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Principle-driven treatment

Your office phone rings shortly after 5.30 p.m. on a Friday evening. You’ve had a long and stressful week and are anticipating a relaxing weekend. One of your clients is on the line. She reveals that she is in a suicidal crisis and is currently standing by a major transport bridge in your area (she is vague about which one) with the intention ofjumping off. Her plan had been to leave a message for you on the office answer phone apologizing for her action. She has flattened affect and indicates that several events have occurred in the last 48 hours that indicate to you that her already chronic risk has increased. She has frequently been hospitalized in similar situations in the past, but this has rarely helped. She expresses extreme hopelessness and remains reluctant to talk. Do you remain on the phone and try to soothe her out of the plan by offering extra support or other interventions? Do you remain matter of fact, attempt to solve the problem or problems that led to the crisis? Do you try to find out where she is and then send emergency services to her aid? And if you do, do you stay on the phone while you wait for them to arrive? Do you try to arrange hospitalization? What do you do and, perhaps more importantly, what principles do you use to decide what to do?

Dialectical Behaviour Therapy (DBT) articulates a series of principles to help the practitioner decide what to do in circumstances like these. The treatment also describes how to integrate responses during crises with an overarching treatment plan. These principles are designed to enhance therapist effectiveness in applying the treatment adherently while remaining maximally responsive to the client.

DBT flexibly applies the treatment principles within a highly structured and comprehensive treatment programme as applying traditional cognitive-behavioural treatment to clients with a diagnosis of borderline personality disorder (BPD) and other complex presentations, which presents several challenges (Linehan, 1993a). Frequently, clients present varied problems from week to week, each of which may require a different CBT treatment protocol. For example, one week the client may report extensive panic attacks and avoidance of social activities; the following week, the presented problems are bingeing and vomiting; the week after the client presents with an acute suicidal crisis. The extent of comorbidity within the client population makes adhering to the procedure of any single traditional cognitive-behavioural treatment problematic and may account, in part, for the impaired effectiveness of such treatments for clients with a personality disorder diagnosis (Shea et al., 1990; Steiger & Stotland, 1996). Following a highly structured treatment protocol, with a clear and consistent therapeutic focus and a unified formulation, in the face of multiple and varied problems is almost impossible. Furthermore, clients diagnosed with BPD and other complex difficulties frequently present with therapy-interfering behaviours (e.g. not attending sessions, complaints, hostility towards the therapy, therapist, or both) that add to the challenge of delivering therapy. Under these circumstances, many therapists report a “war of attrition” occurring between the client and the therapist. The therapist persistently attempts and fails to implement the protocol, and the client deems the therapist’s efforts more and more irrelevant. Eventually, the therapist delivers the antithesis of a structured, focused intervention and instead follows the client impulsively, adding whatever strategy he or she thinks may prove helpful as a problem whizzes by. DBT endeavours to steer a dialectical course between these two extremes.

To counteract these challenges in delivering a traditional cognitive-behavioural treatment for clients with BPD, Linehan developed a treatment that is more principle than protocol-driven. The focus on principles has also led to the adaptation and application of DBT to other complex psychiatric disorders and clinical presentations. At the time Linehan developed DBT, cognitive-behavioural treatments were already demonstrating their considerable effectiveness in treating a range of Axis I disorders. Derived from basic research and associated cognitive-behavioural models, disorder-based treatments derive a clear series of treatment tasks or steps to modify the processes underlying each respective disorder. Each treatment task or step may have specific strategies associated with it. For example, in cognitive therapy for panic disorder the therapist demonstrates to the client that hyperventilation, driven by catastrophic interpretations of normal bodily sensations, leads to physiological sensations that the client further misinterprets. The therapist then proceeds to intervene in this vicious cycle using a range of cognitive and behavioural techniques. Because of the high level of structure these treatments provide in terms of conceptualization and the clarity with which they specify each step of implementation, traditional cognitive-behavioural treatments can be described as protocol-driven treatments.1

Although all treatments are principle based, not all are principle driven. Principle-driven treatments use a guiding theory to assist the therapist in drawing and following a map of the direction of travel within therapy. All treatments have a theory of the aetiology and maintenance of the psychiatric disorder that guides the therapist in deciding which strategies to employ to ameliorate clients’ difficulties. Often the high level of specification of treatment strategies in CBT, however, can lead the therapist to moving away from principles and to following a series of procedures instead. The therapist may only return to principles at times of difficulty or challenge within the therapy. In a protocol-driven treatment, detailed maps of the therapy journey are available with all roadways marked and the defining features of the landscape defined. Therapists have a clear idea of how they will reach the destination, although several possible routes may be available. In a principle-driven treatment therapists must constantly attend to the key principles. Therapists have minimally detailed maps, with few landmarks and only parts of roads and some features marked. In the absence of existing roads to the destination, the therapist first surveys the landscape to determine the best strategy for building roads to the destination. A protocol-driven therapist needs to drive well, especially over rough terrain in poor weather conditions. A principle-driven therapist must also drive well, but also must know something about surveying the territory, building roads and, of course, drawing maps to minimize the chance of becoming lost.

In comparison to protocol-driven treatments, delivering principle- driven treatments presents at least three additional challenges. First, the therapist must assess and determine which principles to apply and how to apply them in any given circumstance. Many therapists prefer simply to develop and apply a rule and in learning the treatment constantly seek to distil the principles into a set or rules.

Second, in principle-driven treatments usually multiple principles are relevant at any one time. For example, DBT provides clients with feedback about the impact of their behaviour on the therapist (self-involving self-disclosure). Therapists should not follow this principle ubiquitously, however. In some circumstances, providing this feedback may contradict another key principle of the treatment, namely minimizing the reinforcement of problematic behaviours. For example, in response to the therapist’s confrontation about nonattendance at skills class, a client verbally threatened the therapist who then experienced anxiety and avoided further confrontation. Sharing this sequence of events with the client may motivate the client to change, but only if the client does not intend to frighten the therapist. If the client wishes to frighten the therapist in order to stop the confrontation, the therapist self-disclosure is unlikely to motivate the client to stop the threats. In these circumstances, the therapist may need to manage his or her own anxiety while maintaining a confrontational stance towards the client about solving non-attendance at class. Alternatively, to counteract the reinforcing contingencies the therapist may highlight other aversive contingencies for the client, for example, how the client’s behaviour blocks another of the client’s treatment goals such as building and maintaining supportive relationships.

The final difficulty for therapists with principle-based treatments relates to the relative familiarity of some principles compared to others. Because DBT integrates principles from a range of therapeutic and non-therapeutic traditions, therapists from all orientations find familiar principles within the treatment. The challenge for any therapist learning DBT is to attend to learning and applying novel principles rather than only relying on familiar beliefs and practices.


1 Notwithstanding these characteristics, the effective implementation of these treatments still requires the development of an individualized formulation, the capacity to develop and to maintain a collaborative working alliance with the client and a degree of flexibility in the application of the strategies. As a consequence of the high degree of specification, CBT approaches are often viewed as merely a series of techniques that can be applied in the absence of a theoretical and conceptual understanding. Application of techniques in the absence of wider understanding is unlikely to be effective (Tarrier & Wykes, 2004). Delivery of these well-specified CBT treatments still requires extensive training and supervision.

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