Assignment 19

NEW GENERATION COGNITIVE BEHAVIOUR THERAPIES:

Submitted by

Disha Toshniwal
Enrollment no. – 201199011
MSc Clinical Psychology (Semester 4)

Submitted to

Prof. Dinesh N. Kurup

Manipal College of Health Professionals, MAHE

Date of submission

13th April 2021

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 Contents

Introduction……………………………………………………………………...…………………….3

Foundation…………………………………………………….………………....…………………….5

Foundation in dialectical philosophy…………….…….………………....…………………….5

Foundation in Social Behavioural Theory…………….……….………....…………………….6

Foundation in Zen Practice and Contemplative Prayer……………….......…………………….7

Practice…………………………………………………………………............………………………8

Stages of DBT……………………………………….……………….......………………….....8

Skill Development in DBT…………………………..……………….......………………..….10

Conclusion…………………………………………...………………..……………….………..…....14

References…………………………………………….……………………………………………....15

Appendices…………………………………………….…………………...………………………....16

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 INTRODUCTION:

DBT in a nutshell

DBT is a cognitive-behavioural treatment originally developed by Marsha M. Linehan, PhD,

as a treatment first validated with suicidal women who met criteria for borderline personality

disorder (BPD). It’s focus was to help individuals who were often chronically suicidal and went

in and out of psychiatric hospitals to build lives they experienced as worth living. Its main goals

are to teach people how to live in the moment, develop healthy ways to cope with stress,

regulate their emotions, and improve their relationships with others.

DBT is a comprehensive program of treatment consisting of individual therapy, group therapy,

and a therapist consultation team. It is important to remember that the most critical element of

any DBT program has to do with whether it fulfils the five following key functions of treatment.

1. Enhancing capabilities.

Within DBT, the assumption is that patients with BPD either lack or need to improve

several important life skills, including those that involve

(a) regulating emotions (emotion regulation skills),

(b) paying attention to the experience of the present moment and regulating attention

(mindfulness skills),

(c) effectively navigating interpersonal situations (interpersonal effectiveness), and

(d) tolerating distress and surviving crises without making situations worse (distress

tolerance skills).

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2. Generalizing capabilities.

If the skills learned in therapy sessions do not transfer to patients' daily lives, then it

would be difficult to say that therapy was successful. So it is important DBT involves

generalizing treatment gains to the patient's natural environment.

3. Improving motivation and reducing dysfunctional behaviours.

A third function of DBT involves improving patients' motivation to change and

reducing behaviours inconsistent with a life worth living. The therapist may have the

patient complete a self-monitoring form (called a “diary card”) on which he or she

tracks various treatment targets (e.g., self-harm, suicide attempts, emotional misery).

4. Enhancing and maintaining therapist capabilities and motivation.

One of the essential ingredients of an effective treatment for BPD patients is a system

of providing support, validation, continued training and skill-building, feedback, and

encouragement to therapists. As these patients may engage in a potent mix of

behaviours that can tax the coping resources, competencies, and resolve of their

treatment providers.

5. Structuring the environment.

A fourth important function of DBT involves structuring the treatment in a manner that

most effectively promotes progress. Structuring the environment may also involve

helping patients find ways to modify their environments. For instance, drug-using

patients may need to learn how to modify or avoid social circles that promote drug use.

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 FOUNDATION:

Roots of DBT

Initial attempts to develop the treatment focused on a theoretical foundation comprised of

behaviourism, social learning theory, social psychology, and the cognitive behavioral therapy

principles of the time. The three major frameworks contributing to DBT theory are: dialectics,

social behavioral theory, and Zen practice.

FOUNDATION IN DIALECTICAL PHILOSOPHY

Dialectics emerged as a theoretical framework that holds together DBT’s focus on techniques

for both acceptance and change. Dialectics serves as a method of persuasion or argumentation

in which the therapist identifies and voices the contradictions (antithesis) in the client’s position

(thesis) and helps the client arrive at a new stance that can reconcile opposing views (synthesis).

DBT clinicians are thus agents of dialectical persuasion for one another.

Several principles speak to dialectics as a worldview.

First, the world is seen as being systemic, complex, and interconnected, made of “parts” that

together create a “whole.” The “parts” cannot be understood in isolation but only when one

considers how they relate to one another.

Second, the parts of the system are in continuous interaction with one another generating

constant change. Change is thus seen as the only constant in the system, something to be fully

embraced and accepted.

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The dialectical dilemmas are described as oscillations between two opposite poles of

behaviours. Not all patterns of such behaviours are present in everyone with high emotion

dysregulation and therapists (working individually or as team members) need to do their own

assessment to see the extent to which these dilemmas are relevant for each patient.

FOUNDATION IN SOCIAL BEHAVIORAL THEORY

Staat’s social behavioral model of personality represented the foundation for the behavioral

model of DBT (Staats & Staats, 1963; Staats, 1975). Following this model, three behaviour

response systems are fundamental for understanding human behaviour and function: the overt

behavioral response system, the cognitive response system, and the physiological/affective

response system. From this perspective, emotions are understood as responses of the entire

organism that include all three response systems which were interdependent, such that change

in one response system is likely to impact the other response systems.

Linehan developed the biosocial model of emotion dysregulation to explain developmental

factors that contribute to emotion dysregulation. The model comprises two factors that

interact with one another: an individual who is biologically vulnerable to have heightened

emotional responses (either due to heredity, epigenetics, or due to neural insults), and an

invalidating social environment that does not teach the child how to understand, accept,

tolerate, and manage emotions (particularly distressing or negative emotions).

Emotion dysregulation, and sometimes associated behavioral and cognitive dysregulation,

emerges because of repeated transactions between emotionally vulnerable individuals and

invalidating social environments.

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 FOUNDATION IN ZEN PRACTICE AND CONTEMPLATIVE PRAYER

The strong influence of Zen practice in DBT stems from Linehan’s search for a technology of

acceptance that would not have an ulterior goal of change. Linehan started her own quest for

discovering who were the best teachers of acceptance, which resulted in her focusing on Zen

practice and contemplative prayer teachings. Zen practice was chosen also because it fit well

with a behavioural worldview and techniques that were already at the core of DBT.

The main question to be answered was “What do people do when they practice Zen?”

recognizing that while meditation was one way of practicing Zen, it was not the only one.

DBT has two different foci in answering this question.

First, the DBT skill of “Wise Mind” was derived from the Zen teaching that everyone has an

inherent capacity for wisdom. The idea was not that the therapist embarks on a process to teach

a client how to be wise, but that the client already had that capacity within, and the role of the

therapist was to help him/her remove the barriers and develop the habit of accessing that

wisdom.

Second, DBT deconstructed mindfulness meditation into small pieces that therapists could

teach, and clients could learn and practice. Such practices leads to the skill of describing just

what is observed rather than what is interpreted.

The DBT skill of radical acceptance came both from Zen (letting go of attachment) and from

that of Christianity (“Thy will be done”) and willingness has roots in May’s work.

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 PRACTICE:

DBT at play

STAGES OF DBT

In order to effectively treat patients, DBT is divided into stages of treatment. The first stage of

treatment with all DBT clients is pre-treatment, followed by one to four subsequent stages. In

the pre-treatment stage, as with other

The number of subsequent stages depends on the extent of behaviour disorder when the client

begins treatment. The stages are defined by how severe a patient’s behaviours are. These are

the four stages:

Stage 1

In stage 1, the patient has out of control behaviour and typically feels miserable. Their

behaviour exhibits their emotional distress. They may be self-harming, trying to kill

themselves, using drugs or alcohol, or engaging in other self-destructive behaviours. Patients

typically describe their mental state during this stage as “hell”. The goal for DBT in stage 1 is

to help the patient move forward by gaining behavioural control.

Stage 2

During stage 2, a patient may be in control of their behaviours but continue to suffer in silence.

They often suffer due to past trauma and issues. While their behaviour is improving their

emotional and mental state is still inhibited. The goal of DBT in stage 2 is to get the patient out

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of their quiet desperation and into an emotionally healthy space. During this stage, past traumas

and any PTSD would be treated.

Stage 3

Stage 3 is where patients learn to live. Now that they have control over their behaviours and

are in an emotionally healthy place, they can learn how to live a functioning life. This is where

patients define goals, build up self-respect, and find happiness. The main goal of DBT in stage

3 is for the patient to live a normal life and be able to cope with the ups and downs that life

throws their way.

Stage 4

Unlike the first three stages, stage 4 is necessary for all patients. Here, patients learn to find

deeper meaning through a spiritual existence. Some patients need spiritual fulfilment to meet

their life goals. During stage 4, patients gain a sense of connectedness from being a part of a

greater whole and gain a capacity for experiencing joy and freedom.

Although the stages of therapy are presented linearly, progress is often not linear, and the stages

overlap. It is not uncommon to return to discussions like those of pre-treatment to regain

commitment to the treatment goals or methods.

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SKILLS DEVELOPMENT IN DBT

With DBT, one learns to use four core skills, sometimes called modules, to cope with emotional

distress in positive, productive ways. Linehan refers to these four skills as the “active

ingredients” of DBT.

Mindfulness and distress tolerance skills help one work toward acceptance of one’s thoughts

and behaviours. Emotion regulation and interpersonal effectiveness skills help one work

toward changing one’s thoughts and behaviours.

1. Mindfulness Skills

Mindfulness is about being aware of and accepting what’s happening in the present moment,

noticing and accepting your thoughts and feelings without judgement.

In the context of DBT, mindfulness is broken down into “what” skills and “how” skills.

“What” skills teach you what you’re focusing on, which might be: the present, your awareness

in the present your emotions, thoughts, and sensations separating emotions and sensations from

thoughts.

“How” skills teach you how to be more mindful by balancing rational thoughts with emotions,

using radical acceptance to learn to tolerate aspects of yourself (as long as they aren’t hurting

you or others), taking effective action, using mindfulness skills regularly, overcoming things

that make mindfulness difficult, such as sleepiness, restlessness, and doubt.

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 2. Distress tolerance

Distress tolerance skills help one get through rough patches without turning to potentially

destructive coping techniques.

These skills can help you: distract yourself until you’re calm enough to deal with the situation

or emotion, self-soothe by relaxing and using your senses to feel more at peace, find ways to

improve the moment despite pain or difficulty and compare coping strategies by listing pros

and cons.

3. Interpersonal effectiveness

Interpersonal effectiveness skills can help one be clear about these things. These skills combine

listening skills, social skills, and assertiveness training to help you learn how to change

situations while remaining true to your values.

These skills include:

1. Objective effectiveness or learning how to ask for what you want and take steps to get

it. This includes “DEAR MAN” Skills

 Describe.

 Express.

 Assert.

 Reinforce.

 Mindful.

 Appear confident.

 Negotiate.

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 2. Interpersonal effectiveness or learning how to work through conflict and challenges in

relationships. This includes “GIVE” Skills

 Gentle.

 Interested.

 Validate.

 Easy manner.

3. Self-respect effectiveness or building greater respect for yourself. This includes

“FAST” Skills

 Fair.

 Apologies / no apologies.

 Stick to value.

 Truthful.

4. Emotion regulation

Emotion regulation skills help one learn to deal with primary emotional reactions before they

lead to a chain of distressing secondary reactions. For example, a primary emotion of anger

might lead to guilt, worthlessness, shame, and even depression.

Emotion regulation skills includes:

1) Reducing Vulnerability Skills

 Treat physical illness.

 Eating.

 Altering drugs (only those prescribed by a doctor).

 Sleep.

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  Exercise.

2) Build Mastery Skills

 Build positive experiences.

 Be mindful of current emotion.

 Opposite to emotion action.

While Dialectical Behaviour Therapy focuses on the treatment of severely distressed

individuals, the means of working towards these goals are not mystical or mysterious. The

methods of furthering treatment are grounded in common sense and the straightforward

practice of skills. In fact, these skills are so generally applicable that many of them have

practical applications for everyone.

[Find a few examples of DBT worksheets attached at the end of the assignment]

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 CONCLUSION:

Empirical Evidence

In summary, the patients for whom DBT has the strongest and most consistent empirical

support include parasuicidal women with BPD. There also are some promising data on DBT

for women with BPD who struggle with substance use problems. Preliminary data suggest that

DBT may have promise in reducing binge-eating and other eating-disordered behaviours. DBT

is a comprehensive treatment that includes elements of several evidence-based, cognitive-

behavioural interventions for other clinical problems. As such, DBT often is applied in clinical

settings to multi-problematic patients in general, including those patients who have comorbid

Axis I and II disorders, and/or who are suicidal or self-injurious; however, caution is important

in applying a treatment beyond the patients with whom it has been evaluated in the research.

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 REFERENCES

Blennerhassett, R. (2008). Dialectical Behaviour Therapy in Clinical Practice. Quart J Mental

Health, 1(3), 15-21.

Chapman, A. L. (2006). Dialectical behaviour therapy: Current indications and unique

elements. Psychiatry (Edgmont), 3(9), 62.

Eist, H. I. (2015). DBT Skills Training Manual, Marsha M. Linehan (2015) New York: The

Guilford Press. 504 pp.: DBT Skills Training Handouts and Worksheets: Marsha M.

Linehan (2015) New York: The Guilford Press. 422 pp.

Lungu, A., & Linehan, M. M. (2017). Dialectical behaviour therapy: Overview, characteristics,

and future directions. The Science of Cognitive Behavioral Therapy, 429-459.

Van Dijk, S. (2013). DBT made simple: A step-by-step guide to dialectical behaviour therapy.

New Harbinger Publications.

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APPENDICES

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