Dialectical Behaviour Therapy: Validation as Acceptance vs.

Change
Sarah Penny, Tina Stephenson & Stacey Wilson The way forward is to simultaneously accept the client and push for change ationale !or the Develop"ent o! DBT Linehan realized CBT wasnt effective in her work with clients with Borderline Personality isorder !BP "# who typically e$perience emotion dysregulation !Linehan % e$ter&'azza# ())*+ ,an i-k# ().(" o #"otion dysregulation is an ina/ility to change or regulate emotional cues# e$periences# actions# ver/al0non&ver/al responses o Pervasive e"otion dysregulation is an ina/ility to regulate emotions across a wide range of emotions# pro/lems and situational conte$ts leading to maladaptive /ehaviours !i1e1 suicidal# /inge0purge# su/stance a/use" !2oerner# ().." o The $iosocial theory proposes that emotion dysregulation arises from the com/ination of vulnera/le /iology and invalidating social environments !i1e1 poor fit# chaotic home# a/usive home# etc1" !2oerner# ().." BT is essentially CBT with the addition of acceptance and mindfulness techni3ues o BT takes the -udgment out of CBT so that clients thinking isnt wrong or distorted o BT acknowledges that there is a pro/lem with the way the clients think# /ut the therapist first encourages clients acceptance rather than -udging# then helps them to look at how they can make changes to more /alanced thinking !,an i-k# ().("

Theoretical %rientation 4ntroduced /y 'arsha Linehan in .556 BT is /ased primarily in a /ehaviourist theoretical /ackground with roots in CBT# /ut it also contains elements of client&centered theory# 7en practices# and dialectical philosophy !Linehan % e$ter&'azza# ())*+ ,an i-k# ().("

Client Populations 4nitially created to treat the multi&diagnostic# difficult to treat suicidal# self&harming# and BP clients !Linehan % e$ter&'azza# ())*# p16**" BT has also /een found to /e effective for clients with eating disorders# depression# su/stance use# /i&polar disorder# oppositional defiant disorder# PT8 # and an$iety !9ederici % :isniewski# ().6+ Pistorello# 9ruzzetti# 'acLane# ;allop % 4verson# ().(+ :agner# <izvi % =arned# ())>"

Core Treat"ent Strategies Behavioural Change Strategies o Change&oriented strategies that weave together /ehavioural principles and protocols from CBT o 9or e$ample# /ehavioural chain analysis# self&monitoring# etc1 !2oerner# ().." Validation Strategies o ?cceptance&oriented strategies that are derived from the client&centered and 7en traditions

Penny# 8tephenson % :ilson ( o @mpathy A communicating the clients perspective is valid in some way !2oerner# ().." Dialectical Strategies o ? com/ination of change and acceptance strategies o The primary dialectic in BT is /etween change and acceptance o The tension /etween the need to accept clients true vulnera/ilities and yet encourage them to make necessary changes to live a life worth living !,an i-k# ().(" #valuation o! &ntervention #!!ectiveness ?merican Psychiatric ?ssociation !())B" considers BT to /e an evidence&/ased and empirically supported treatment for BP and suicidal and self&harming /ehaviors To date# more than a dozen <andomized Controlled Trials have found efficacy of BT for the treatment of BP !<izvi et al1# ().6" <eductions seen in self&harming /ehaviors# hopelessness# depression# fre3uency and length of hospitalizations# treatment drop out# anger# depression and suicidal ideation !2liem# 2roger % 2osfelder# ().)+ <izvi et al1# ().6" 8tudies have also shown potential efficacy for the use of BT for depression# an$iety# comor/id BP and su/stance a/use# eating disorders !@ " without comor/id BP # and adolescents# however# further studies are needed !'acPherson# Cheavens % 9ristad# ().6+ <izvi et al1# ().6"

Contraindications and #thical Considerations ? strong /ackground in /ehavioural therapy is recommended !2oerner % Linehan# ().." Criticized for /eing resource&intensive and costly !=ad-ipavlou % Cgrodniczuk# ().)" iscussing parasuicidal acts in group setting can foster a contagion effect !Linehan# ()))" Caution must /e e$ercised when applying only portions of BT with clients !<izvi et al1# ().6" Clinicians must /e transparent a/out offering components of BT rather than the full treatment in order not to mislead clients# or leave them with the view that they have failed BT# when they didnt receive full treatment !<izvi et al1# ().6" 4f offering a component of BT to a client as an intervention# the clinician must advise the client they are only going to receive a portion of the treatment# and must provide a rationale as to why they are choosing a specific component !<izvi et al1# ().6" Dot advised to offer the full BT protocol as a private practitioner# given that a treatment team is re3uired for consultation and to maintain a dialectical /alance elivering a skills group independently would likely contri/ute to therapist /urn&out !<izvi et al1# ().6"1

Purpose and &ntended %utco"e o! DBT BTs overarching treatment rationale is to teach and support emotion regulation and to reinstate the natural organizing and communicative functions of emotion to create a life worth living !=ayes# 'asuda# Bissett# Luoma % ;uerrero# ())E+ 2oerner# ().(" BT treatment targets specific goals in therapy in highest to lowest priority .1 8uicidal and non&suicidal self&harming (1 Behaviours that interfere with therapy 61 8uicide ideation and misery E1 'aintaining treatment gains

Penny# 8tephenson % :ilson 6 F1 Cther goals as the client identifies !,an i-k# ().(" Contains !our treat"ent "odesG ." individual therapy# (" skills training# 6" client&therapist consultation outside sessions+ and E" therapist consultation team meetings Contains !ive stages o! therapy that typically occurs over the course of a year or moreG .1 Pretreat"ent when goals are set and a commitment to therapy is o/tained (1 Stage & when the goal is to assist client in o/taining /asic capa/ilities and increasing /ehavioral skills in four categories of skills !as discussed /elow" 61 Stage &&# which focuses on emotional pro/lems# such as trauma&related affects through e$posure E1 Stage &&&# which focuses on ac3uiring living skills in such areas as employment# education# and interpersonal relationships F1 Stage &V# which focuses on enhancing living skills with contentment and -oy# while acknowledging life difficulties !=ayes et al1# ())E+ 2oerner# ().(" %ur Selected DBT &ntervention: What is Validation' BT defines validation as empathy plus the communication that the clients perspective is valid in some way !2oerner# ().(# p1 ..." o :ith empathy# you accurately understand the world from the clients perspective o :ith validation you also actively communicate that the clients perspective makes sense given their conte$t !2oerner# ().(" The therapist must simultaneously align with the clients goals and remain open to whats valid a/out the clients response without reinforcing dysfunctional /ehaviour# without evoking such emotional reactivity that the therapeutic task is derailed# and without dropping a focus on needed change !2oerner# ().("

What Does Validation Do' <educes physiological arousal !down&regulates emotion" Cues adaptive emotions to fire which regulates emotion# meaning that the clients whole system reorganizes !2oerner# ().(" Hsed genuinely and with skill# it reduces physiological arousal that is a normal effect of invalidation and it can cue more adaptive emotions to fire !2oerner# ().(" o ?ctive# disciplined# precise validation is re3uired to motivate emotion regulation and there/y create conditions for other change !Linehan# .55>"

(o) to Validate' 8earch for the valid 2now thy client !what is valid0invalid for him0her" ,alidate the valid# invalidate the invalid V alue others A sk 3uestions * isten and reflect & dentify with others D iscuss emotions A ttend to nonver/als T urn the mind

Penny# 8tephenson % :ilson # ncourage participation Validation +uidelines Linehan !.55>" listed si$ levels of validation and advised therapists to validate at the highest possi/le levelG .1 (1 61 E1 *evel , Listen with Complete ?wareness# Be ?wake *evel - ?ccurately <eflect the Clients Communication *evel . ?rticulate Donver/alized @motions# Thoughts# or Behavior Patterns *evel / escri/e =ow the Clients Behavior 'akes 8ense in Terms of Past Learning =istory or Biology F1 *evel 0 ?ctively 8earch for the :ays That the Clients Behavior 'akes 8ense in the Current Circumstances# and Communicate B1 *evel 1 Be <adically ;enuine What Validation is 2ot ?greeing or giving in Personalizing clients e$perience Taking on clients distress I9i$ing the client Cheerleading0encouraging ,alidating the Iinvalid e!erences

?merican Psychiatric ?ssociation1 !())B"1 ?merican Psychiatric ?ssociation practice guidelines for the treatment of psychiatric disordersG Compendium ())B !pp1 .((6J.6.E"1 :ashington# CG ?uthor1 9ederici# ?1 % :isniewski# L1 !().6"1 ?n intensive BT program for patients with multidiagnostic eating disorder presentationsG ? case series analysis1 International Journal of Eating Disorders, 46, 6((&66.1 doiG .)1.))(0eat1((..(1 =ayes# 81 C1# 'asuda# ?1# Bissett# <1# Luoma# K1# % ;uerrero# L1 91 !())E"1 BT# 9?P# and ?CTG =ow empirically oriented are the new /ehavior therapy technologiesL Behavior Therapy, 35# 6F& FE1 doiG.)1.).B1(98)))F&>*5E1(*)E1(5*)))6&) =ad-ipavlou# ;1# % Cgrodniczuk# K1 81 !().)"1 Promising psychotherapies for personality disorders1 Canadian Journal of Psy hiatry, 55!E"# ()(&(.)1 <etrieved from httpG00ezpro$y1li/1ucalgary1ca0loginLurlMhttpG00search1pro3uest1com0docview0(((*)(E5BL accountidM5*6* 2liem# 81# 2roger# C1# % 2osfelder# K1 !().)"1 ialectical /ehavior therapy for /orderline personality disorderG ? meta&analysis using mi$ed&effects modeling1 Journal of Consulting and Clini al Psy hology, !", 56BJ5F.1 doiG.)1.)6>0a))(.).F

Penny# 8tephenson % :ilson 2oerner# 21 !().("1 Doing diale ti al #ehavior therapy$ % pra ti al guide1 Dew Nork# DNG The ;uilford Press1 Linehan# '1 '1 !.55>"1 ,alidation and psychotherapy1 4n ?1 Bohart % L1 ;reen/erg !@ds1"# E&pathy re onsidered$ 'e( dire tions in psy hotherapy !pp1 6F6J 65("1 :ashington# CG ?merican Psychological ?ssociation1 Linehan# '1 '1 !()))"1 The empirical /asis of dialectical /ehavior therapyG evelopment of new treatments versus evaluation of e$isting treatments1 Clini al Psy hology$ ) ien e and Pra ti e, !# ..6J..51 doiG .)1.)560clipsy1>1.1..6

Linehan# '1'1 % e$ter& 'azza# @1T1 !())*"1 ialectical /ehavior therapy for /orderline personality disorder1 4n# Clini al *and#oo+ of Psy hologi al Disorders$ % step,#y step treat&ent &anual -4th ed./ avid =1 Barlow !ed1" Dew Nork# DNG The ;uilford Press1 'acPherson# =1 ?1# Cheavens# K1 81# % 9ristad# '1 ?1 !().6"1 ialectical /ehavior therapy for adolescentsG Theory# treatment adaptations# and empirical outcomes1 Clini al Child and 0a&ily Psy hology 1evie(, 26# F5J*)1 doiG.)1.))>0s.)FB>&).(&).(B&> Pistorello# K1# 9ruzzetti# ?1# 'acLane# c1# ;allop# <1# % 4verson# 21 '1 !().("1 ialectical /ehavior therapy ! BT" applied to college studentsG ? randomized clinical trial1 Kournal of Consulting and Clinical Psychology# *)!B"# ecem/er ().(# p 5*(J55E1 C4G .)1.)6>0a))(5)5B <izvi# 81 L1# 8teffel# L1 '1# % Carson&:ong# ?1 !().6"1 ?n overview of dialectical /ehavior therapy for professional psychologists1 Professional Psy hology$ 1esear h and Pra ti e, 44!("# >6J*)1 doiG.)1.)6>0a))(5*)* ,an i-k# 81 !().("1 DBT &ade si&ple$ % step,#y,step guide to diale ti al #ehavioural therapy1 Cakland# C?G Dew =ar/inger Pu/lications :agner# ?1 :1# <izvi# 81 L1# % =arned# '1 81 !())>"1 ?pplications of dialectical /ehavior therapy to the treatment of comple$ trauma&related pro/lemsG :hen one case formulation does not fit all1 Journal 3f Trau&ati )tress, 45!E"# 65.&E))1 doiG.)1.))(0-ts1()(B* ,an i-k# 81 !().(/. Cal&ing the e&otional stor&$ 6sing diale ti al #ehavior therapy to &anage your e&otions and #alan e your life. Cakland# C?G Dew =ar/inger Pu/lications1 DBT We$ esources httpG00www1soundstrue1com0podcast0transcripts0erin&olivo1phpLcamefromhomeMcamefromhome httpG00www1mind1org1uk0mentalOhealthOa&z0*)6)OdialecticalO/ehaviourOtherapy httpG00www1d/tselfhelp1com0html0overview(1html

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