Dialectical behavior therapy is a psychosocial treatment that targets maladaptive behaviors exhibited by some people that put them at risk of both psychological and physical harm. It is hypothesized that such self-destructive behaviors occur as a result of intense emotional experiences. Dialectical behavior therapy applies a variety of cognitive and behavioral techniques, including problem solving, exposure training, contingency management, and behavior modification to treat such maladaptive behavior. The treatment consists of three interconnected modes of counseling: individual counseling, group-based skills training, and telephone coaching. Each mode of counseling concurrently addresses skills relating to interpersonal effectiveness, emotional regulation, and distress tolerance. Teaching the art of mindfulness is also integrated into the model. The central goal of DBT is to improve quality of life, essentially assisting clients to create a life worth living despite the experience of intense emotion (Linehan, 1993a).

Goals of Counseling and Psychotherapy

Dialectical behavior therapy organizes treatment into stages and targets and, with very few exceptions, adheres exactingly to the order in which problems are addressed (Linehan, 1993a, 1993b). The organization of the treatment into stages and targets prevents DBT from being a treatment that, week after week, addresses the crisis of the moment. In addition, it has a rational progression that first addresses behaviors that could lead to the client's death, then behaviors that could lead to premature termination of the counseling process, and finally behaviors that demolish the quality of life and the need for alternative skills. In other words, the first goal is to ensure the client stays alive, so that the second goal of staying in therapy results in meeting the third goal of building a better quality life. This is achieved partly through the acquisition of new skills and behaviors.

Before beginning the therapeutic process, the counselor explains to the client the treatment model, shares an understanding of the client's difficulties as identified from the assessment, and orients the client to the expectations of counseling. The client must commit to reducing self-injurious behaviors, to work on interpersonal challenges that may interfere with the process of counseling, and to work on developing new skills. The counselor adopts a dialectical position, highlighting both the need for change and the difficulties with change. This approach increases commitment and allows both the counselor and the client to identify obstacles that may need to be addressed.

After giving a commitment to participate in counseling, clients participate in a structured therapeutic process organized into the following stages of counseling (see Figure 10.3). The targets of counseling are specific to each stage.

Stage 1: Moving from being out of control of one's behavior to being in control. The goal of this stage is for the client to move from behavioral dyscontrol to behavioral control so that there is a normal life expectancy.

Target 1: Reduce, then eliminate, life-threatening behaviors, such as suicide attempts, suicidal thinking, or intentional self-harm.

Target 2: Reduce, then eliminate, behaviors that interfere with the counseling process, such as behaviors that alienate helping professionals, intermittent completion of homework assignments, nonattendance of sessions, or noncollaboration with counselors. This target includes reducing and then eliminating the use of hospitalization as a way to handle crises.

Stages of Treatment

Figure 10.3. Stages of Treatment

Target 3: Decrease behaviors that destroy the quality of life, such as depression, phobias, eating disorders, nonattendance at work or school, disregard for medical problems, poor budgeting, inferior housing, or lack of friends. In addition, increase behaviors that make life worth living, such as going to school or having a rewarding job, having friends, effective budgeting, appropriate housing, or having minimal symptoms of depression or anxiety.

Target 4: Leam skills that help individuals do the following:

a. Control their concentration, so they stop obsessing about the future or worrying about the past. Also amplify self-awareness to assist with learning more about what contributes to feeling good or bad.

b. Initiate new relationships, improve existing relationships, or end unhealthy relationships.

c. Understand what emotions are, how they function, and how to experience them in a way that is not overwhelming.

d. Endure emotional pain without resorting to self-harm or self-destructive behaviors.

Stage 2: Moving from being emotionally shut down to experiencing emotions fully. In this stage, DBT addresses the client's repressed emotional functioning. The goal is to help the client move from a state of quiet desperation to one of full emotional experiencing. The main target of this stage is to help clients experience feelings without having to shut down by dissociating, avoiding life, or having symptoms of PTSD. Teaching clients to suffer in silence is not the goal of treatment. The counselor works with the client in this stage to treat PTSD symptoms and teaches the client to experience a full range of emotion without shutting the emotions down or allowing the emotions to become unmanageable.

Stage 3: Building an ordinary life, solving ordinary life problems. This stage focuses on problems in living, with the goal being that the client has a life of ordinary happiness and unhappiness. Clients work on common problems such as marital or partner conflict, job dissatisfaction, career goals, and so on. Some clients choose to continue with the same counselor to accomplish these goals. Some take a break from counseling and work on goals without a counselor. Still others take a break and then work with a different counselor in a different type of counseling.

Stage 4: Moving from incompleteness to completeness/connection. Linehan has promoted Stage 4 specifically for those clients for whom a life of ordinary happiness and unhappiness fails to result in spiritual fulfillment or a sense of connectedness to a greater whole. At the end of Stage 3, some individuals may have the lives they wanted but continue to feel somewhat empty or incomplete. In Stage 4, the goal of treatment is for the client to move from a sense of incompleteness toward a life that involves an ongoing capacity for experiences of joy and freedom.

Thus, DBT targets behaviors in a descending hierarchy:

• Decreasing high-risk suicidal behaviors

• Decreasing responses or behaviors by the counselor or client that interfere with the counseling process

• Decreasing behaviors that interfere with or reduce the quality of life

• Decreasing and dealing with posttraumatic stress responses

• Enhancing respect for self

• Acquiring the behavioral skills taught in group

• Including additional goals set by the client

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