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Reflecting on DBT Assumptions about Patients and Therapy (Part 1)

“The most important thing to remember about assumptions is that they are just that—assumptions, not facts.”

Cognitive Behavioral Therapy for Borderline Personality Disorder; Marsha M. Linehan, Ph.D, 1993

This feature by Vibh Forsythe Cox, PhD is Part 1 of 4 in a series about assumptions about patients with Borderline Personality Disorder and therapy described in the treatment manual. In DBT, we adhere to several assumptions that help us organize our behavior towards our clients. The first is the assumption that “Patients are doing the best they can.”

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The Role of Emotion Regulation in DBT (Part 2)

The Role of Emotion Regulation in DBT Part 2 - Blog

We sat down with Behavioral Tech Trainer Dr. Sara Schmidt to learn all about the role that emotion regulation plays in DBT.  In Part 1 of this interview, Sara took a deep dive into the idea of emotion regulation and what it means to experience emotion dysregulation, as well as a framework therapists can use to help their clients assess their emotions.

In part 2, we take a closer look at how we support clients in understanding those emotions and the specific DBT skills to give clients to help them regulate emotions and change problematic behaviors.

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The Role of Emotion Regulation in DBT (Part 1)

The Role of Emotion Regulation in DBT Part 1 - Featuring Dr. Sara Schmidt

We sat down with Behavioral Tech Trainer, Dr. Sara Schmidt, to learn all about the role that emotion regulation plays in DBT.  With emotion regulation being such a central topic to the practice of Dialectical Behavior Therapy, Sara shed light not only on how it factors in, but specifically how DBT allows therapists to work with clients to regulate emotions in a way that will enable them to change problematic behaviors.

In part 1, we started by uncovering what emotion regulation is and what it means for clients when they have trouble regulating their emotions.

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Zen Mindfulness in DBT

Zen Mindfulness in DBT - Featuring Randy Wolbert

In our research and practice, we have seen the connection between Zen mindfulness and DBT. Behavior therapy has an inherent compatibility with Zen principles. Behavioral Tech trainer and Zen teacher, Randy Wolbert, breaks down for us the seven points of overlap between Zen mindfulness and DBT and how these links came to be.

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The Measure of Mindfulness

The Measure of Mindfulness

For the first years of this century, mindfulness-based interventions generated a lot of enthusiasm from the general public and researchers alike. Research on mindfulness treatments for education, health, and mental health increased exponentially (Farias & Wikholm 2016). Recently, however, reviews of mindfulness-based interventions have re-assessed the data, especially because of small effect sizes and a lack of real control conditions (Farias & Wikhom 2016). A serious, methodological problem common to most of the studies is the lack of a standard operational definition for mindfulness (Lutz 2015).

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DBT’s Approach to Treating Individuals at High Risk for Suicide

DBT’s Approach to Treating Individuals at High Risk for Suicide

Mental health professionals play an important role in efforts to prevent suicide, as about one-third of individuals who die by suicide had contact with mental health services in the year before their death (Luoma, Martin, & Pearson, 2002). The U.S. National Strategy for Suicide Prevention emphasizes the importance of providing evidence-based psychotherapies (EBPs) that directly address suicide risk to high-risk clients, particularly those with a history of attempting suicide.

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Dialectical Behavior Therapy for Children

Dialectical Behavior Therapy for Children

DBT for children (DBT-C) was developed to address treatment needs of pre-adolescent children with severe emotional dysregulation and corresponding behavioral discontrol. These children experience emotions on a different level, and much stronger than their peers. Little things irritate them, and emotions may be so overwhelming that verbal or physical aggression occurs. It may seem at times that these children are manipulative and are trying to push everyone’s buttons. However, the child’s volatile behaviors may indeed be the best way they know how to deal with their intense emotions. Further, these behaviors may continue because they are frequently reinforced (e.g., attention from adults and peers, getting their way when parents finally give in, reduction in the intensity of emotional arousal). The environment may not be ready to effectively manage the challenges such children present, and “good-enough parenting” may not be sufficient to meet these demands. As a child’s needs cannot be adequately met by the environment, the environment frequently invalidates these needs, and destabilizes the child further. A more destabilized child continues to stretch an environment’s ability to respond adequately, which leads to further invalidation, and so forth. This transaction over time may lead to the development of a psychopathology. Indeed, research shows that such children are at an increased risk to develop alcohol and substance use problems, suicidality and non-suicidal self-injury, depression, anxiety, and personality disorders in adolescence and adulthood (Althoff, Verhulst, Retlew, Hudziak, & Van der Ende, 2010; Okado & Bierman, 2014; Pickles et al., 2009). The main goals of DBT-C are to teach these children adaptive coping skills and effective problem-solving and to teach their parents how to create a validating and change-ready environment.

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Dialectical Behavior Therapy for Substance Use Disorders

Dialectical Behavior Therapy for Substance Use Disorders

Following the initial evidence supporting DBT for suicide and non-suicidal self-injury (NSSI) in the early 1990s, Marsha Linehan and colleagues introduced modifications to target substance use disorders (SUD) as one of the greatest risk factors for fatal outcomes. DBT-SUD developed by adding new principles, strategies, protocols, and modalities to address common problems and complications of addiction, while maintaining all of those from the original model for NSSI. For example, individuals with BPD and SUDs tend to demonstrate “butterfly attachment,” characterized by limited treatment inclination, fleeting commitment, and minimal attachment to providers; whereas those with BPD without SUDS more often show an opposite attachment-seeking pattern. Therefore, a number of Attachment Strategies were added, such as assigning regular phone check-ins to build connection, orienting social networks to help reconnect with “lost” clients, and reinforcement of treatment participation. Some added DBT-SUD modalities include social networking meetings supporting attachment, urine toxicology screening, and pharmacotherapy to provide replacement medication for opioid addiction given its empirical support.

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How DBT Can Help Treat Eating Disorders

How DBT Can Help Treat Eating Disorders

Therapy Models for Treating Eating Disorders

The rationale for applying DBT to the treatment of eating disorders (EDs) has been described comprehensively in the literature. The rationale proposed suggests that alternative approaches are necessary for eating disorders because current empirically founded treatments (e.g. cognitive behavioral therapy and interpersonal psychotheray) may only be partially effective or ineffective for a select number of patients. DBT can be considered a logical alternative because, unlike other approaches, it is based on an affect-regulation model of treating ED symptoms. Eating pathology (e.g. binge-eating, self-induced vomiting, restriction, etc.) may now be understood as mechanisms to cope with emotional vulnerability (Telch et al., 2000), as opposed to errors in cognition or faulty interpersonal relationships alone ( Fairburn et al., 1993).

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Dialectical Behavior Therapy and Mental Healthcare Costs

Dialectical Behavior Therapy and Mental Healthcare Costs

The need for implementation of effective treatments for individuals at high-risk for suicide — and those diagnosed with borderline personality disorder (BPD) — is greater than ever. The most recent and highest quality epidemiological evidence indicates that the lifetime prevalence of BPD is between three and six percent in the U.S. population (Grant et al., 2008; Trull et al., 2010). Worldwide, nearly 1 million people die annually as a result of suicide (World Health Organization, 2016). Recently released data from the Centers for Disease Control and Prevention (CDC) indicates that rate of death by suicide has reached its highest level since 1991 (13.0 deaths per 100,000), making it the 10th leading cause of death for all ages (CDC, 2016). The rate of death by suicide has increased nearly uninterrupted since 1999, a 24 percent increase. And of great concern, over 40 percent of individuals who attempt suicide do not receive mental health care; half of those who do receive treatment report perceived unmet treatment need (Han, et al 2014). Subsequently, suicide results in an estimated $51 billion in combined medical and work loss costs in the U.S. (CDC, 2013).

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