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Dialectical Behavior Therapy (DBT)

(3-24-07)

Core assumptions

  • intense emotional discomfort leads to emotional escape and avoidance behaviors
  • attempted escape and avoidance (like repression in psychodynamic approaches) is central to psychopathology
  • the intensity of affect is caused by dialectic conflict between self and environment (inadequate compromised between needs and wants; attachment, trauma, and loss experiences; or genetic or neurological kindling effects)
  • prolonged high intensity of affect leads to high baseline arousal in even nonthreatening environments and frantic attempts to reduce emotional arousal, and the slow return to emotional baseline following exposure to threat
  • assumes patients accurately reported their experiences as perceived and that faulty cognitions are not major causative factors in developing or sustaining emotional pain
  • assumes that emotions (intensity, duration, perceived nonspecific manifestations) are primary causative factor in psychopathology
  • assumes that patient’s goal of escape and avoidance tends to focus their attention on (and be responsive to) emotional cues [acceptance of emotional pain decreases it]

Therapeutic strategies

  • acceptance of patient’s experience (validation of their emotional pain and suffering)
    • nonpejorative stance very influencial in reducing parasuicidal behavior (Shearin & Linehan, 1994)
  • new coping strategies, including a refocus on meaning in their life
  • exposure to previously intolerated emotions, prevention of emotional escape, and a new goal orientation
    [acceptance of emotional pain decreases it]
  • dialectics involve the polemics, opposites, opposing forces, conflicts, and paradoxes life inevitably involves: DBT about balancing therapeutic strategies: some promote change, some promote acceptance; some promote exploration of feelings and history, some promote distraction and arousal reduction
    • the balance of acceptance and change: there are things about our life we cannot change and attempting to do so leads to misery; and, the changes that are possible often require acceptance of the changes that are not possible (Becker & Zayfert, 2001)
  • Nonspecific effects of treatment
    • exposure to emotions and prevent avoidance of emotional processes leads to change
      therapeutic relationship important in achieving this
  • Comparisons to other approaches
    • CBT: DBT less cognitive than traditional CBT—thoughts are less important than affect regulation
    • psychodynamic: DBT accepts central role of compromise formation in human suffering but sees the dialectic as between self and society, rather than between conscious and unconscious
    • humanistic: DBT accepts assumption that relationship is the main therapeutic tool but relies on strategic procedures for patient to alter their day-to-day life outside the therapy environment
  • Emotion regulation as a core therapeutic target
    • Marra (2005) argues that “general and high emotionality or arousal accounts for most acute mental disorders.” (p. 43)
      • high emotional arousal
      • slow return to emotional baseline
      • hypervigilance
    • Psychological factors predisposing patients to emotionality
      • attachment issues
      • trauma
        • short-term, intense experiences of threat, processed in hippocampus rather than cerebral cortex
        • prolonged and inescapable arousal (chronic stress) leading to kindling effects on a neuronal level
      • loss
      • invalidation of affect
    • Dialectic failures contributing to high arousal and low problem solving

References

Marra, T. (2005). Dialectical Behavior Therapy in Private Practice: A practical and comprehensive guide. Oakland, CA: New Harbinger Publications.

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