The Process of Change
Linehan (1993a) hypothesized that a successful counseling intervention must meet the following five critical functions:
1. Improve and preserve the client's incentive to change. It is frequently the individual counselor who maintains the client's motivation for treatment because the counselor is the most significant individual for the client.
2. Boost the client's capabilities. Skills are acquired, strengthened, and generalized through the combination of skills groups, phone coaching, coaching, and homework assignments.
3. Ensure that the client's new capabilities are generalized to all relative environments.
4. Enhance the counselor's motivation to treat clients while also enhancing the counselor's skills. Counselors enhance capabilities and avoid burnout through weekly consultation meetings and supervision.
5. Structure the environment so that the treatment can take place. For example, the client and the counselor may meet with family members to ensure that the client is not being reinforced for maladaptive behaviors or punished for effective behaviors in the home.
Traditional Intervention Strategies
Dialectical behavior therapy consists of three parts (Linehan, 1993b). Individual counseling sessions are scheduled weekly during which a particular problematic behavior or incident from the past week is examined in detail, beginning with the series of events leading up to it, going through alternative solutions that might have been used, and exploring what kept the client from using more adaptive solutions to the problem. The individual sessions are 60 to 90 minutes, and the function is to relate the skills learned to the specific goals and targets of the individual. The individual sessions have a clear structure and focus. Both between and during sessions, the counselor actively teaches and reinforces adaptive behaviors, especially as they occur within the therapeutic relationship. The emphasis is on teaching clients how to deal with emotional disturbance rather than reducing or taking them out of crisis. Telephone contact with the individual counselor between sessions is part of the DBT procedures. The purpose of these brief telephone consultations is to assist the clients to identify an appropriate skill to use and to overcome obstacles to using the skill effectively. There are a variety of techniques used to generalize to the environment, such as flashcards, handouts, tapes of the skills, planned phone calls, and teaching skills to friends and family members.
In addition to the individual counseling, weekly 2.5-hour group counseling sessions are conducted. The skills training group is intended to boost the capabilities of the client. The format is psychoeducational, structured expressly for the learning and rehearsal of new skills. These group sessions address specific modules, including interpersonal effectiveness, distress tolerance, reality acceptance skills, emotion regulation, and mindfulness skills. Group counselors are not available over the phone between sessions, and they refer clients in crisis to the individual counselor.
Neither component is used by itself. The individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, whereas the group sessions teach the skills unique to DBT and also provide practice with regulating emotions and behavior in a social context. In addition to these two therapy components, counselors provide phone coaching between sessions to assist clients in overcoming challenges and consistently implementing appropriate responses.
Dialectical behavior therapy uses the primary strategies of cognitive-behavioral therapy, including behavioral analysis, exposure, contingency management, and cognitive restructuring. However, a number of supplementary and distinctive strategies are included in the treatment to augment the value of treatment for individuals with BPD. In line with dialectical ideology, change strategies are combined with acceptance strategies. As a principle-driven therapy, DBT provides a framework in which the counselor selects and incorporates therapeutic techniques based on the target of the moment (Linehan, 1993b). Some of the strategies are discussed below.
Strategies to Increase Commitment to Therapy
Securing a commitment from the client to participate in the therapeutic process is critical. Treatment contracts, motivational strategies to adhere to goals, dialectical strategies such as devil's advocate to engage clients in taking some ownership of the process, and the use of metaphors are often less threatening or confrontational for these clients who require a great deal of validation.
The main problem-solving strategy in DBT is behavioral chain analysis used to identify triggers that lead to dysfunctional behaviors. This strategy addresses the need for change. The client and counselor then generate and rehearse a solution, using existing skills and suggesting new skills. Obstacles are considered and resolved.
To balance asking for change, counselors use acceptance strategies. These strategies assist the client in learning to validate themselves, strengthen the therapeutic relationship, and act as a form of feedback.
While attempting to promote balance, counselors use dialectical strategies to facilitate comfort with movement between change and acceptance. This could include the counselor being nurturing yet challenging or moving between flexibility and stability.