Dialectical behavior therapy is considered a principle- or theory-driven therapy. There are three primary theories that create the foundation of the treatment. At its center, DBT is guided by behavior theory. It is also guided by the biosocial theory of BPD and the theory of dialectics (Linehan, 1993a). As a therapy guided by behavioral theory, behavior is conceptualized according to the principles of classical and operant conditioning, observational learning, and the transfer of information. The principles of learning theory state that a behavior will continue or increase when reinforced, will reduce or extinguish when punished, and will slowly cease when previous reinforcement is removed. As a fundamentally behavioral-based treatment, the DBT model emphasizes the identification of stimuli that trigger dysfunctional behaviors through previously learned associations and the outcomes that shape the development and maintenance of a behavior. Intrinsic motivation such as feelings of relief or reduction in anxiety or extrinsic motivation such as increased attention or praise may be complex, and the function of behaviors will depend on the range and relative strengths of these benefits. Dialectical behavior therapy conceptualizes behavior broadly to comprehensively address thinking, feeling, and behavior. Emphasis is placed on the function of behavior and the context in which behavior occurs. Its strength is its ability to explain the development of thought and experience over time.

A significant assumption in behavioral theory is that the factors associated with the preservation of behavior may be different from the factors related to the initial development of behavior. This hypothesis is particularly important in the conceptualization of chronic, long-standing problems, such as those associated with childhood abuse or trauma. Although a behavior may have originated in the context of abuse, it may now be maintained by current triggers and contingencies not directly related to the trauma history. For example, a client may have developed a tendency to dissociate in response to childhood abuse, but ultimately the client may dissociate in response to any strong negative emotion. In this case, processing the past abuse would likely have little effect on reducing the dysfunctional behavior. Effective treatment would more likely focus on intervention related to current triggers and emphasize regulation of strong negative emotions.

In DBT, behavioral theory influences all aspects of the treatment, including the method in which problems are defined, the ways in which behaviors are assessed, case conceptualization, and the interventions that are used. In general, the behavioral conceptualization of BPD within DBT emphasizes capability deficits and motivational factors in the maintenance of problem behaviors. Specifically, behaviors are viewed as maintained by some combination of deficits in skills, cued responding, reinforcement, or thought processes (Linehan, 1993a). Primary behavioral interventions from this view include skills training, exposure, contingency management, and cognitive restructuring (Linehan, 1993b).

Linehan suggested that BPD develops when a child who is biologically susceptible to difficulties regulating emotions is placed in environments perceived as interpersonally lethal or invalidating. The child is more sensitive to emotional stimuli, has more intense emotional reactions, and returns slowly to baseline. An invalidating atmosphere constantly trivializes, blames, and assigns socially undesirable characteristics to an individual's cognitive, behavioral, and emotional responses despite the fact that the responses make sense in the context of facts, circumstances, norms, or events (Katz et al., 2002).

Some environments, such as those that are physically or sexually abusive, are pervasively invalidating, whereas others are invalidating only when there is a poor fit between the family's and child's temperaments. Still other environments do not start out as invalidating but become so as a result of stresses arising out of interactions between the individual and others. The BPD individual's intense emotional reactions elicit invalidating behavior of caregivers, which then elicits further emotional dysregulation, and it becomes a vicious cycle. This transaction between an emotionally vulnerable individual and an invalidating rearing environment leads to dysregulation across the individual's emotional system, characterized broadly by difficulty in regulating physiological arousal as well as difficulty in turning attention away from emotional stimuli. As a result, individuals who have BPD often experience considerable disruption of their cognitive, emotional, and behavioral systems when emotionally aroused.

Anger and emotional dysfunction in individuals with BPD are central problems. The individuals struggle with fears of abandonment and chaotic relationships; confusion about identity, values, or feelings; and a chronic sense of emptiness. Cognitive dysregulation in the form of rigid thinking, irrational beliefs, paranoid ideation, and isolation may also occur. Finally, as an attempt to regulate emotions, behavioral dysregulation such as impulsiv- ity or suicidality is common (see Figure 10.1).

Dialectics is the basis for understanding an individual's past experience and is the foundation of validation (Linehan, 1993a). Dialectical behavior therapy therefore expands on

The Cycle of Dysregulation

Figure 10.1. The Cycle of Dysregulation

traditional behavioral therapy by including interventions that attend to the role of invalidation in the development of BPD and emotion dysregulation in the maintenance of BPD, such as the provision of validation and teaching of behavioral skills.

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