Linehan's Dialectical Behavior Therapy example essay topic

Borderline personality disorder (BPD) is a challenging condition that has received a surfeit of attention in the literature on personality disorders. The notorious difficulties in treating BPD patients have resulted in many theories and practices as clinicians attempt to make headway in treating people who are frequently suicidal and therapy-aversive, but whose intense psychological pain draws therapists in to their world. The diagnosis itself is often problematic; a key point is that as a personality disorder, the pattern of dys regulation and instability carries across all domains of the person's life, unlike a mood disorder, which can leave a person some intact areas of functioning. Extreme impulsivity, irritability, raging, and reactivity are common to all BPD patients, but still, the population is heterogeneous.

Psychodynamic approaches, the most well known being Otto Kernberg's work, have not been scientifically studied, but a psychoanalytical model (Bateman & Fo nagy) that relies on partial hospitalization as well as individual therapy has proven successful in certain important areas such as suicide reduction. Several behavioral and cognitive approaches may be helpful but most have not been studied. Psycho pharmacological interventions have included a number of different classes of drugs, reflecting the variety of problems associated with BPD. As might be expected, drugs can alleviate particular aspects of the disorder, but no single drug tackles the whole beast; in any case BPD patients usually have difficulty following medication regimens. One model does stand out from all the others in terms of proven efficacy: Marsha Linehan's Dialectical Behavior Therapy. Interestingly, Linehan's published research includes studies with the most difficult BPD population (e.g. those with a high frequency of parasuicidal and suicidal behaviors), and her model has shown success when compared with treatment as usual in a number of areas, among them less anger, better social adjustment, and fewer parasuicidal behaviors and medical interventions.

The DBT model is a highly original and involved one that is influenced by cognitive therapy, behavioral science, dialectical philosophy, and Zen practice. (It should be noted that the model deviates from authentic Zen understanding and practice, in my opinion). Philosophically, Linehan takes a position, along with dialectics, that reality is more process than form, and that it is important to comprehend both the whole (systems) and its many interrelated parts to arrive at worthwhile conclusions. Change is the ubiquitous, constant back and forth between poles of influence; paradox is the life-force that drives the reciprocal transactions between person and environment.

It is a "both-and" position rather than an "either-or" position. Linehan sees the core pathology of BPD as emotional dysfunction with a probable biological cause. Invalidating environments (those that dismiss or punish private experience and control emotional expression) also play a big part in the development of BPD behaviors because the individual cannot learn appropriate emotional responses in such an environment. This lack of emotional intelligence leads to excessive reliance on others, distrust of one's own emotions and the tendency to express emotions dramatically or not at all. DBT treatment strategies and protocols cover a lot of territory; a few of the central ideas follow. An initial commitment from the patient is crucial in light of the fact that typically BPD patients drop out of therapy.

The early phase of therapy emphasizes stability, the reduction of suicidal and therapy-interfering behaviors, and the achievement of some behavioral control. Behavioral techniques utilized include diary cards that record targeted behaviors on a weekly basis. In DBT emotional regulation, a crucial part of any BPD therapy, emphasizes the concept of learning to bear pain rather than thinking one can change the environment. Following the dialectical pattern, change is assumed to move forward along with acceptance, i. e., it is not necessary to reject behaviors in order to change them; one simply accepts oneself and then gets on with change where needed (likewise the therapist must be able to convey total acceptance of the patient while looking for change). More effective interpersonal skills, self soothing techniques, and other behavioral skills are ideally taught in a separate setting from individual therapy; Linehan recommends weekly group skills training sessions. The therapist running skills training groups is considered part of a team along with the individual therapist, supervisors or consultants, and the client.

When environmental stresses impinge on client functioning, the team meets with the appropriate people (as in case management), but the DBT model asks that the patient make the arrangements and attend the meeting, throwing the balance of power away from the professionals. DBT contains many such non-traditional approaches. Therapists may use highly irreverent commentary in order to pull the rug out form the patient, allowing fresh insights to emerge. Playing devil's advocate by going along with counterproductive assertions the patient makes to reveal their irrationality is another favored technique. However, validation, an active, radical acceptance of the patient and problem-solving strategies are always at the core of the work. Validation in the DBT model has numerous levels, from basic listening to empathetic understanding, to responding to the client with the respect of an equal, typically a difficult thing for the therapist to do when the client's behavior is needy and difficult.

Problem solving techniques begin with an exhaustive behavioral analysis of the problem in order to fully understand it. Analyzing the chain of events leading up to a problem and understanding how consequences reinforce behaviors requires tremendous patience, but results in better insight which, coupled with information (such as an explanation of how emotional arousal distorts thinking), can lead to many possible solutions. These solutions are then analyzed in order to choose the best one. As problems become more benign, there is time to explore the patient's history to better understand dysfunctional behaviors. Traumatic events in particular are investigated for their impact on the life of the client. Later in therapy the client's self-respect is reinforced, and finally a more spiritual emphasis can explore feelings of incompleteness.