Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations

Abstract

Dialectical behavior therapy (DBT) can be considered a well-established treatment for borderline personality disorder (BPD) as evidenced by seven well-controlled randomized clinical trials across four independent research teams. The primary purpose of this article is to address a variety of potential mechanisms of change that may be associated with those aspects of DBT that are unique to the treatment and its theoretical underpinnings. Based on the biosocial theory of BPD, many of these mechanisms can be distilled down to the following process: the reduction of ineffective action tendencies linked with dysregulated emotions. Specifically we address the following interventions and associated mechanisms of change: mindfulness, validation, targeting and chain analysis, and dialectics. Patient change in BPD is conceptualized primarily as helping the patient to engage in functional, life-enhancing behavior, even when intense emotions are present. Ultimately, our goal was to provide guidance for theoretically and empirically grounded research on the mechanisms of change in DBT.

Repairing “Difficult” Patient-Clinician Relationships

“…Jane's emotions got the better of her, prompting Dr. Balewa's invalidation of her internal experiences when what she, and others like her, seeks is validation [5]. Dr. Balewa could help by lowering his voice, being still and calm in the midst of Jane's anger, and by setting concrete expectations and boundaries early in the appointment.…”

Relação terapêutica com pacientes borderlines na terapia comportamental dialética

“…Essa desregulação afetiva manifesta-se pela elevada sensibilidade e reatividade a estímulos emocionais e a um lento retorno para um nível emocional basal (Crowell et al, 2009;Lynch, Chapman, Rosenthal, Kuo & Linehan, 2006), decorrentes do aprendizado com o ambiente invalidante, o qual somente dava atenção para as reações emocionais mais intensas do sujeito, reforçando ainda mais seus comportamentos extremos. Imerso nesse ambiente, o indivíduo aprendeu que somente o extremo pode efetuar respostas no ambiente (McMain et al, 2001).…”

“…Imerso nesse ambiente, o indivíduo aprendeu que somente o extremo pode efetuar respostas no ambiente (McMain et al, 2001). Assim, os pacientes com TPB apresentam dificuldade de regular todo o seu repertório de respostas associado aos estados emocionais (Crowell et al, 2009;Lynch et al, 2006). É comum ocorrerem intensos afetos disfóricos, como raiva, tristeza, vergonha, pânico, terror e sentimentos crônicos de vazio e solidão.…”

Mutual Regulation in the Context of Inconsolable Crying: Promoting Tolerance to Distress

“…As noted by Lynch, Chapman, Rosenthal, Kuo, and Linehan (2006), this skill set is based on the premise that individuals have to build self-monitoring skills in order to maintain being present in the moment of "crisis" and not reacting impulsively (in the extreme this could be shaking the infant) or shutting down (in the extreme this is depression, withdrawal, neglect). The belief is that all individuals are of two minds-Emotional Mind and Reasonable Mind.…”