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Integrative treatment

Perhaps few therapies emphasize integration so explicitly on as many disparate levels as DBT. The treatment is integrative in the “dialectical/developmental” sense of the word (Stricker & Gold, 1993), meaning that it emphasizes the “open-ended dialogical process in which differences are examined and novel integrations are welcomed” (p. 7). Thus, while at any given moment DBT constitutes a single, unified psychotherapy, it also changes continuously as new developments become incorporated rather than avoided, rather like a client effectively participating in therapy.

As the treatment’s name suggests, the concepts of synthesis and integration permeate DBT in several ways. First, reflecting the broad academic setting in which the treatment evolved, Linehan (1993a) proposed a transactional theory of the aetiology and maintenance of BPD that integrates both biological and environmental models, as well as developmental and learning perspectives. The treatment continues to adapt in response to new data from these areas.

Second, the treatment evolved out of a tension between an emphasis on change as the essence of CBTs versus an emphasis on radical acceptance of the client in the moment as a requisite context for treating clients with BPD or complex multi-problem presentations. Initially, Linehan applied standard behaviour therapy procedures to chronically suicidal and self-harming clients. Compared with most clients who successfully complete behavioural programmes, these clients had significantly more behaviours to target, poorer treatment compliance and higher treatment drop-out. The difficulties of forming a collaborative relationship, maintaining safety, keeping a stable set of goals and priorities across sessions and unrelenting crises made the application of traditional CBT in any straightforward, manualized way fraught with difficulty.

The difficulty in applying standard CBTs suggested an inherent poorness of fit between these therapies and clients with BPD. Line- han hypothesized that the therapy-interfering behaviours occurred as a result of the treatment’s perceived focus on changing behaviours, ranging from emotions and cognitions to overt behaviour. She suggested that the clients experienced the treatment not only as invalidating of specific behaviours but as invalidating of themselves as a whole. Being told that one must change is inherently invalidating to oneself, even if one agrees with the statement. In a sense, therapists validated clients’ fears that they indeed could not trust their own reactions, cognitive interpretations or behavioural responses. Research by Swann and colleagues (Swann et al., 1992) may explain how such perceived invalidation leads to problematic behaviour in therapy. Their research revealed that when an individual’s basic self-constructs are not verified, the individual’s arousal increases. The increased arousal then leads to cognitive dysregulation and the failure to process new information. The biosocial theory described later would suggest that BPD clients are particularly sensitive to any potentially invalidating cues and more likely to become highly aroused.

To balance the emphasis on change, Linehan began to integrate the principles of Zen (e.g. Aitken, 1982) and the associated practice of mindfulness (e.g. Hanh, 1987), which describe acceptance at its most radical level. Zen encourages radical acceptance of the moment without change. We will discuss Zen and mindfulness in greater detail later. Unfortunately, as Linehan further proposed, a therapeutic approach based on unconditional acceptance and validation of the client’s behaviours may prove equally problematic and, paradoxically, invalidating. If the therapist only urges the client to accept and self-validate, it can appear that the therapist does not take the client’s problems seriously. Without attention to change and solving problems, the client’s personal experience of life as intolerable and unendurable is invalidated, and therapy-interfering behaviours will likely occur.

The tensions arising from Linehan’s attempt to integrate the principles of behaviourism with those of Zen required a framework that could house opposing views. The dialectical philosophy, which highlights the process of synthesizing oppositions, provides such a framework. Through the continual resolution of tensions between theory and research versus clinical experience and between Western psychology versus Eastern philosophy, DBT evolved in a manner similar to the theoretical integration model described by psychotherapy integration researchers (Arkowitz, 1989, 1992; Norcross & Newman, 1992).

Third, in response to the complexity and severity of problems presented by clients with BPD, the structural aspects of DBT are integrated to support each other. This appears most obviously in the relationships among the standard treatment modalities (individual therapy, skills training class, phone consultation and team consultation), which we describe in greater detail later. Each modality supports the work of another. For example, skills trainers help the clients to acquire the basic elements of each skills set and to strengthen those skills. Then, the individual therapist further strengthens the skills, and telephone coaching facilitates generalizing the skills to everyday life. If the individual therapist had to teach the basic elements as well, substantially less time would remain for implementing other solutions. Similarly, without the support of individual therapy and telephone coaching, many clients would either not use the skills or would use them ineffectively.

In contrast with a common practice in treatment as usual to “bolt on” additional interventions, DBT requires the primary therapist to identify the specific function(s) of any additional intervention and to clarify how it will interact with the DBT programme. Clinical experience would suggest that without such clarification additional interventions interact less efficiently at best. They may also negate DBT interventions and increase the likelihood of therapy-interfering behaviour by the client or “splitting” among staff. For example, adding a “support worker” in response to a client’s increased suicidal communications may increase those communications in the future if the client values having as much contact with healthcare providers as possible. To minimize the likelihood of such problems, the treatment requires that the client does not participate concurrently in any other intensive psychotherapy.

Lastly, DBT integrates strategies and techniques from across the field of psychology and beyond. Though primarily a CBT, DBT also employs techniques from other clinical interventions, such as crisis management, and from other areas of psychology. For example, it requires clients to agree upon goals and make an explicit commitment to the treatment because of the social psychology research (e.g. Hall et al., 1990; Wang & Katzev, 1990) that indicates that individuals will more likely follow through with a plan or remain in a situation if they have committed to that plan or situation. To facilitate this process, Linehan (1993a) adapted two social psychology commitment techniques: the foot-in-the-door (Freedman & Fraser, 1966) and the door-in-the-face (Cialdini et al., 1975). Finally, reaching beyond Western psychology, the treatment interweaves the Zen practice of mindfulness. DBT modifies the technical eclecticism approach of psychotherapy integration (Arkowitz, 1992; Norcross & Newman, 1992) by requiring that all techniques fit within a dialectical framework synthesizing behaviourism and key principles from Zen. The reliance on a coherent set of principles may prove crucial to treating the therapist, as well as the client. When treating difficult populations, therapists desperately require a coherent framework on which they can depend.

 
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