negative
emotion, rather than trying to escape from it. The skills taught in this module
help the client survive crises from a more manageable emotional place.
This module explores six different skills:

 TIPP (Temperature, Intense Exercise, Paced breathing, and Paired muscle

relaxation).

 ACCEPTS (Activities, Contributing, Comparisons, Emotions, Push away,

Thoughts, and Sensation).

 Improving the moment

 Self-soothing

 Focusing on pros and cons

 Radical acceptance

TIPP
T- Temperature
The body increases its temperature when disturbed. If the client uses cold water
or ice, it could decrease the body’s temperature and help him/her to cool down
(both physically and emotionally).

 Instructions:
o Change your body temperature using cold water or ice.

I- Intense exercise
Increasing oxygen flow helps decrease stress levels. Exercising intensely will
help the body release energy that can sometimes be stored due to strong
emotions.

 Instructions:
o Walk quickly, climb the stairs, run on the spot.

P- Paced Breathing
Steady breathing reduces the body’s fight or flight response.

 Instructions:
 o Breathe in while counting to 5. Hold. Then exhale to the count of
7.

P- Paired muscle relaxation

This is a variation on progressive muscle relaxation. It is useful to gear towards
physically relaxing major and minor muscle groups in the body, to help release
tension and stress.

 Instructions:
o Tense an area of your body, notice the tension and hold it for 5 –
10 seconds.
o Then, release the tension and relax for 5 -10 seconds.  
o When relaxing the muscle, breathe out and say the word “Relax”.

ACCEPTS
This set of skills stands for Activities, Contributing, Comparisons, Emotions,
Push Away, Thoughts and Sensations.

The goal is to keep the clients’ emotions under control and help them tolerate
negative emotions until they can solve the problem.
Activities
Any healthy activity can be useful for this purpose. Activities that keep clients
busy and keep their minds off the negative emotion will help. If they finish with
one activity they should move to a new one. Examples include: cooking a
delicious dessert, washing dishes, and going for a walk.
Contributing
Giving service to other people can help clients get their minds off the problem
at hand. When we help others, we can feel good about ourselves and that helps
us to deal with stress.
Comparisons
Compare the client’s life with previous times when he or she has faced difficult
situations and challenges. If this is the most intense situation they have ever
experienced, they need to review the TIPP skills. They can also make
comparisons with other people who have suffered more than them. The aim of
this skill is to add a different perspective to what they are experiencing at the
moment.
Emotion
When you help the client to add a dose of the opposite emotion you can reduce
the intensity of the present one.  For example, if the clients feel depressed, make
them search on the internet for adorable puppies. This will make them feel less
depressed.
Push Away
A good strategy when clients cannot deal with a problem is to push it out of
their minds for a short period of time, by distracting themselves with other
activities, thoughts or being mindful. You can also advise them to set a time to
come back to the issue, so they will be relaxed in the meantime.
Thoughts
A client’s negative or anxious thoughts can be replaced with activities that make
their minds busy, such as solving a puzzle or crossword. These distractions will
help them avoid life-threatening behavior until they can reach emotional
regulation.
Sensations
The five senses can help clients self-soothe during times of distress. Activities
that appeal to their senses, like smelling a nice perfume or listening to music,
can help them cope with the problematic situation.  

Improving the moment (IMPROVE)

The goal of IMPROVE skills is to reduce the intensity of their emotions in any
kind of situation and feel more in control of their lives.
This set of skills stands for Imagery, Meaning, Prayer, Relaxation, One thing in
the moment, Vacation, and Encouragement.
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Self-soothing
Using the body’s senses can quickly reduce the intensity of negative emotions
during a crisis. Senses are a perfect tool that you are always carrying with you.
This tool can help reduce stress and the intensity of a situation. It is important to
focus on only one sense at a time, to be able to incorporate mindfulness into the
self-soothing skill.

 Sight: This sense is very useful to focus on something else. Make clients
focus on some pictures that they like or in the color of the room.
 Hearing: Make them listen to the sounds of birds, or their favorite song,
for example. Any sound is useful to practice hearing.
 Taste: Some small pieces of food that taste good can give them
something pleasurable to focus on while they are going through a tough
moment. A candy or piece of gum will work. It’s not necessary for them
to eat a whole meal.   
 Touch: Make the clients feel the sense of touch by noticing the tip of their
fingers when touching something or taking a warm bath or shower is
possible.
 Smell: No matter if it is a good or bad smell, clients should focus on the
scent that is in the air. They have to think about the smell and break it
down into its components.
 Movement: This is the sixth sense introduced by DBT. The emotional
state can be altered by body movements, so you can suggest clients take a
 walk around the block or dance. You can even make them play a football
match to make them conscious about movement.  

Focusing on the pros and cons

Taking into account the difficulties of making a wise decision, a Pro and Con
List can help the clients weigh out the consequences of their decisions.
Make clients do a few bullet points in their minds. Or, if they prefer, write that
list down on a piece of paper, so they can dig deep in their minds. Make them
think about which behavior is the best for them. This can help them fight
impulsive urges and their negative outcomes.  

Radical acceptance
Distress tolerance involves Radical acceptance. It means that clients are able to
acknowledge situations in their lives that they have no control over and fully
accept them as reality, rather than fighting against them by denying that they
exist or complaining because they are unfair.

4. Emotion regulation module

The objective of regulating emotions is to teach clients how to handle negative
and overwhelming emotions while increasing positive experiences. There are
three main goals in emotion regulation:
Understanding emotions
Negative emotions should not be avoided. They are a normal part of life, but
they should not take full control either. The client must learn how to label
his/her emotions.
In DBT, clients are often taught to be specific about how they feel. Instead of
describing it as “I feel bad”, they have to put a label to it, like feeling “anxious”
or “frustrated”.  
Reducing emotional vulnerability
The purpose of this skill is to build positive experiences in order to balance
life’s negative feelings and incidents. Patients are encouraged to plan daily
experiences that they can enjoy and expect, such as playing sports, spending
time with good friends, or reading a book. Engagement in these activities has to
be mindful, completely centering attention on the activity they are currently
doing. They are also encouraged to set long-term goals that can provide positive
experiences to them.
The acronym for the skillset aimed to reduce emotional vulnerability is
PLEASE MASTER:
PL – represents taking care of physical health and treating pain and/or illness.
E – is for eating. Having a balanced diet and avoiding excessive sugar, fat, and
caffeine.
A – stands for avoiding alcohol and drugs, which only exacerbate emotional
instability.
S – represents getting regular and adequate sleep.
E – is for exercising regularly.
MASTER – refers to having daily activities that build confidence and
competence.
Decreasing emotional suffering
Two skills compose this module: letting go and taking opposite action.

 Letting go

This skill refers to being aware of the current emotion by being mindful,
labeling it, and then letting it go—rather than avoiding, dwelling on, or fighting
it. This might involve taking a deep breath and visualizing the thought or feeling
floating away, or picturing the emotion as a wave that comes and then goes.

 Taking opposite action

This skill requires engaging in behaviors that would come naturally when
experiencing the emotion that is in direct contrast to the current one.
The patient will be required to label the emotion and let it go. The main purpose
is not to deny the current emotion, but to act opposite to it. This way, the
negative emotion will be less intense. For example, if a patient is very angry she
could try to speak in a soft and calm voice.