Enhancing motivation

To address factors impeding the client’s motivation to engage in more skilful behaviour, DBT programmes most frequently develop the modality of individual DBT psychotherapy. Within this modality, comprehensive behavioural and solution analyses (Chapters 18 and 19) address the client’s most problematic behaviours by identifying and treating the factors that interfere with the acquisition or implementation of more functional behaviours. During the solution analysis, the therapist utilizes the full panoply of cognitive-behavioural change procedures (Chapters 20-23), including exposure, contingency management and cognitive restructuring (Heard & Swales, 2015). Furthermore, for clients with a BPD diagnosis, sustaining the motivation to change presents a special challenge. Consequently, maintaining motivation to change during the therapeutic process requires continuous attention.

Ensuring generalization

As a cognitive-behavioural treatment, DBT recognizes that skills learnt in therapy do not automatically transfer from one environment (therapy) to another (clients’ non-therapy life). Effecting this transition requires rigorous planning and frequent rehearsal. The intensity and lability of the clients’ emotional responses frequently leads to significant environmental dependency in terms of skills utilization. For example, the client who can negotiate an interpersonal conflict successfully when emotionally calm may be at a loss for words in the presence of moderate affect. To compensate for this environmental dependency, DBT devotes an entire modality to generalization. In most of the empirically validated versions of the treatment telephone consultation fulfils this function (see Chapter 11). DBT teams may utilize other modalities applicable to their setting. For example, in-patient milieu staff may provide in vivo skills coaching to address problems on the unit as they arise. In applications of the treatment for clients dually diagnosed with BPD and substance dependence, DBT case managers may enter the clients’ natural environments to provide coaching in specific skills (McMain et al., 2007).

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