Dialectical Behavior

Therapy
Paulette Aasen, Ph.D.
Director of Psychology Services
West Central Human Service Center

Bismarck, ND
(701) 328-8888

Badlands Human Service Center

Dickinson, ND
(701) 227-7500

February 10, 2014

Overview of DBT
Developed

by Marsha Linehan, Ph.D., in

1993 as treatment for clients struggling
with severe & persistent emotional,
behavioral, & thought difficulties, especially
those diagnosed with Borderline Personality
Disorder.

Dr.

Linehan recently shared that she

struggles with Borderline Personality
Disorder.

The

Goal of DBT: Create a life worth

living.

Foundations of DBT
DBT

is a synthesis of three paradigms:

Dialectics
Behaviorism
Mindfulness
Purpose:

Reducing dysfunctional behaviors

Increasing skillful behaviors
Building a life worth living
Client

needs validating environment in

which s/he is taught to regulate emotions,
deal with interpersonal conflicts, tolerate
distress, and find balance.

Swenson, Witterholt, & Bohus, 2007

Linehan Diagnosis for

Borderline Personality Disorder
Emotion

Dysregulation

Affective lability
Problems with anger
Interpersonal

Dysregulation

Chaotic relationships
Fears of abandonment
Self

Dysregulation

Identity disturbance difficulties with sense of self

Sense of emptiness
Behavioral

Dysregulation

Parasuicidal behavior
Impulsive behavior
Cognitive

Dysregulation

Dissociation / paranoid ideation

(Linehan, 1993)

Bio-Social Model
Biological Sensitivity
AND Invalidating Environment =
Dsyregulation Disorder Symptoms
Invalidati
ng
Environm
ent

Invalidati
ng
Environm
ent

Invalidati
ng
Environm
ent

Biology
Biology

Biology

Bio-Social Model (cont.)

High

Sensitivity
High Reactivity
Slow Return to Baseline
Often Transactional with the
Environment

Slow Return to Baseline

9
8
7

Emotion
s

6
5
4
3
2
1
0

Average
Dysregulated
Threshold

Dialectical Paradigm
Dialectics is the theory that opposites can co-exist.

Hegel: Process of change in which a

concept or its realization passes over into
and is preserved and fulfilled by its
opposite.
Bohr: The Universe is so constructed that
the opposite of a true statement is a false
statement, but the opposite of a profound
truth is usually another profound truth.

Dialectical Paradigm

From DBT Self Help at

http://www.dbtselfhelp.com

Dialectics: A Model for

Change
Thesis

Antithes
is

Synthesis

Movement Over Time

Primary Dialectic in DBT

Acceptan
ce

Change

Dialectical Dilemmas
Unrelentin
g Crisis

Emotional
Vulnerabili
ty

Active
Passivity

Biological
Social

Apparent
Competen
ce

Inhibited
Experienci
ng
Self-Invalidation

Dialectical Strategies
Balance

Treatment
Strategies
Enter the paradox
Metaphor
Devils Advocate
Extending
Wise Mind
Lemonade out of lemons
Allowing natural change
Dialectical Assessment

Behaviorism Paradigm

From DBT Self Help at

http://www.dbtselfhelp.com

Behavior Therapy Basics

Behavioral

Principles necessary to be

effective
Behavior Therapy: a non-biological form
of therapy that developed from learning
theory. The purpose is to change
maladaptive patterns of behavior.
Shaping: Divide a behavior to be
learned into a series of steps.
DBT: Harm reduction model so shape
clients toward that

DBT Assumptions about

Clients
Clients

are doing the best they

can.
Clients want to improve.
Clients need to do better, try
harder, and be more motivated to
change.
Clients may not have caused all
of their own problems, AND they
need to solve them anyway.

Assumptions about Clients

(cont.)
The

lives of suicidal individuals

with Borderline Personality
Disorder are unbearable as they
are currently being lived.
Clients must learn new behaviors
in all relevant contexts.
Clients cannot fail in DBT.

Assumptions About
Therapy
The

most caring thing a therapist

can do is help clients change in
ways that bring them closer to
their own ultimate goals.
Clarity, precision, and
compassion are of utmost
importance in conducting DBT.
The therapeutic relationship is a
real relationship between equals.

Hierarchy of Targets
Individual
1.
2.
3.
4.

Therapy

Life threatening behaviors

Therapy interfering behaviors
Quality of life interfering behaviors
Increasing behavioral skills

Client Agreement
Client

and Therapist BOTH sign

the agreement to acknowledge
what it is they are agreeing to in
the therapy relationship.

Session Structure
Review

Diary Card
Attention to Target Hierarchy
Chain Analysis on highest
targeted behavior
Weave in Solution Analysis
Continue to move down hierarchy
until able to discuss skills related
to current life situations or
session time ends

Commitment Strategies
Therapist

discusses PROs and CONs of

commitment to change
Use the DEVILS ADVOCATE technique
to strengthen commitment and build
sense of control
Highlight PRIOR COMMITMENTS
consumer has made
Present consumer with CHOICE stressing
the freedom to choose while presenting
the consequences of choices clearly and
directly

Commitment Strategies
(cont.)
Therapist

uses principles of
SHAPING to elicit commitment
Therapist generates hope by
CHEERLEADING
Therapist and client agree on
HOMEWORK

Validation of Consumer
Stay

Awake
Accurate Reflection
Articulating unverbalized emotions,
thoughts, and behavior patterns
Validation in terms of past learning
or biological dysfunction
Validation in terms of current
context or normative functioning
Radical Genuineness

Self-Verification Theory
Validation

= Self-Verification
Invalidation of Self-Construct
leads to AROUSAL!!! (Sense of
out-of-control)
HIGH AROUSAL + OUT-OFCONTROL leads to >>>>
Failure to process New
Information =
NO NEW LEARNING!

Relationship Strategies
Accept

the relationship as it is in
the current moment, use the
relationship as therapy YOU are
the Key
Use problem solving on the
relationship
Attend directly to generalization
of behaviors learned in the
relationship

Be

honest about limits

Be consistently firm
Combine Soothing, Validating, &
Problem Solving with Observing Limits
Warm Engagement:
Limits on Warmth
Coping with anger/rage at the consumer
Warm engagement and touch in
psychotherapy
Genuineness

DBT Skills Group

Screening

session
1-year commitment
Both client and therapist sign
agreement
Agreement includes statements
regarding homework completion
and attendance
Co-facilitators

Hierarchy of Targets
DBT

Skills Group

1. Therapy destroying behavior

2. Skills acquisition, strengthening,
and generalization
3. Therapy interfering behaviors

Zen Practice
Be

Mindful to the current moment

See reality as it is without delusions
Accept reality without judgment
Focus on ones own experiencing as
a means of understanding the world
Let go of attachments that obstruct
seeing and accepting reality as it is
Use skillful means
Find the middle way

Mindfulness Paradigm
Mindfulness

is at the core of

Emotion Regulation (emotions,

thoughts, and behaviors).
Distress Tolerance (skills used to help us
cope and survive during a crisis,
distracting or soothing activities).
Interpersonal Effectiveness (skills
which help us to attend to relationships,
balance priorities versus demands,
balance the wants and the shoulds,
and build a sense of mastery and selfrespect.
From DBT Self Help at
http://www.dbtselfhelp.com

Mindfulness
Paying

attention on purpose, in the present

moment, and nonjudgmentally to the
unfolding of experiences moment by
moment. (Kabat-Zinn, 2003, p. 145).

Non-Judgment
Patience
Beginners

Mind or Childs Mind

Trust
Non-Striving
Acceptance
Letting

Go

Kabat-Zinn, 1990

1.

2.

3.

4.

5 Stages of
Accomplishment

Denial

I cant
do it!

Maybe I
can do it!

Uncertainty
Resistance
Panic

Theres no
way I can
do it!

AAAARGH!
What if I
cant do it?!

5.

Acceptance

ALL RIGHT!
I DID IT!
LETS
PARTY!

CONGRATULATIONS!

References

DBT Self-Help Website http://www.dbtselfhelp.com

Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the

Wisdom of Your Body and Mind to Face Stress, Pain, and
Illness. New York: Delacorte.

Linehan, M. (1993). Cognitive-Behavioral Treatment of

Borderline Personality Disorder. New York: Guilford.

Miller, A. L., Rathus, J. H., & Linehan, M. I. (2007).

Dialectical Behavior Therapy for Suicidal Adolescents. New
York: Guilford.

Swenson, C. R., Witterholt, S., & Bohus, M. (2007).

Dialectical behavior therapy on inpatient units. In: L.
Dimeff & K. Koerner (eds.). Dialectical Behavior Therapy in
Clinical Practice. New York: Guilford.

DBT Associates
Christine

Kvidera, MSW, LICW

7362 University Ave. NE, Suite
101
Fridley, Minnesota 55432
Phone & Fax: (763) 503-3981
www.dbtassociates.com
Email: chrisco28@aol.com