lecture 5: dialectical behavioural therapy

Who developed Dialectical Behaviour Therapy (DBT), and in what clinical context?

Developed by Dr. Marsha Linehan in the context of suicidal and self-injurious behaviours often displayed by individuals with Borderline Personality Disorder (BPD).

DBT is considered a “Third-Wave” treatment. What does this mean it integrates with traditional behavioural principles?

It integrates acceptance and mindfulness principles with behavioural change principles.

What are the three major theoretical foundations of DBT?

1. Learning theory/behavioural principles

2. Zen philosophy

3. Dialectical philosophy

In DBT, the "fundamental dialectical dilemma" is the balance between ________ and ________.

Change (Problem Solving) and Acceptance (Validation)

According to Zen philosophy in DBT, what is the root of suffering?

Suffering stems from attachment; decreasing it involves accepting reality.

Define the core concept of Dialectical Philosophy.

There is no absolute truth; extreme positions can both contain truth, and change involves finding a balance between extreme poles.

What is the core assumption of DBT regarding problematic behaviours?

Emotional dysregulation is at the core of problematic behaviours.

From a DBT perspective, what are problematic behaviours (eg substance abuse, self-harm) viewed as?

Solutions for coping with distressing emtoions.

What are the two components of the Biosocial Theory of Psychopathology?

1. Biological predisposition to emotional vulnerability

2. Invalidating environment

Name the three characteristics of a biological predisposition to emotional vulnerability.

1. High emotional sensitivity

2. High emotional reactivity (intense emotions)

3. A slow return to baseline

Describe an invalidating environment.

An environment that negates, pathologizes, or criticizes emotional experiences, and oversimplifies problems.

What is a common consequence of chronic invalidation?

The individual learns that emotions cannot be trusted and depends on others for cues on how to feel/react.

In stage 1 of DBT, what is the primary focus?

Addressing life-threatening behaviours (1a), therapy-interfering behaviours (1b), and quality-of-life issues (1c).

Absences, lateness, and being unprepared for sessions are examples of ________ ________ behaviours.

Therapy-interfering.

What is the focus of Stage 2 of treatment?

Processing emotional suffering.

What occurs in Stage 3 and Stage 4 of DBT?

Stage 3 focuses on ordinary problems of living; Stage 4 focuses on deeper personal work.

If a client expresses suicidal thoughts AND shows up late to a session, which must the therapist address first according to the DBT hierarchy?

Suicidal thoughts (Life-threatening behaviours take priority over therapy-interfering behaviours).

What are the four components/modes of a standard DBT treatment plan?

1. Weekly individual therapy

2. Weekly group skills training

3. Phone consultations

4. Therapist team consultation

What is the purpose of the team consultation for therapists?

To provide support to the therapists and ensure collaboration in the treatment plan.

In which mode of DBT are the four modules of skills actually taught?

Group skills training.

What tool is used in individual therapy to track emotions and behaviours between sessions?

Diary cards.

Name the four modules of DBT skills.

1. Mindfulness

2. Distress Tolerance

3. Emotion Regulation

4. Interpersonal Effectiveness

Which two skills are focused on Acceptance?

Mindfulness and Distress Tolerance

Which two skills are focused on Change?

Emotion Regulation and Interpersonal Effectiveness

Define Mindfulness in a DBT context.

Paying attention, on purpose, in the present moment, without judgment.

What are the three “What” skills of Mindfulness?

1. Observe

2. Describe

3. Participate

What is the goal of Distress Tolerance skills?

To manage crises and improve resilience in the face of stress without making the situation worse.

What does the acronym TIPP stand for in Distress Tolerance?

Temperature (cold water), Intense exercise, Paced breathing, and Paired muscle relaxation.

When should a client use TIPP skills?

When emotional arousal is extreme (10/10), the brain is not processing information, and they cannot use other skills.

What is the goal of Emotion Regulation?

To gain greater control over emotions and cultivate positive experiences.

Describe the Opposite Action skill.

Identifying an action urge that is not effective and acting in the exact opposite way (eg approaching what you fear).

What is the goal of Interpersonal Effectiveness?

To communicate needs and boundaries while maintaining self-respect and the quality of the relationship.

How is Validation used as a technique in DBT?

Letting go of judgment, mirroring what the client says, and choosing wisely what to validate.

Describe exposure in DBT.

Based on behavioural principles to extinguish fear/anxiety by experiencing the stimulus without the negative consequence.

Explain Contingency Management in the context of DBT.

Reinforcing adaptive behaviour and extinguishing maladaptive behaviour (eg providing more time for therapy if no self-harm occurs).

What is a Behavioural Chain Analysis?

A technique used to identify prompting situations, vulnerabilities, emotions, and consequences of a specific problem behaviour.

Why is DBT considered the “gold-standard” treatment for Borderline Personality Disorder (BPD)?

It has been shown in multiple RCTs to decrease the frequency/severity of self-harm and increase therapy retention.

Peri et al. (2024) found that mindfulness-based interventions in DBT were particularly effective for reducing ________ ________.

Substance use.

True or False: DBT is only used to treat Borderline Personality Disorder.

False. There is evidence it is helpful for eating disorders, substance abuse, and anxiety.

Summarize the Biosocial cycle of psychopathology in DBT.

Biological vulnerability x Invalidating environment → Emotion dysregulation → Maladaptive behaviours (as a way to cope).

How do the three theoretical foundations map onto treatment strategies?

1. Learning theory → change/problem solving

2. Dialectical philosophy → dialectics

3. Zen philosophy → validation/acceptance

What are the consequences of invalidation?

• Emotions are interpreted as aversive or difficult to deal with

• Individual learns that emotions cannot be trusted and that they should depend on others for cues about how to feel/react

• Failure to identify, describe, express, and regulate emotions

• Intense vacillation between over-regulated and under-regulated emotional control