The lives of people with borderline personality disorder are often filled with irrational thoughts, problems in relationships, self-damaging behavior, and chronic suicidality. In this article, Sirius Project will discuss dialectical behavioral therapy. If you are a new visitor to this website, go to the main page to find out what is Sirius.
What is DBT?
Dialectical behavioral therapy (DBT) is a complete compassion and a proven model of care. DBT is a complex cognitive-behavioral therapy system intended for the treatment of complex, difficult-to-treat personality and behavioral disorders. Originally created for patients with chronic suicidal behavior, DBT gradually evolved into a method designed to treat patients with multiple behavioral problems and borderline personality disorder (PRL).
Since that time, DBT adaptations have been created for difficult-to-treat behavioral disorders accompanied by emotional dysregulation, including substance dependencies, anorexia and bulimia, depression and suicidal behavior in adolescents, depression in the elderly, bipolar affective disorder. There are DBT skills that are applicable in a variety of care formats, including outpatient and inpatient care, group and individual therapy.
Dialectic behavioral therapy is the global standard for helping people with borderline personality disorder, suicidal behavior and self-harm. DBT is based on a combined deficient-motivational model of PRL, which assumes that:
- people with PRL do not have important interpersonal skills, self-regulation (including emotion management), and distress transfer;
- individual and environmental factors often block or inhibit the acquisition and patient use of behavioral skills and reinforce dysfunctional behavior.
DBT combines basic behavioral therapy strategies with mindfulness practitioners. DBT comes from a balanced dialectic therapeutic position that emphasizes the synthesis of opposites. The dialectical approach implies the inevitability of the emergence in the treatment of suicidal patients with PRL of many difficult to combine opposites (the need for acceptance and change, passivity and activity, the patient’s vulnerability and the need for active contact with the environment, etc.). DBT encourages the formation of flexible dialectic patterns of thinking and behavior instead of a rigid “black and white” type of thinking and irrational thoughts.
The fundamental dialectic balance in DBT is the balance between accepting the patient as he is and helping him to achieve change.
Adoption procedures in the DBT include awareness techniques (that is, attention to the present moment, taking a non-judgmental attitude, focusing on efficiency), as well as a number of validation and adoption strategies. Strategies for changes in DBT include behavioral analysis of maladaptive behavior and decision-making techniques, including training in interpersonal skills, emotional self-regulation, learning management (reinforcement and punishment in therapy), cognitive modification, exposure-based strategies, learning how to stop dissociating, alternatives to self-harm.
As part of a comprehensive treatment, DBT skills aim to achieve five main goals:
- expanding the behavioral repertoire;
- increasing motivation to change (through modification of suppression and reinforcement factors);
- the generalization of new patterns of behavior beyond the therapeutic space;
- structuring of the therapeutic environment necessary for the realization of therapist’s and patient’s resources;
- increasing the ability and motivation of the therapist to effectively help the patient.
In standard DBT, these functions are distributed between different aid formats, including individual psychotherapy, group skills training, telephone coaching, and the DBT counseling group.
Dialectic behavioral therapy is the global standard for helping people with borderline personality disorder, suicidal behavior and self-harm. Originally created for patients with chronic suicidal behavior, DBT gradually evolved into a method designed to treat patients with complex behavioral problems and borderline personality disorder (PRL).
Since then, DBT has been adapted for difficult-to-treat behavioral disorders accompanied by emotional dysregulation, including dependence on surfactants, anorexia and bulimia, bipolar affective disorder, depression and suicidal behavior in adolescents, and depression in the elderly.
Currently, there are versions of DBT, applicable in the framework of outpatient treatment and inpatient care, in the format of individual and group therapy. In addition to standard integrated DBT, various formats and modifications of DBT have been developed and have proven to be effective, including the “lightweight” versions, such as abbreviated DBT skills training programs (without individual therapy), as well as “DBT-informed therapy” (t . e., cognitive-behavioral therapy with elements of DBT).
Indications for DBT:
- Borderline personality disorder;
- Irritating thoughts;
- Suicidal intentions / suicidal behavior;
- Self-harm or auto-aggressive behavior (self-cuts, burns, etc.);
- Alcohol and substance abuse;
- Eating disorders (bulimia nervosa / anorexia nervosa).
Contraindications to DBT:
- Psychotic disorders (paranoiac, paranoid, paraphrenic syndrome, catatonia, conditions accompanied by impaired consciousness);
- Severe somatic diseases that do not allow the patient to physically participate in the program.
4 components of dialectic behavior therapy
Dialectical behavioral therapy consists of several components. It is usually carried out on an outpatient basis and lasts for one year, although patients may attend a program of dialectical behavioral therapy for a second year or even longer.
The main components for patients are:
- weekly attendance at the outpatient individual therapy session,
- weekly attendance at the group skills sessions and possible telephone contact during after-hours.
In addition, counseling meetings are held weekly for the psychotherapeutic brigade. In the event of a crisis, drug therapy may be advised. Sirius Project cooperates with My Canadian Pharmacy – a store that supplies affordable drugs online for treating mental health problems.
1. Individual sessions
Individual psychotherapy sessions are usually held weekly and last 45–60 minutes. The last week is devoted to the analysis of the results achieved, which is conducted on the basis of the CBT thought record filled in by the patient. You should first discuss the behavioral manifestations that are life-threatening, then the behaviors that impede the process of psychotherapy, reduce the quality of life and attention to the formation of skills. In practice, the details of the developed content of the sessions depend on the work style of the particular psychiatrist (how much does a psychiatrist cost also depends on your choice of a specialist). However, the whole process should be aimed at creating a safe environment for the patient. As a rule, much attention is paid to the immediate prerequisites of disturbing experiences and actions of the patient, and a careful analysis of the sequences can be used to accurately understand how a particular crisis situation arose. Developed forms that will help the patient and the psychiatrist to recreate the sequence of the main etiological factors. Initially, emphasis is placed on stimulating more active use of DBT skills necessary to survive and cope with difficult experiences. These skills are mainly taught in weekly skills training groups.
2. Forming skills in a group
Skills training is conducted weekly during group sessions, which usually last 2-2.5 hours. The style of group sessions is didactic. Therefore, the premises for their conduct should be arranged as a classroom, skills training instructors – usually two – sit in front. They may also be individual psychotherapists for some members of the group, but this dual role does not apply to the group. Work problems and emotional manifestations in a group are discussed and analyzed during group sessions only if they clearly interfere with their implementation.
Thus, if someone looks angry and scattered, he should pay attention only if it adversely affects the work of the group. These external manifestations are usually not considered. Therefore, Sirius instructors sometimes have to continue the lesson, regardless of the impression they have, that the thoughts of the group members are somewhere far away. However, external signs can be deceptive, or the therapist must hope so.
Skills training is carried out according to the manual, which details the content of the program, and provides recommendations on how to develop them (provided by My Canadian Pharmacy). In addition, there are also handouts for patients in the book, which can be reproduced for free for this purpose.
The content of group skills training sessions is divided into four modules, each of which is usually taught in blocks for several weeks. The themes of the three modules – regulation of emotions, increasing the tolerance of psycho-traumatic events and the effectiveness of interpersonal relationships – are similar to those discussed in other programs of cognitive-behavioral therapy and related programs. Another module is the development of the ability to understand the true nature of things, their essence, and to be aware of their involvement in everything. This module is often repeated in brief form in the intervals between the use of other modules. Moreover, Sitrius usually begin each group skill-building exercise with these exercises.
3. Telephone contact during non-business hours
Patients participating in a Sirius Project can communicate with their psychotherapist by phone in between sessions. Such contact can sometimes be planned, but it concerns mainly those cases when the patient needs to receive assistance in overcoming the crisis. During a telephone conversation, you basically need to teach the patient to properly use DBT skills that he has already learned during the group sessions. During dialectic behavioral therapy, the duration of a telephone conversation should not exceed 5–10 minutes in order not to turn into an additional psychotherapy session. Its function is different. In general, you should teach the patient how to avoid self-harm and sometimes maintain or restore the therapeutic relationship. The patient cannot contact the psychotherapist within 24 hours after self-harm.
The psychotherapist and the patient must agree on the period in which they can talk on the phone. Arrangements can be changed if they are abused. However, perhaps this is surprising, even patients with very disorganized behavior usually follow the rules of the game. If they violate them, they have an exhaustive discussion of this violation as a behavior that impedes psychotherapy in Sirius Project.
4. Advisory group
The fourth important component of dialectic cognitive therapy does not involve the direct participation of the patient. These are weekly advisory group meetings attended by My Canadian Pharmacy team. Dialectic behavioral therapy is a team-based treatment method, individual psychotherapists and skill-building instructors meet to discuss and revise the program and their practical work. The dialectical style, which is characteristic of working with patients when using dialectical behavioral therapy, is maintained even in this advisory group of equal specialists.