These excerpts speak about the experience I had with cbt, and seem to illustrate well what is different about dbt from cbt. click on the headings to view the sources.
by Barry Kiehn and Michaela Swales
Dialectical Behaviour Therapy is based on a bio-social theory of borderline personality disorder. Linehan hypothesises that the disorder is a consequence of an emotionally vulnerable individual growing up within a particular set of environmental circumstances which she refers to as the ‘Invalidating Environment’.
An ’emotionally vulnerable’ person in this sense is someone whose autonomic nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to baseline once the stress is removed. It is proposed that this is the consequence of a biological diathesis.
The term ‘Invalidating Environment’ refers essentially to a situation in which the personal experiences and responses of the growing child are disqualified or “invalidated” by the significant others in her life. The child’s personal communications are not accepted as an accurate indication of her true feelings and it is implied that, if they were accurate, then such feelings would not be a valid response to circumstances. Furthermore, an Invalidating Environment is characterised by a tendency to place a high value on self-control and self-reliance. Possible difficulties in these areas are not acknowledged and it is implied that problem solving should be easy given proper motivation. Any failure on the part of the child to perform to the expected standard is therefore ascribed to lack of motivation or some other negative characteristic of her character. (The feminine pronoun will be used throughout this paper when referring to the patient since the majority of BPD patients are female and Linehan’s work has focused on this subgroup).
Linehan suggests that an emotionally vulnerable child can be expected to experience particular problems in such an environment. She will neither have the opportunity accurately to label and understand her feelings nor will she learn to trust her own responses to events. Neither is she helped to cope with situations that she may find difficult or stressful, since such problems are not acknowledged. It may be expected then that she will look to other people for indications of how she should be feeling and to solve her problems for her. However, it is in the nature of such an environment that the demands that she is allowed to make on others will tend to be severely restricted. The child’s behaviour may then oscillate between opposite poles of emotional inhibition in an attempt to gain acceptance and extreme displays of emotion in order to have her feelings acknowledged. Erratic response to this pattern of behaviour by those in the environment may then create a situation of intermittent reinforcement resulting in the behaviour pattern becoming persistent.
Linehan suggests that a particular consequence of this state of affairs will be a failure to understand and control emotions; a failure to learn the skills required for ’emotion modulation’. Given the emotional vulnerability of these individuals this is postulated to result in a state of ’emotional dysregulation’ which combines in a transactional manner with the Invalidating Environment to produce the typical symptoms of Borderline Personality Disorder.
Patients with BPD frequently describe a history of childhood sexual abuse and this is regarded within the model as representing a particularly extreme form of invalidation.
Linehan emphasises that this theory is not yet supported by empirical evidence but the value of the technique does not depend on the theory being correct since the clinical effectiveness of DBT does have empirical support.
Treatment of Borderline Personality Disorder Using Dialectical Behavior Therapy
By Thomas Lynch, Ph.D. and Clive Robins, Ph.D.
THOMAS R. LYNCH, Ph.D. is a Clinical Associate at Duke University Medical Center where he conducts research, maintains a clinical practice and participates nationally as a trainer for Dialectical Behavior Therapy.
CLIVE J. ROBINS, Ph.D. is an Associate Professor in Psychology and Medical Psychology at Duke University, a diplomate in Behavioral Psychology and is both a researcher and therapist, as well as a national trainer for Dialectical Behavior Therapy.
While, one focus of treatment is to help the patient learn ways to modulate intense emotions, change cognitive distortions, and improve interpersonal relationships, too much of a focus on change strategies can mimic the invalidating environment to which the patient was originally exposed. Change strategies to some degree suggest that the patient is the problem and that she cannot trust her own reactions to events. Mistrust of her own reactions to events leads to eventual self invalidation and experiences of shame, fear, and / or anger. This tendency is addressed through acceptance oriented strategies such as mindfulness and the use of validation by the therapist.
Validation in DBT involves five different levels. This first two are similar to other psychotherapies and involve unbiased listening and observing, and eliciting and accurately reflecting the patient’s thoughts, feelings, and assumptions. The third step of validation is to articulate for the patient unverbalized emotions, thoughts, or behavior patterns. The idea is to accurately “read their minds” and help them learn to accurately label internal states. The fourth step is for the therapist to validate the person’s present behavior based on their past learning history. In other words, from the DBT perspective, any human given the same biological makeup and learning history would end up responding in exactly the same way given the same context. Fifth, the therapist looks for and articulates the part of the patient’s response that is valid and / or wise. The idea is that even dysfunctional behavior, to some degree, makes absolute sense at the time the patient engaged in the behavior (e.g., served to reduce pain) and that if the patient could have done anything different (i.e., more adaptive), he or she would have done so. Thus, the therapist validates the grain of truth in any given response, while at the same time he or she works with the patient to change that very same response.
Excerpt from a copyrighted article which was “reprinted by special permission from the publisher of The JOURNAL of the California Alliance for the Mentally Ill. It is a part of a 32 article issue entitled “Borderline Personality Disorder”” available for $10 + $ 1 shipping charge from The JOURNAL/CAMI, 1111 Howe Ave., Suite 475, Sacramento, CA 95825.”
MARSHA M. LINEHAN, Ph.D. is the originator of Dialectical Behavior Therapy and is a professor in the Department of Psychology at the University of Washington.
NOTE: Writing of this manuscript was partially supported by grants MH34486 and DA08674 from the National Institutes on Mental Health and Drug Abuse, respectively, Bethesda, Maryland.
The main point is that the final result, BPD, is due to a transaction where both the individual and the environment co-create each other over time with the individual becoming progressively more emotionally unregulated and the environment becoming progressively more invalidating.
Helping the BPD individual make therapeutic changes is extraordinarily difficult, however, for at least two reasons. First, focusing on patient change, either of motivation or by teaching new behavioral skills, is often experienced as invalidating by traumatized individuals and can precipitate withdrawal, non-compliance, and early drop out from treatment, on the one hand, or anger, aggression, and attack, on the other. Second, ignoring the need for the patient to change (and thereby, not promoting needed change) is also experienced as invalidating. Such a stance does not take the very real problems and negative consequences of patient behavior seriously and can, in turn, precipitate panic, hopelessness and suicidality.
It was the tension and ultimate resolution of this essential conflict between acceptance of the patient as he or she is in the moment versus demanding that the patient change this very moment that led to the use of dialectics in the title of the treatment. In DBT, treatment requires confrontation, commitment and patient responsibility, on the one hand, and on the other, focuses considerable therapeutic energy on accepting and validating the patient’s current condition while simultaneously teaching a broad range of behavioral skills. Confrontation is balanced by support. The therapeutic task, over time, is to balance this focus on acceptance with a corresponding focus on change. As a world view, furthermore, dialectics anchors the treatment within other perspectives that emphasize: The holistic, systemic and inter-related nature of human functioning and reality as a whole (asking always “what is being left out of our understanding here?”); searching for synthesis and balance, (to replace the rigid, often extreme, and dichotomous responses characteristic of severely dysfunctional individuals); enhancing comfort with ambiguity and change which are viewed as inevitable aspects of life.
By John Cloud/Seattle
Linehan’s achievement was to realize that borderlines are, in fact, on the border between various dualities — dualities that they have to learn to accept and reconcile in order to change their lives. That’s easy to say but seems impossible to do — until you see it work.
- Linehan, creator of Dialectical Behavior Therapy, reveals her own struggles. (traumatherapy.typepad.com)
- New evidence for dialectical behavior therapy’s effectiveness (psychscoop.wordpress.com)
- Embrace Your Self-Destructive Impulses? How People Can Connect with Dark Parts of Their Psyche for Personal Change (alternet.org)
- Post-doctoral Fellowship in Dialectical and Cognitive Behavior Therapy at the Center for Cognitive & Dialectical Behavior Therapy, Long Island, New York (cwpclinicalpsychologyalum.wordpress.com)
- POSTDOCTORAL FELLOWSHIP in CBT and DBT in NYC Metro Area (cwpclinicalpsychologyalum.wordpress.com)
- Dialectical Behavioral Therapy and the Worthlessness of My Experience with Group Therapy (mindfuckery.wordpress.com)