DBT Some Contrasts with CT and Possibilities for Integration

In comparison with other treatment approaches, CT and DBT share many important features, both being forms of cognitive-behavioral therapy. Both recognize the need for cognitive change, exposure to feared situations, skills training, and attention to reinforcers. Nonetheless, some differences between approaches, at least in emphasis, are worth noting. CT emphasizes developmental experiences as determinants of schema development and other key cognitive processes viewed as underlying BPD, whereas DBT proposes a biosocial model in which such developmental experiences transact with biologically based emotional vulnerability. DBT does not include the construct of schema; instead it involves patterns of cognitive behaviors (thoughts) and is generally a more behavioral, less cognitive treatment. Structurally, DBT explicitly includes four treatment modes—individual psychotherapy, group skills training, telephone consultation, and a therapists consultation team, whereas CT involves individual therapy and may include telephone consultation. This may in part be a function of the need created by the severity level of the patients treated in Linehan's programs. DBT emphasizes more and provides more detailed treatment guidelines for self-injurious behaviors. Deliberate management of reinforcement contingencies, particularly use of the therapeutic relationship contingently, is emphasized more in DBT, and there is probably a higher threshold for hospitaliza-tion. Dialectical principles and strategies are more explicitly emphasized in DBT, though in many ways CT certainly addresses similar dialectics, such as acceptance and validation versus change and problem solving. Teaching mindfulness practices as acceptance skills to patients with BPD is fairly unique to DBT and possibly an important component (Robins, 2002).

One of the challenges in working with a patient with BPD is the sheer number of problems with which he/she often presents and the fact that the problem viewed as most urgent by the patient and/or therapist often changes from session to session. A loss of focus and continuity can easily result. This is addressed in DBT in part by establishing a clear list of therapy targets and arranging these in a hierarchical order of priority that depends on their severity and impact on functioning in the long-term rather than on a short-term sense of urgency. Patients who have severe behavioral dys-control, such as repeated self-injury, hospitalizations, or severe eating disorder or substance abuse, are considered to have the highest level of severity and to require Stage 1 treatment, in which the primary focus is simply on getting those behaviors under control. Within Stage 1, the highest priority is given not only to life-threatening behaviors, including suicide attempts, but also to any deliberate self-injury, regardless of intent or severity, as well as to major changes in suicidal ideation and behaviors related to harming others. Whenever one of these behaviors has occurred since the last therapy session, understanding that incident and problem-solving about it for the future become the primary focus of the session. The second highest priority is therapy-interfering behavior, because insufficient attention to this can lead the therapist to lose motivation to work with the patient or to the patient dropping out of treatment prematurely. The third priority target category in Stage 1 is severe quality-of-life-interfering behaviors, such as serious substance abuse or other mental health problems that, if not addressed, make a life of reasonable quality almost impossible.

Stage 2 focuses on some ofthe sources ofthe patient's misery, which he/ she is likely to continue experiencing even after behaviors are more under control. This might include exposing the patient to trauma-related cues and other trauma-focused work, and helping the patient to become more willing and able to tolerate experiencing the full range of emotions that he/she may have been avoiding and escaping from through self-injurious or other problem behaviors. The most important thing is that the therapist not embark on this until there is evidence that the patient is sufficiently equipped to handle the strong emotions it may elicit, without resorting to extreme behaviors. If the patient no longer has serious difficulties with severe behavioral dyscontrol or posttraumatic stress disorder-related phenomena, the therapist can proceed to Stage 3, in which the goal is to help the person solve the ordinary problems in living that bring most people to psychotherapy, such as relationship difficulties, low self-esteem, dysthymia, and so on. To complete the continuum from extreme mental ill health to optimal mental health, Linehan has recently added a Stage 4 to her treatment model, in which the goal is to help the individual to have a greater capacity for joy and freedom.

In this stage model, because severe disabling depression is usually viewed as a severe quality-of-life problem, it is a focus during Stage 1, if the patient has no life-threatening or recent therapy-interfering behavior that takes precedence. A lower level of depression that does not seriously interfere with a person's ability to work or to be in relationship with others, however, is usually viewed as a target for Stage 3 treatment.

In our treatment program, we treat patients with BPD in Stage 1 using a standard DBT model. Stage 2 treatment draws primarily on protocols for treating the effects of trauma, such as prolonged exposure or cognitive processing therapy. In this model, cognitive styles and patterns, though never ignored, are less a focus in Stage 1 than is typical in CT, in part because of the theoretical perspective that distorted cognition often is a result rather than a cause of intense emotions, so that it is more useful to focus on development of behavior skills for regulating emotions. In addition, many patients with BPD experience a focus on distorted cognition, particularly early in treatment, as invalidating; therefore, they reject it and may reject treatment. By Stage 2, and particularly Stage 3, it is often far more useful to use standard CT forms, exercises, and so on, none of which are incompatible with continuing DBT.

If one does not have access to all the modes of treatment of a DBT program, there may be ways that elements ofDBT can usefully be incorporated into a CT-oriented individual therapy. Following the previous sequence of treatment stages and target hierarchy is strongly recommended. Problem behaviors that occur can be subjected to detailed, moment-by-moment behavioral analysis to help both therapist and patient develop insight into the situations that are likely to occasion such behavior—the person's thoughts, emotions, urges, and behaviors in response to the situation—and the consequences that may influence the behavior through reinforcement or punishment. This can lead to useful ideas about changing several behaviors in the future. A focus on skills building is essential in our view. Although patients with BPD often have deficits in motivation to engage in skillful behavior, because of fear, hopelessness, reinforcement contingencies, or other factors, it is easy to underestimate the extent to which these patients simply do not have more skillful means in their repertoires. Although a consistent focus on skills training is difficult in individual therapy when crises often occur (hence, the rationale for skills-training group), it is at times possible to teach whatever skill is needed for a current situation, and Linehan's (1993b) skills training manual is a helpful resource. The emphasis in DBT on looking for and highlighting what is valid in a patient's responses can easily be incorporated into CT, as those writing about CT for BPD have done.

We recommend that, particularly early in treatment, the approach to thoughts be different than that in standard CT. Rather than encouraging a patient to evaluate the validity of his/her thinking, it is often more helpful simply to point out repeatedly that the patient's thought or belief is just a thought or belief, not a fact, and to help him/her to develop a stance of observing thoughts as sensations or external objects of perception, as in mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002). Mindfulness exercises can be helpful tools for decentering from cognition in this way.

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