Biosocial Theory of BPD
Emotional Invalidating
Vulnerability Environment
Emotional
Dysregulation
Dr. Janet Feigenbaum
Senior Lecturer UCL
Strategic and Clinical Lead for Personality Disorder, NELFT
Philosophical Underpinnings of DBT
Emotional
Dysregulation
Mindfulness
Emotional Dysregulation
Cognitive Dysregulation Physiological arousal Validation
information processing attention to emotion Thesis Antithesis
problem solving
Radical Acceptance
Acceptance Change
Behavioural dysregulation Synthesis
direct response to emotion
attempts to control emotions
Therapeutic Principles DBT Model
DBT as a skills deficit model
Mindfulness
Emotional Regulation
skills training Interpersonal Effectiveness Cue or Emotional Problem
Distress Tolerance Solution:
Trigger Dysregulation Behaviour
behavioural chain analysis Avoid or
solution analysis reduce
rehearsal
generalization Temporary
Relief
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Emotional Regulation
DBT Therapeutic Programme
DBT Model change emotion Distress Tolerance
reduce emotional Distract or Avoid Direct Modes
vulnerability Radical Acceptance Individual DBT therapy (1hr weekly)
DBT skills group (2 ½ hrs weekly)
Cue or Emotional Problem Telephone consultation (generalization)
X X In-vivo coaching
Trigger Dysregulation Behaviour
Psychiatric input
Opposite
X X Action
Indirect modes
External teaching of DBT
Exposure
Temporary External consultation
Stimulus
Control Relief Team development of skills (weekly)
Contingency management
Team consultation (weekly)
Stages and Targets of DBT So what can we use from DBT for CBT?
• Pre-Commitment
Relationship to thoughts
commitment to reduce problem behaviours
commitment to increase skills
• Stage One: stability, connection, safety Mindfulness
reducing life threatening behaviours
reducing therapy interfering behaviours
The What – observe, describe, participate
reducing quality of life interfering behaviours
• Stage Two: post-traumatic stress/shame/blame/guilt The How - in the moment, non-judgemental,
exposure to traumatic experiences effective
emotional processing
• Stages Three and Four: synthesis and joy
increasing self-respect and trust
individual life goals
“Don’t get on the train”
So what can we use from DBT for CBT?
Functions of validation:
So what can we use from DBT for CBT?
to strengthen clinical progress
as acceptance to balance change Dialectical Stance
to strengthen self-validation
as feedback
to strengthen the therapeutic relationship
Attend to the bigger picture
Types of validation: Embrace conflict as opportunity to move to truth
explicit verbal
implicit functional
The truth is found in the synthesis of different views
Levels of validation:
staying awake: unbiased listening and observing Making lemonade out of lemons
Metaphors
accurate reflection
articulating the unverbalized emotions, thoughts or behaviours
validation in terms of learning or biological dysfunction
validation in terms of present context or normative functioning
radical genuineness
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So what can we use from DBT for CBT? So what can we use from DBT for CBT?
Reciprocal communication - Self disclosure Radical Acceptance
“DBT identifies self-disclosure as a strategy that reflects one The world is as it should be
Suffering
aspect of the radically genuine nature of the therapeutic relationship.
About suffering
… DBT therapists must disclose only information in the best interests To solve a problem you must
of the client.” (Swales and Heard, 2009) accept the problem
Suffering
Feedback Pain + non-acceptance of pain
Belief / Hope
Normalization
Modelling Pain
Facilitating
Randomized Control Trials
Linehan et al. (1991) DBT vs. TAU
reduction in parasuicide, in patient bed days
increased retention in therapy, improvements in anger and social functioning
sustained at follow up
However, small sample, specific, originators
Koons et al. (2001) DBT vs. TAU
Advancement: outside originators of the therapy
reductions in suicidal ideation, anger expression, hopelessness, depression
no reduction in parasuicide nor in-patient bed days
However, small sample, exclusion criteria, no follow up
The Evidence Base
Randomized Control Trials
Randomized Control Trials
Verheul et al. (2003) DBT vs. TAU BPD with Substance Abuse
Advancement: allowed for referrals from addiction services
reduced drop outs, reduced DSH, reduction in impulsive behaviours
However, no significant change in depression, helplessness, life satisfaction Linehan et al. (1999) DBT-S vs. TAU
DBT-S: reduction in substance abuse, retained at 12m follow up
Van den Bosch et al. (2005) – 6m follow up of Verheul study better retention in therapy
reduction in DSH and impulsive behaviours retained
Main message – trend in data suggests that one year may not be long enough Linehan et al. (2002) DBT-S vs. Comprehensive Validation Therapy + 12 Step
both group reduced opiate use
Linehan et al. (2006) DBT vs. Treatment by Experts CVT + 12S – better retention, but more relapse last four months
DBT – less suicide attempts, less severe SA, less use of crisis services
less inpatient admissions
better retention of patients in therapy
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Extensions to DBT
Bohus et al. (2000; 2004) In-patient DBT vs. TAU
reduction in DSH and general psychopathology
However, no follow up
Telch, Agras, Linehan (2001) Binge Eating Disorder
improvements in eating pathology
89% cessation of binging – 56% at follow up
Low et al. (2001) DBT in secure setting
reduction self harm, dissociative experiences, increased coping skills
Lynch et al. (2003; 2007) Chronic Depression in older adults (DBT vs. clin. Man.)
improvements in sociotropy and coping skills, reduction in depression
Katz et al. (2004) Suicidal Adolescents – in-patient (DBT vs. TAU)
reduction behavioural problems, depression, hopelessness
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