Dialectical Behavior Therapy

Psychotherapeutic strategies and techniques have transformed the psychology discipline from a nursing perspective. Hence, psychotherapeutic strategies are often developed and employed to enhance the overall mental health status and outcomes associated with patients suffering from related issues. Psychotherapeutic strategies are inclusive of dialectical behavioral therapy (DBT) aids in improving unwanted behaviors among patients suffering from varying disorders and addictions. This paper seeks to provide a brief introduction followed by an overview of the history underlying the approach, DBT. Thereafter, the paper seeks to offer reasons why DBT was selected as a psychotherapeutic approach as well as ways in which DBT is currently applied in my clinical work. The applicability of this approach will be used to describe several clients I counseled and ways in which I integrated DBT into practice. The advantage and disadvantages commonly associated with DBT are also identified in addition to ways in which my counseling skills have enhanced upon using dialectical behavior therapy. Lastly, this paper seeks to examine the drawbacks and recommendations associated with utilizing this psychotherapeutic approach.

Brief Introduction and History of DBT

Brief Introduction

Counselors and therapists are continuously searching for state-of-the-art psychotherapeutic approaches to use among patients and clients who suffer from addiction or an array of disorders. Dialectical behavior therapy is defined as “a form of therapy that engages the individual and teaches them how to deal more productively with social situations that bring about the unwanted behaviors” (“The History of Dialectical Behavior Therapy,” 2016, para. 1). DBT teaches clients the skills needed to change the manner in which clients react to different situations. This approach varies from the traditional behavior approach that stifled counselors and therapists from effectively treating suicidal patients during the 1970s and 1980s (“The History of Dialectical Behavior Therapy,” 2016). 

History

Throughout the 1970s and 1980s, standardized behavioral therapy and approaches to treat chronically suicidal individuals were lacking and proved to be ineffective by most counselors and therapists (“The History of Dialectical Behavior Therapy,” 2016). During this time, mental health therapists and other therapists found it rather difficult to effectively treat individuals who were deemed suicidal. Effective treatment approaches were rather obsolete as clients held negative thoughts and notions about therapy. Since a majority of suicidal clients persistently attempted suicide, standardized behavioral therapy at this time focused on minimizing suicidal thoughts and behaviors instead of trying to highlight the underlying issues that could yield real-world changes in the client’s life (Dimeff & Linehan, 2008; “The History of Dialectical Behavior Therapy,” 2016). These clients demonstrated a high degree of unwillingness to exude positivity and were often withdrawn from recommended treatment strategies or unresponsive to treatment approaches. 

During the early-most part of the 1990s, a psychologist named Dr. Marsha M. Linehan developed dialectical behavior therapy to treat suicidal individuals (Dimeff & Linehan, 2008; Linehan, 1993; “The History of Dialectical Behavior Therapy,” 2016). The new behavioral therapy served as an alternative psychotherapeutic approach to the standard cognitive therapy once used to treat her own borderline personality disorder. As a modified therapy, Linehan was able to utilize her own personal insight to develop a better understanding of her disorder, borderline personality disorder. Linehan’s ability to live successfully with borderline personality disorder led to the developer of DBT as an innovative therapy (Dimeff & Linehan, 2008; “The History of Dialectical Behavior Therapy,” 2016). 

The use of dialectical behavioral therapy has continued to broaden its scope and is now applicable throughout a number of different disciplines. The applicability of DBT proved to be more widespread than simply being a proven success in Linehan’s life. Due to this expansion, DBT was later adapted for individuals suffering from both a borderline personality disorder and substance use disorder (SUD) (Dimeff & Linehan, 2008). The dual diagnoses of BPD and SUD were considered one of the most common dual diagnoses in clinical practice for mental health and substance use (Dimeff & Linehan, 2008). Dialectical behavioral therapy is currently applied to individuals addicted to drugs or alcohol as well as individuals known to inflict self-harm (Dimeff & Linehan, 2008).

Reasons for Selection and Application in Daily Clinical Work

Dialectical behavior therapy was selected due to its proven effectiveness in significantly reducing acts associated with self-harm, self-injurious behaviors, and suicide attempts (Dimeff & Linehan, 2008). Dialectical behavior therapy commonly referred to as ‘talk therapy’ has transformed the way in which therapists conduct clinical practice (Freedman & Duckworth, 2013; Rossouw, 2007). Instead of simply talking at the clients which were once considered the norm, counselors, and therapists focus on increasing engagement between themselves and the client (Dimeff & Linehan, 2008; Freedman & Duckworth, 2013). I selected DBT because it allows counselors and therapists to reflect on personal experiences or real-life cases that are more relatable. This enables clients to build the skills needed to better understand the underlying purpose associated with using DBT. As a result, the use of DBT-related skills yields a more preferred response to unwanted behaviors commonly exhibited by clients with a borderline personality disorder. 

I found it rather intriguing that DBT is applicable across different phenomena of interest. Throughout my research, I learned that dialectical behavior therapy is not solely used among suicidal clients or clients with a borderline personality disorder. However, DBT is much more widespread as it has transcended and is now applicable among clients with syndromes associated with anxiety and depression (Dimeff & Linehan, 2008; Rossouw, 2007). Clients who actively participant in DBT as treatment are generally diagnosed with a borderline personality disorder. However, DBT was selected as it has proven to be adaptive for behavioral disorders (Dimeff & Linehan; Freedman & Duckworth, 2013). Behavioral disorders such as binge eating disorders and substance dependency among individuals previously diagnosed with borderline personality disorder demonstrate DBT’s applicability across varying phenomena of interest (Freedman & Duckworth, 2013). This is applicable within my daily clinical work as I work with a client that complains of depression and attempted suicide. Freedman and Duckworth (2013) proclaim that individuals treated with DBT also suffer from severe depression and suicidal thoughts and behaviors. Due to this correlation, the application of DBT in my daily clinical work plays a significant role in improving the depressive symptoms my client may experience. The proper utilization of DBT also aids in significantly minimizing and possibly eliminating the frequency of suicidal acts my client may attempt.

Ways DBT have been Used for Clients that were Counselled

DBT has been incorporated in my clinical practice in a number of ways that differ based on the clients in which I counseled. I have taught a few clients mindfulness practices and techniques, which have allotted clients to become more aware of their thoughts and feelings by becoming better acquainted with the sensations of their body (Freedman & Duckworth, 2013). Some of my clients practice mindfulness practices such as muscle relaxation and deep breathing techniques while other clients practice other Zen-based techniques. By using this mindfulness practice, my clients learned ways in which to accept distressing thoughts without criticizing themselves (Freedman & Duckworth, 2013). This has enabled my clients to tolerate urges and impulses of self-harm and suicidal attempts without acting on those urges and impulses. Hence, the use of mindfulness practices and techniques enabled one of the clients I counseled to make more informed choices, which has taught the client how to avoid acting on the urge to inflict self-harm and attempt to commit suicide. 

Since clients I had the opportunity to counsel varied, I was not able to use dialectical behavior therapy for all of my clients. However, my experience with one particular client that suffered from depression and attempted suicide on multiple occasions will be examined further. During a small group skill training session, this client was able to enhance DBT-related skills. DBT was also employed after group skill training and counseling sessions. The client was assigned homework also known as activities to practice or engage in prior to the next counseling session. The client was advised to take notes about their urges an impulses and the symptoms the client experienced during this time. The notes could be kept on note cards or in a diary or journal. The main purpose of this homework-based exercise is for the client to express their thoughts, feelings, and symptoms during an urge or impulse. Moreover, the client was taught how to keep track of their individual successes and overall progress. For example, the client will experience a success when the client encounters symptoms associated with the urge to attempt suicide or inflict self-harm but fails to do act on that urge. My client truly enjoyed this exercise because it allows the client to increase their awareness of symptoms associated with the urge to commit a self-injurious act or commit suicide while providing them the skills and resources needed to tolerate unwanted thoughts, urges, and impulses. 

It is also important to keep in mind that DBT can be used among clients with severe anxiety, severe depression, borderline personality disorder, substance abusing or drug-addicted individuals, and individuals who are considered chronically suicidal. I had the keen opportunity of using the selected psychotherapeutic approach on another client who was previously addicted to drugs. These counseling sessions were rather different from the counseling sessions involving my other client that suffered from depression and attempted suicide. During my first counseling session with this substance abusing and drug-addicted client, I tried to create an environment that focuses on abstinence. I asked the client to immediately refrain from using drugs and other substances. Since I am aware that abstinence throughout the entirety of this clients’ life may be hard to achieve, I encouraged my clients to only commit to abstinence for a length of time they are comfortable with. The client felt that remaining abstinence for only a month was attainable. Despite the original length of abstinence, after that period of time, the client would commit themselves again to another timeframe which would hopefully be longer than the original length of abstinence. 

Advantages and Disadvantage

Advantages

According to the National Alliance on Mental Health, the use of DBT as a comprehensively novel treatment yields a number of prospective advantages (Freedman & Duckworth, 2013). A number of research studies associated with the use of DBT have revealed improved outcomes among patients with borderline personality disorder or patients who are suicidal. In an article titled “The Limitations of Dialectical Behaviour Therapy and Psychodynamic Therapies of Suicidality from an Existential-Phenomenological Perspective,” Rossouw (2007) states that some researchers proclaim that DBT is “perhaps the most specific effective psychotherapeutic intervention to reduce life-threatening impulse-control disorders such as borderline personality disorder, in which suicide is a significant feature” (p. 2). Another study conducted by Persius, Öjehagen, Ekdahl, Åsberg, and Samuelson (as cited in Rossouw, 2007) demonstrate that DBT is associated with a significant reduction in the number of attempted suicide incidents and cases of self-harm. These advantages are becoming more prevalent as therapists are working to build and maintain a trusting relationship based on respect. Such a relationship shows clients that therapists understand them individually and are working toward enhancing DBT skills, which play a vital role in minimizing and possibly eliminating the impulses commonly associated with self-harm as well as suicidal thoughts and behaviors (Dimeff & Linehan, 2008; Rossouw, 2007).

Evidence-based practice regarding DBT has shown that when used properly DBT is successful across varying phenomena of interest. DBT is deemed successful when applied to suicidal patients and is also considered to be of equal significance when used on patients that suffer from different syndromes associated with anxiety and depression (Freedman & Duckworth, 2013). Other advantages are measured based on the severity and frequency of self-destructive thoughts and behaviors (Freedman & Duckworth, 2013). Motivation and positive reinforcement are commonly practiced among counselors and therapists, which teaches clients new skills so they could learn how to tolerate unwanted behaviors. Research on dialectical behavior therapy is strongly correlated with both significant and long-lasting symptom relief and remission (Freedman & Duckworth, 2013). Some clients tend to recover completely by using DBT; however, other clients will never experience a complete recovery as some symptoms, thoughts, feelings, and behaviors will linger throughout the entirety of the clients’ life (Freedman & Linehan, 2008; Rossouw, 2007). Regardless of the extent of symptom remission, clients that partake in DBT will live meaningful lives that are worth living (Dimeff & Linehan, 2008).

When DBT is successful, the client is able to articulate, envision, and pursue goals and objectives that are not dependent on the unwanted behaviors most clients exhibit (Dimeff & Linehan, 2008). According to a five randomized controlled trials (RCTs) conducted on women with borderline personality disorder who also were chronically suicidal, research findings reveal that “DBT is efficacious in reducing suicidal behaviors (including non-suicidal self-injury and suicide ideation) and their severity, decreasing hospital stays and improving treatment retention” (Feltham & Horton, 2012, p. 296). In regards to the use of DBT among drug abusing and drug dependent women with a borderline personality disorder, two trials have shown that DBT decreases substance misuse (Feltham & Horton, 2012). Recent studies have proven that dialectical behavior therapy is also useful in effectively managing behavioral disturbances when patients partake in inpatient settings (Feltham & Horton, 2012).

Disadvantages 

Despite the presence of a number of advantages associated with dialectical behavior therapy, several disadvantages emerge. Rossouw (2007) proclaims that one “major inadequacy, from an existential-phenomenological perspective, is that DBT does not provide insight into what suicidality means for the participants or how they experience and understand this phenomenon in treatment” (p. 2). Dialectical behavior therapy is also costly for clients, which is deemed a major disadvantage as some clients cannot afford this psychotherapeutic approach. 

Ways Counselling Skills Have Enhanced Using DBT

Adoption and utilization of dialectical behavior therapy in my clinical practice have enhanced my counseling skills in varying ways. My counseling skills are now primarily focused on developing and maintaining a relationship based on trust and respect. This is key when working with clients that require the use of DBT. My counseling skills are now focused on the premise of a dialectical approach which must be maintained at all times. The dialectical approach incorporates and fuses change and acceptance (Dimeff & Linehan, 2008). Some of my new counseling skills are based on modeling ways in which the client could view things from an entirely new perspective. As clients look at what is left out of the equation and assume a position that is rather different from the traditional black-and-white frame of thinking, the client will be capable of balancing acceptance and change (Dimeff & Linehan, 2008; Feltham & Horton, 2012; Olenchek, 2008). debt counseling has enhanced my ability to have clients eliminate painful experiences while accepting the inevitable pain that comes with accepting life’s unwanted and unforeseen challenges (Dimeff & Linehan, 2008). 

My counseling now involves a lot more validation of the logical aspects underlying the clients’ behavior. This form of validation precedes the identification of dysfunctional and unwanted behaviors the client exhibits (Dimeff & Linehan, 2008). For instance, if a client states ‘I know most people are disgusted and driven away from my self-inflicted scars caused by cutting so I decide to hide at home and don’t go out much, if at all.’ By assessing psychology from a nursing perspective, I will validate the clients’ feelings with my new set of skills and inform the client that it is sensible to assume that people are disgusted and driven away by self-inflicted scars and hiding at home is reasonable when trying to avoid responding to other individuals. My new counseling skills will allow me to ask the client if there exist other ways in which they could have addressed the current issue at hand that will minimize isolation? These new skills enable me to actively engage with the client while consulting with the client about ways in which to manage the problem in the clients’ environment instead of “instructing the environment on how to manage the client” (Feltham & Horton, 2012, p. 295). My newly enhanced counseling skills have allowed my clients to develop the knowledge and skills necessary to steer away from distressing stimuli. This form of counseling has enhanced the effectiveness of my interpersonal skills, which is deemed useful in developing and maintain a trusting relationship with clients (Hackney & Cormier, 2013).

Conclusion: Drawbacks and Recommendations

Drawbacks

Despite the proven effectiveness of dialectical behavioral therapy across different phenomena of interest, several drawbacks still manage to emerge. Some behaviors exhibited by clients tend to prevent or hinder professionals from delivering therapy in a manner that the client is receptive of and willing to receive (Feltham & Horton, 2012). Client unwillingness to partake in DBT increases the number of missed therapy sessions. Moreover, clients that are unresponsive or display the same response such as ‘I don’t know’ may plausibly hamper the effective of dialectical behavior therapy (Feltham & Horton, 2012). Due to the varying modes (emotion regulation, distress tolerance or skills associated with the acceptance of reality, interpersonal effectiveness, sleep hygiene, and mindfulness skills), DBT can be quite costly for clients which will present a problem among clients that lack health insurance coverage (Dimeff & Linehan, 2008; Feltham & Horton, 2012).

Other drawbacks are based on the counselor or therapists level of commitment to DBT. The counselor and therapist must be dedicated and committed to the dialectical approach to ensure effective implementation. Adherence to dialectical behavioral therapy is essential. Counselors and therapists must also be fully committed to the approach because a significant amount of time has to be allocated to group skills training, individual psychotherapy, and phone consultations (Olenchek, 2008). Moreover, DBT presents more drawbacks as counselors and therapists are required to partake in case consultation. Case consultation is a meeting held by therapists so they could provide advice, support, and guidance to fellow therapists that use DBT (Olenchek, 2008). The number of hours a therapist is required to assign to psychotherapeutic sessions may be difficult and at times nearly impossible for clients who suffer from unstable personality relationships and mood swings attributed to borderline personality disorder (Olenchek, 2008). 

Recommendations 

Due to the presence of emerging evidence regarding the utilization of dialectical behavior therapy on patients diagnosed with binge-eating disorder and older adults with personality disorder and comorbid depression, it is recommended that more studies preferably randomized trials are conducted to demonstrate the effectiveness and efficacy among other phenomena of interest (Feltham & Horton, 2012). Olenchek (2008) states that “private practice clinicians may report good results with DBT because their clients, by asking for help, are showing the motivation necessary to handle the demands of the therapy…The results may not be promising among patients who are court referred to therapy or who want a quick fix from medications” (para. 31). Since results demonstrating the effectiveness of DBT may consist of clients who demonstrate more of a willingness to partake in therapy and adhere to the selected psychotherapeutic approach, more studies should be performed on patients who are referred to therapy through a court-appointed order (Olenchek, 2008). This will allow researchers to properly gauge and assess how a clients’ willingness and motivation to fully engage in the therapy and counseling sessions affects the effectiveness of dialectical behavior therapy across different groups of patients.

References

Dimeff, L. A., & Linehan, M. M. (2008). Dialectical behavior therapy for substance abusers. Addiction Science & Clinical Practice, 4(2), 39-47. 

Feltham, C., & Horton, I. (2012). The SAGE handbook of counselling and psychotherapy (3rd ed.). Thousand Oaks, CA: SAGE Publications.

Freedman, J. L., & Duckworth, K. (2013). Dialectical behavior therapy fact sheet. National Alliance on Mental Illness. Retrieved from https://www2.nami.org/factsheets/DBT_ factsheet.pdf

Hackney, H., & Cormier L. (2013). The professional counselor. Massachusetts: Allyn and Bacon.

Linehan, M. M. (1993). Skills training manual for treating Borderline Personality Disorder. United States: Guilford Publications.

Olenchek, C. (2008). Dialectical behavior therapy: Treating borderline personality disorder. Social Work Today, 8(6), 22. 

Rossouw, G. (2007). The limitations of dialectical behavior therapy and psychodynamic therapies of suicidality from an existential-phenomenological perspective. Indo-Pacific Journal of Phenomenology, 7(2), 1-13. doi: 10.1080/20797222.2007.11433951

The history of dialectical behavior therapy. (2016). Michael’s House Treatment Centers. Retrieved from http://www.michaelhouse.com/addiction-treatment/the-history-of-dialectical-behavior-therapy/