Dialectical Behavioral Therapy
The dialectical behavior therapy (DBT even dialectic behavioral therapy ) is a form of psychotherapy for the treatment of patients with a tendency to self threat or danger to others, and often the treatment comes in the frame borderline personality disorder are used. The DBT, developed by the American psychologist Marsha M. Linehan in the 1980s, is based on cognitive behavioral therapy , but also includes elements of other therapy directions as well as Far Eastern meditation techniques .
Linehan initially developed DBT as an outpatient treatment concept for chronically suicidal patients with borderline disorder (BPD). The therapy concept is now also used in the inpatient area and its implementation has also been specialized in various patient groups (adolescents, patients with eating disorders, in prison and others).
The practitioner's task is to find a balance between strategies of understanding and respecting a problem and changing it. This “dialectical strategy” (Linehan, 1996) forms the basis for the term dialectical behavioral therapy. In the sense of the DBT, dialectic looks at apparent opposites in the patient's world in order to dissolve them and to integrate them step by step.
The (outpatient) DBT includes:
- Individual therapy
- Group skills training
- Telephone contact in an emergency
- regular intervision of therapists.
In individual therapy, the problem areas are arranged hierarchically in terms of urgency. Primarily, suicidal and parasuicidal behavior, followed by behavior that endangers therapy, impairment of quality of life and inadequate behavioral skills. The problem areas are dealt with in this order and - if necessary - the treatment focus immediately goes back to the next higher level.
The essential basis of treatment is a stable therapeutic relationship with the support of the therapist in the auxiliary ego function, for example with appropriate boundary setting, development of self-discipline, appreciation of the skills achieved and other things.
- In this sense, see reparenting as an essential part of many therapeutic relationships.
The therapeutic relationship plays a special role in the treatment of BPD patients, as these patients are more prone than others to premature abandonment of therapy, difficult action, extreme negativism, etc., especially due to their various problems in the emotional and interpersonal area and the corresponding lack of suitable forms of coping . A so-called commitment is made between the patient and the therapist / clinic . The patients undertake to cooperate and adhere to rules and agreements, the therapist undertakes to provide the best possible assistance. The commitment is checked regularly during therapy and renewed or modified (expanded) if necessary.
The patients keep a diary card in which suicidal thoughts, states of tension, drug consumption, other dysfunctional behaviors, but also the use of skills and positive daily events are to be entered. Behavioral analyzes should give those affected an insight into the build-up of tension and learn to incorporate what they have learned in skills training into action plans. After self-harming behavior or suicide attempts, patients are asked to conduct such analyzes themselves. The prerequisite for the eventual processing of a trauma in a second phase of therapy is that the patient has learned to regulate emotional crises, states of tension and dissociations themselves through the skills they have learned. Trauma processing takes place using techniques from cognitive behavioral therapy and exposure strategies.
Skills training in group therapy
The skills imparted in group therapy also apply to individual treatment.
According to the concept, the skills training, led by two therapists, has the character of a workshop. The emphasis is on teaching skills. Group dynamic processes are only taken into account where necessary. Interactional problems are solved by applying skills in the sense of DBT. Criticism and suggestions on the part of the participants are expressly desired, an experimental partnership-like atmosphere should arise.
The skills training takes place regularly, at least once a week, and consists of five modules:
- Inner mindfulness
- Interpersonal skills
- Dealing with feelings
- Stress tolerance and
- Self-worth or self-acceptance
With Inner Mindfulness , the patient is taught techniques to feel and perceive himself better and to trust his perception. He should be able to feel safe in a situation without having to evaluate or devalue it, and find the right measure to be able to participate in the situation or to keep distance from it. The approaches of Zen are incorporated here . The goals are to gain more awareness in everyday life, to have more control over yourself and to bring feelings and mind into harmony.
The Interpersonal Skills module is designed to enable you to establish and maintain relationships. The aim is to weigh up in the encounter with others whether it is more important in the respective situation to maintain the relationship or to enforce one's own will. Factors that impair the social competence of the participant in question are identified, as well as factors that promote his or her competence. For the respective areas, beneficial self-statements are worked out (e.g. "I can trust myself. I can respect myself. I am worth being respected. I am entitled to make sure that I am fine." ). It should be possible for people to insist on their own wishes, goals and opinions without endangering the relationship with others, to be respected by other people and to maintain their own self-respect.
This module is related to social skills training . It is about the perception of one's own needs, their expression, implementation and delimitation from others. Social self-confidence strategies are taught and appropriate behavior is trained, with the aim of strengthening skills in dealing with others. For example: “How can I ask when I need something. How can I say no or better assert myself. How can I deal appropriately and effectively with conflicts with other people. How can I maintain a relationship. "
In dealing with feelings , patients learn to recognize and name their different feelings and to understand their meaning for their actions. Feelings are signals that give people orientation, for example about whether something is making them angry, and it is important to express unpleasant feelings as well. Discussed and practiced are skills such as observing, describing and understanding feelings, reducing vulnerability, taking steps towards pleasant feelings, letting go of emotional suffering. The aim is to learn to understand and accept feelings in their meanings and effects and to strengthen trust in one's own feelings.
In the stress tolerance of the first step is to accept the fact of being in the moment of stress. In these moments, there are still possibilities to distance yourself (to take a step back inside), to limit your thinking to the now and the next few minutes, and to use a strong sensory stimulus to get through the situation. Patients learn to endure crises and to reduce tension through techniques such as: distracting themselves through strong sensory stimuli (e.g. ice cubes), through various techniques "improving the moment", "pros and cons" (which arguments speak for self-harming behavior, which against), acceptance of reality, breathing exercises, "light smiling" and mindfulness exercises. Another goal is to learn to endure unpleasant events and feelings as long as the situation cannot be changed (“radical acceptance”).
In the self-esteem module , the person concerned should learn that he too is worth something. The attitude towards oneself should be improved, one should learn to take care of oneself, to love oneself and to take care of oneself. The aim of the exercise is to build healthy self-confidence and self-acceptance.
Patients are instructed to set up an individual "emergency kit" in which important aids for stress tolerance skills are kept. Patients should carry cards with them showing the most helpful skills. The patients also receive forms on which the skills they have learned are recorded and a record of which skills they have practiced with what success.
These five modules are an integral part of the DBT skill training .
From the point of view of depth psychology, the attempt was made to formulate own concepts (work with the inner child ) in the language of the DBT and to suggest skills group sessions for "adults with inner problem children".
Patients can call their therapists during a suicidal crisis or before harming themselves. The availability by telephone must be clarified with the therapist beforehand and is also based on the therapist's limits. Telephone calls should follow certain rules. Patients report why they are in a crisis and which skills they have already tried. The therapist and patient discuss skills that the patient should use. To this end, it is helpful if patients can name skills they have learned.
If the patients injure themselves or commit a suicide attempt, this should not be aggravated by increased attention, which is not easy to realize. The aim is for the patients to conduct behavioral analyzes of these situations afterwards.
The individual and group therapists meet regularly to exchange ideas about the common patients and to advise one another.
Dialectical Behavioral Therapy (DBT) has achieved moderate, i.e. medium effects in randomized, controlled studies ( long-term studies in which the patients are randomly assigned to the treatment conditions). The therapy comparison studies showed significantly more positive treatment courses and more convincing therapeutic successes compared to conventional behavioral therapeutic approaches. The proof of effectiveness is for DBT through different studies, especially for problem behavior as a target variable, e.g. B. “suicidal” and “self-harming behavior”, but also “hospitalization-promoting behavior” have been shown (see Linehan et al. 1999, 1998; Bohus, Martin et al. 1996). The superiority with regard to social and professional integration as well as the duration of hospitalization was still demonstrable one year after the end of the therapy (summarized by Bohus et al. 1996; Linehan et al. 1993; Dammann et al., 2000).
According to Linehan, the group of BPS with multiple self-harming and primarily non-final suicidal acts ( parasuicidality ), which is fluid in its manifestations, shows the following behavioral patterns, which in themselves are target variables of the DBT concept:
- Emotional vulnerability (emotional dysregulation )
- Negation of one's own thinking, feeling and acting
- Inevitable crises
- Blocking grief
- Active passivity
According to Linehan, the disturbance of the emotion regulation is in the foreground in BPS. At the same time, there may be neurobiological vulnerabilities, early traumatic experiences and a psychosocial environment that becomes invalid in the early development phase for the development of a complex emotional dysregulation with dysfunctional basic assumptions and consequences of action. In the case of borderline disorders, a
- Responsiveness ( hyperarousal ) to above all negative emotional stimuli paired with excessive intensity, poorly differentiated and delayed regression ( hyperarousal )
- a primarily psychosocial communication disorder (insufficient verbalization, clarification of interpersonal interactions)
- the permanent feeling of differentiated and undifferentiated threat and
- with fear of loss of control and increased tension.
This emotional instability with an increased willingness to decompensate and a narrowing of resources leads - mostly triggered psychosocially - in varying degrees to undifferentiated, for the patient unbearable, excessive emotional states of excitement, which in turn can only be interrupted by the patient - negatively increased - by self-harm. This emotional dysregulation determines the mostly chaotic relationship between the patient suffering from a borderline disorder and himself and with other people. The DBT of patients with BPD now shows the following distinct advantages of DBT compared to other established therapies:
- The frequency of self-harming behavior decreases significantly
- The frequency of discontinuing therapy and changing therapists is reduced
- The number of inpatient treatment days per year is reduced
- The treatment costs per patient and year are lower
Dialectical-behavioral therapy, which conceptually aims to work through specific deficits in important basic skills in borderline personality disorders , is a modification of various treatment methods in behavioral therapy. A behavior therapist must complete specific additional therapeutic training for this purpose, as the behavioral therapy training itself does not provide in-depth teaching of this complex disorder and its treatment. In Germany, advanced training in dialectical behavioral therapy is offered by the umbrella association DBT eV .
- John F. Clarkin, Frank E. Yeomans, Otto F. Kernberg: Psychotherapy of the borderline personality: Manual for psychodynamic therapy . Schattauer, 2017, ISBN 978-3-7945-2579-9 , pp. 28 ( limited preview in Google Book search).
- Martin Bohus , Heike Bathruff: Dialectical Behavioral Therapy of Borderline Disorders in an inpatient setting. In: Psychotherapy in dialogue. 1 (4), 2000, pp. 55-66. doi: 10.1055 / s-2000-16703
- 2007 Charité - Campus Benjamin Franklin Berlin The borderline disorder
- Willi Herbold, Ulrich Sachsse: The so-called inner child. From Inner Child to Self. Schattauer-Verlag 2007, ISBN 978-3-7945-2588-1 , pp. 51-91.
- LG Öst: Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis. In: Behavior Research and Therapy. Volume 46, number 3, March 2008, pp. 296–321, doi: 10.1016 / j.brat.2007.12.005 . PMID 18258216 (Review).
- S. Kliem, C. Kröger, J. Kosfelder: Dialectical behavior therapy for borderline personality disorder: a meta-analysis using mixed-effects modeling. In: Journal of consulting and clinical psychology. Volume 78, number 6, December 2010, pp. 936-951, doi: 10.1037 / a0021015 . PMID 21114345 .
- Marsha M. Linehan: Dialectical Behavior Therapy for Borderline Personality Disorder: Theory and Method. In: Bull Menninger Clin. 51, 1987, pp. 261-276.
- Marsha M. Linehan: Dialectical Behavior Therapy: A Cognitive Behavioral Approach to Parasuicide. In: J Pers Disord. 1, 1987, pp. 328-333.
- Marsha M. Linehan, Hubert E. Armstrong, Alejandra Suarez, Douglas Allmon, Heidi L. Heard: Cognitive Behavioral Treatment of Chronically Parasuicidal Borderline Patients. In: Archives of General Psychiatry . 48, 1991, pp. 1060-1064.
- Marsha Linehan: Dialectical-Behavioral Therapy of Borderline Personality Disorder. CIP-Medien, 1996, ISBN 3-9803074-8-4 .
- Marsha Linehan: Training manual for dialectical behavioral therapy of borderline personality disorder. CIP-Medien, 1996, ISBN 3-9803074-9-2 .
- Matthew McKay, Jeffrey C. Wood, Jeffrey Brantley: The Dialectical Behavior Therapy Skills Workbook: Practical Dbt Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance. (= New Harbinger Self-Help Workbook ). New Harbinger Publications, 2007, ISBN 978-1-57224-513-6 . (German: Mastering strong emotions. Dialectical behavior therapy in practice. Ways to more mindfulness, stress tolerance and better relationship skills . Junfermann Verlag, Paderborn 2010, ISBN 978-3-87387-688-0 )
- Alice Sendera, Martina Sendera: Skills training for borderline and post - traumatic stress disorder . 2., ext. Edition. Springer-Verlag , Vienna 2007, ISBN 978-3-211-71784-4 .
- Christoph Kröger, Christine Unckel: Borderline disorder. How dialectical behavioral therapy helped me. 1st edition. Hogrefe-Verlag, 2006, ISBN 3-8017-2021-7 .
- M. Bohus, M. Berger: The dialectical-behavioral psychotherapy after M. Linehan. A new approach to treating borderline personality disorders. In: Neurologist. 67, 1996, pp. 911-923.
- G. Dammann, JF Clarkin, H. Kächele: Psychotherapy Research and Borderline Disorder: Results and Problems. In: OF Kernberg, B. Dulz, U. Sachsse (Hrsg.): Handbook of borderline disorders. Schattauer Verlag , 2000, pp. 701-730.
- M. Bohus: Borderline Disorder. (= Progress in psychotherapy. 14). Hogrefe, Göttingen 2002.
- Martin Bohus, Christian Schmahl: Psychopathology and therapy of borderline personality disorder. In: Deutsches Ärzteblatt . 103 (49), 2006, pp. A-3345 / B-2912 / C-2793. Deutsches Ärzteblatt, December 2006 , last accessed on January 20, 2009