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What is the limitation of Biosocial Theory developed by Linehan?

What is the limitation of Biosocial Theory developed by Linehan?



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Linehan's biosocial theory takes into consideration of the accumulation effect of a stress on individuals, which the Diathesis-stress model could not explain. A predisposition (diathesis) with stress may cause a person to be suicidal but the accumulation effect makes the Biosocial model even more persuasive and sound. However, there is always something that a model or theory leaves out. What is it that the Biosocial theory does not explain?


Biosocial theory

Biosocial Theory is a theory in behavioral and social science that describes personality disorders and mental illnesses and disabilities as biologically-determined personality traits reacting to environmental stimuli. [1] [2]

Biosocial Theory also explains the shift from evolution to culture when it comes to gender and mate selection. Biosocial Theory in motivational psychology identifies the differences between males and females concerning physical strength and reproductive capacity, and how these differences interact with expectations from society about social roles. This interaction produces the differences we see in gender. [3]


Biosocial theory of creativity [ edit | edit source ]

This theory suggests that creativity is genetic, and thus, geniuses are indeed born, not made.

The first part of the Biosocial Theory of Creativity is that there is a definitive link between madness, also known as irrationality, and creativity. Many of the greatest creative thinkers, Van Gogh as an example, went mad later in their lifetime. Also, mad people who are held in psychotic wards have been found to create masterpieces of art, especially in the avant-garde style. It has been proposed that the suffering of mentally ill people is compensated when they perform great works of art, as an opposite end of their mental spectrum.

The second part is that creativity is just an outlet to deal with the madness within the patients. There is also the opposite of this being put forth, in that, madness is just a form of creativity that is misunderstood by the general populace. Both of these forms are extremely controversial and are being debated. A conclusion for this may not be available for many years to come.

The third part is that madness is ultimately just a result of some imbalance or defect within the brain. Some examples of these defects are brains that have unusual EEG (Electroencephalography) readings, an unbalanced neurochemistry, abnormal brain structures, or unusual hemisphere lateralization.

The fourth and last part is that the creativity associated with madness is inherited, but where the inheritance comes from is not so clear. Genes and DNA is a possibility, but parental trauma that caused a defect within the womb is also possible. Then, there are environmental factors that could create such a madness. Drugs could affect the brain, which then would become an inherited defect. All of these things are possible within the bounds of modern science.


Cognitive development considers the interaction between the individual&rsquos thought processes and their existence. I have faced several cognitive obstacles throughout my life and have developed many ways of dealing with these challenges. At one point in my life, I moved and was living with my relatives -- my mom's four sisters, and her family in Cypress. This was a strong cognitive challenge for me. My family was back at home in Hawaii and I had begun to feel depressed. The relatives that I lived with didn't make me feel welcoming or inviting in their home, I felt depressed while my aunt and uncle had restricted rules such as coming home early and letting them know every detail of the four W's: who, what, when, why, how questions.

It made me feel like I was trapped, suffocated, and irritated by their rules and the unnecessary comments they made towards me. I don't understand how relatives can be so cruel to you even though your blood-related. I also felt like an outcast because they spoke another language, which I didn't understand. I was miserable living with them, even though I was doing my chores, going to school, and had to put on a fake smile. While living with them I didn't have a good appetite for eating my daily breakfast, lunch, and dinner.

I lost weight due to the stress that I had living in that type of negative environment. I used to cry to my former boyfriend at that time, and my friends back at home because of how they treated me. I was ready to give up and to stop my pursuit of education and go back home to finish my studies. My aunt and uncle hoped I would do that. But that didn't stop me from pursuing my goals.I came to recognize that while my psychosocial situation was highly restrictive in large part the major obstacle I was facing was with the cognitive way that I approached this situation.

I had allowed my aunts and uncles to influence my thoughts and deter my health and positive development and participation in the world. I recognized that I had to change my outlook on my situation and life. With this understanding in mind, I reached out to my cousins.


Marsha Linehan , Ph.D., ABPP

Dr. Linehan retired from the university in 2019 and is not available for interviews or speaking engagements. If you are looking for treatment information, please visit our Treatment Resources section http://depts.washington.edu/uwbrtc/resources/treatment-resources/

If you cannot find the info you’re looking for on this website, you may contact [email protected]

Marsha Linehan is Professor Emeritus of Psychology in the Department of Psychology at the University of Washington and is Director Emeritus of the Behavioral Research and Therapy Clinics, a consortium of research projects developing new treatments and evaluating their efficacy for severely disordered and multi-diagnostic and suicidal populations. Her primary research was in the application of behavioral models to suicidal behaviors, drug abuse, and borderline personality disorder. She also worked to develop effective models for transferring science-based treatments to the clinical community.

She received awards recognizing her clinical and research contributions to the study and treatment of suicidal behaviors, including the Louis I. Dublin Award for Lifetime Achievement in the Field of Suicide, the Distinguished Research in Suicide Award (American Foundation of Suicide Prevention), and the creation of the Marsha Linehan Award for Outstanding Research in the Treatment of Suicidal Behavior established by the American Association of Suicidology. She was recognized for her clinical research including the Distinguished Scientist Award from the Society for a Science of Clinical Psychology, the award for Distinguished Scientific Contributions to Clinical Psychology (Society of Clinical Psychology,) and awards for Distinguished Contributions to the Practice of Psychology (American Association of Applied and Preventive Psychology) and for Distinguished Contributions for Clinical Activities, (Association for the Advancement of Behavior Therapy).

She was president of both the Association for the Advancement of Behavior Therapy and of the Society of Clinical Psychology, Division 12, American Psychological Association. She was a fellow of the American Psychological Association and the American Psychopathological Association and was a diplomat of the American Board of Behavioral Psychology.

She is the developer of dialectical behavior therapy (DBT), a treatment originally developed for the treatment of suicidal behaviors and since expanded to treatment of borderline personality disorder and other severe and complex mental disorders, particularly those that involve serious emotion dysregulation. In comparison to all other clinical interventions for suicidal behaviors, DBT is the only treatment that has been shown effective in multiple trials across several independent research sites. It has been shown both effective in reducing suicidal behavior and cost-effective in comparison to both standard treatment and community treatments delivered by expert therapists. It is currently the gold-standard treatment for borderline personality disorder.

She has written four books, including two treatment manuals: Cognitive-Behavioral Treatment for Borderline Personality Disorder and Skills Training Manual for Treating Borderline Personality Disorder, and her memoir, Building a Life Worth Living. She served on a number of editorial boards and has published extensively in scientific journals.

Dr. Linehan is founder of Behavioral Tech LLC, an organization that provides DBT training to mental health professionals and healthcare systems. She is also co-founder of DBT-Linehan Board of Certification (DBT-LBC), an organization that clearly identifies providers and programs that reliably offer DBT that conforms to the evidence-based research for the treatment. Learn more about the organizations founded by Dr. Linehan.

Linehan was trained in spiritual directions under Gerald May and Tilden Edwards and is an associate Zen teacher in both the Sanbo-Kyodan-School under Willigis Jaeger Roshi (Germany) as well as in the Diamond Sangha (USA).


Biosocial Theory

Dialectical behavior therapy's biosocial theory of BPD views the disorder as primarily one of pervasive emotional dysregulation, a result of both highly emotional vulnerability and deficits in the ability to regulate emotions. Biosocial theory helps a person to understand not only the etiology of BPD and its problem areas but also the maintenance of the disorder. Linehan (1993b) viewed dysfunctional behaviors in individuals with BPD either as an attempt by the individual to regulate intense affect or as an outcome of emotional dysregulation. Thus, for example, clients may deliberately harm themselves as a means to distract attention away from emotionally salient stimuli and thereby reduce anguish, or they may be lashing out when feeling overwhelmed. The DBT theory views emotions as involving a full system response and not merely the individual's phenomenological experience of the emotions. Linehan's model also assumes that emotions are prompted by events and function to organize and motivate action. Emotions inform individuals about the personal significance of situations (McMain et al., 2001). The accurate identification of an emotional response is critical to the regulation of emotions.

The DBT model assumes that individuals with BPD lack key interpersonal and selfregulation skills and that personal and environmental factors may block the use of appropriate responses to stressors or reinforce maladaptive responses. Thus, DBT is designed to facilitate the learning of new skills and generalization of the new skills across contexts.

The source of emotion dysregulation in individuals with BPD is viewed as resulting from the perfect storm of biological anomalies combined with an invalidating environment (Linehan, 1993a). These biological irregularities in BPD are believed to be caused by biological or genetic factors or childhood events. These irregularities are thought to result in emotional vulnerability offering insight into affective instability, impulsive, selfdestructive, and aggressive behaviors characteristic of BPD (Siever & Davis, 1991). Linehan (1993a) believed that an invalidating environment communicates to individuals that their interpretations and perceptions of their experiences are fundamentally wrong. The person therefore does not learn to accurately label internal experience or to regulate emotional arousal. In addition, these individuals do not learn to trust their own thoughts and feelings as accurate and reasonable responses to internal and environmental events. Rather, they are taught to invalidate their own perceptions and to scan the environment for cures about how to react. The invalidating environment also conveys to individuals that their experiences are due to unacceptable and undesirable character traits. For example, "a child is 'bad' for feeling angry, 'lazy' for not getting over loss quickly, or 'weak' for feeling afraid" (McMain et al., 2001, p. 186). Because the child is routinely ignored or punished for his or her emotional responses, appropriate coping mechanisms for dealing with these emotions are not learned. Additionally, because the system within the environment commonly responds to hysterical displays of emotions, the extreme behaviors are inadvertently reinforced, teaching that extreme displays are needed to gamer a response from the environment. This combination of ignoring or punishing emotional responses in combination with reinforcing the extreme emotional states results in teaching the child to shift between emotional inhibition and extreme emotional states.


Marsha Linehan Acknowledges Her Own Struggle with Borderline Personality Disorder

Dr. Marsha Linehan, long best known for her ground-breaking work with a new form of psychotherapy called dialectical behavior therapy (DBT), has let out her own personal secret &mdash she has suffered from borderline personality disorder. In order to help reduce the prejudice surrounding this particular disorder &mdash people labeled as borderline often are seen as attention-getting and always in crisis &mdash Dr. Linehan told her story in public for the first time last week before an audience of friends, family and doctors at the Institute of Living, the Hartford clinic where she was first treated for extreme social withdrawal at age 17, according to The New York Times.

At 17 in 1961, Linehan detailed how when she came to the clinic, she attacked herself habitually, cut her arms legs and stomach, and burner her wrists with cigarettes. She was kept in a seclusion room in the clinic because of never-ending urge to cut herself and to die.

Since borderline personality disorder was not discovered yet, she was diagnosed with schizophrenia and medicated heavily with Thorazine and Librium, as well as strapped down for forced electroconvulsive therapy (ECT). Nothing worked.

So how did she overcome this tragic beginning?

She was not much better 2 years later when she was discharged:

A discharge summary, dated May 31, 1963, noted that &ldquoduring 26 months of hospitalization, Miss Linehan was, for a considerable part of this time, one of the most disturbed patients in the hospital.&rdquo

A verse the troubled girl wrote at the time reads:

They put me in a four-walled room

But left me really out

My soul was tossed somewhere askew

My limbs were tossed here about

She had an epiphany in 1967 one night while praying, that led her to go to graduate school to earn her Ph.D. at Loyola in 1971. During that time, she found the answer to her own demons and suicidal thoughts:

On the surface, it seemed obvious: She had accepted herself as she was. She had tried to kill herself so many times because the gulf between the person she wanted to be and the person she was left her desperate, hopeless, deeply homesick for a life she would never know. That gulf was real, and unbridgeable.

That basic idea &mdash radical acceptance, she now calls it &mdash became increasingly important as she began working with patients, first at a suicide clinic in Buffalo and later as a researcher. Yes, real change was possible. The emerging discipline of behaviorism taught that people could learn new behaviors &mdash and that acting differently can in time alter underlying emotions from the top down.

But deeply suicidal people have tried to change a million times and failed. The only way to get through to them was to acknowledge that their behavior made sense: Thoughts of death were sweet release given what they were suffering. [&hellip]

But now Dr. Linehan was closing in on two seemingly opposed principles that could form the basis of a treatment: acceptance of life as it is, not as it is supposed to be and the need to change, despite that reality and because of it.

Dialectical behavior therapy (DBT) was the eventual result of this thinking. DBT combines techniques from a number of different areas of psychology, including mindfulness, cognitive-behavioral therapy, and relaxation and breathing exercises. Research has demonstrated its general effectiveness for people with borderline personality disorder. She should be very proud of her work with developing and helping people learn about DBT:

In studies in the 1980s and &rsquo90s, researchers at the University of Washington and elsewhere tracked the progress of hundreds of borderline patients at high risk of suicide who attended weekly dialectical therapy sessions. Compared with similar patients who got other experts&rsquo treatments, those who learned Dr. Linehan&rsquos approach made far fewer suicide attempts, landed in the hospital less often and were much more likely to stay in treatment. D.B.T. is now widely used for a variety of stubborn clients, including juvenile offenders, people with eating disorders and those with drug addictions.

Dr. Linehan&rsquos struggle and journey is both eye-opening and inspirational. Although long, the New York Times&rsquo article is well worth the read.


When to Apply DBT: Using the Research Evidence as a Guide

In deciding whether to use DBT or other treatments for a particular patient, one key deciding factor is the research data on the treatment with patients that are similar in terms of problem areas, diagnoses, or characteristics to the patient in question. Researchers and treatment developers have applied DBT to a variety of patient populations, but the preponderance of RCTs has focused on persons (mainly women) with BPD. 3 The following section includes a brief review of the well-controlled RCTs that have evaluated DBT.

Parasuicidal patients with BPD. For parasuicidal BPD patients, the most consistent finding is that DBT results in superior reductions in parasuicidal behavior compared with control conditions. The first RCT of DBT (N=44 parasuicidal women with BPD) found that DBT outperformed a control condition consisting of treatment as it usually is conducted in the community (TAU, or treatment-as-usual) in reducing the frequency and medical severity of parasuicide, inpatient hospitalization days, trait anger, and social functioning. 4 Through the first six months of the 12-month follow-up period, DBT patients demonstrated less parasuicidal behavior and anger and better social adjustment. Findings regarding better social adjustment persisted throughout the final six months of the follow-up period, and DBT patients also had fewer inpatient psychiatric days during this period.

The most recent and largest RCT of DBT (N=101) replicated the first study with a more rigorous control condition consisting of treatment by community practitioners designated as experts in treating BPD (treatment-by-community experts, or TBCE). This study found that DBT patients had greater reductions in suicide attempts, psychiatric hospitalization, medical risk of parasuicidal behavior, angry behavior, and emergency room visits, compared with TBCE patients 5 across the 12-month treatment and the 12-month follow-up period.

A couple of studies have examined DBT for women with BPD in community settings, such as a community mental health center and a VA hospital. In a community mental health setting, Turner 6 compared a modified version of DBT that only included individual therapy to a client-centered therapy control condition. Patients in the DBT condition had greater reductions in suicide attempts, deliberate self-harm, inpatient days, suicidal ideation, impulsivity, anger, and global mental health problems. In addition, a study of women veterans with BPD found that DBT patients had greater reductions in suicidal ideation, hopelessness, depression, and anger experienced than did TAU patients. 7 Follow-up data for these two studies are not available.

Women with BPD and substance use disorders. The second patient group for which DBT has demonstrated promising data consists of women with BPD and a substance use disorder (SUD). The first study in this area compared DBT to TAU for women who met criteria for BPD and SUD 8 and found that DBT patients showed greater reductions in drug use during the 12-month treatment and through the four-month follow up period and had lower drop out rates during treatment. For a second study conducted by Linehan's group, opiate-dependent women with BPD were randomly assigned to two conditions: DBT or a rigorous control condition, called Comprehensive Validation Treatment with 12-step (CVT-12S). In both conditions, participants also received LAAM (levomethadyl acetate hydrochloride), an opiate replacement medication. CVT-12S consisted of a stripped down version of DBT that only involved acceptance-oriented interventions designed to control for time of access to treatment, academic treatment setting, and therapist experience and commitment. Participants in both DBT and CVT-12S showed significant reduction in opiate use during the 12-month treatment, but DBT patients had greater sustained abstinence from opiate use at the 16-month follow-up. 9

A couple of RCTs conducted outside of the US also have examined DBT for substance abusers with BPD. A recent study conducted at the Centre for Addiction and Mental Health (CAMH) in Canada compared standard DBT to treatment-as-usual (TAU) for women with BPD and a substance use disorder (N=27). 10 DBT patients demonstrated greater reductions in suicidal and parasuicidal behaviors and alcohol use, but not other drug use. A study conducted in the Netherlands 11,12 included BPD patients, 53 percent of whom met criteria for a substance use disorder (SUD). Findings indicated that DBT patients had greater reductions in parasuicidal behavior and impulse-control problem behaviors (including bingeing, gambling, and reckless driving, but not substance abuse), compared with TAU patients. DBT patients continued to demonstrate less parasuicidal behavior, impulsive behaviors, and alcohol use throughout the six-month follow-up period.

Other clinical populations and problems. Additionally, some research has examined DBT-oriented treatments for other clinical problems, including eating disorders and depression in elderly patients. Telch and colleagues 13 compared a 20-week DBT-based skills training group to a wait list control condition for women with binge-eating disorder and found that DBT patients had greater improvements in bingeing, body image, eating concerns, and anger. Although 86 percent of DBT participants had stopped bingeing by the end of treatment, this number declined to 56 percent during the six-month follow-up period. A second study compared a modified version of individual DBT that included skills training to a wait list condition. DBT patients had greater reductions in bingeing and purging. 14 No follow-up data are currently available for this latter study.

In a study of depressed elderly patients who met criteria for a personality disorder, 15 investigators compared an adapted version of DBT plus antidepressant medications to medications only. Findings indicated that a larger proportion of DBT patients were in remission from depression at post-treatment and at the six-month follow-up period.

Summary. In summary, the patients for whom DBT has the strongest and most consistent empirical support include parasuicidal women with BPD. There also are some promising data on DBT for women with BPD who struggle with substance use problems. Preliminary data suggest that DBT may have promise in reducing binge-eating and other eating-disordered behaviors. On the one hand, the most conservative clinical choice would be to limit DBT to women with BPD. On the other hand, DBT is a comprehensive treatment that includes elements of several evidence-based, cognitive-behavioral interventions for other clinical problems. As such, DBT often is applied in clinical settings to multiproblematic patients in general, including those patients who have comorbid Axis I and II disorders, and/or who are suicidal or self-injurious however, caution is important in applying a treatment beyond the patients with whom it has been evaluated in the research.


Biosocial Model in DBT: How Symptoms Arise and Are Maintained


Biosocial theory in DBT is the underlying theory which explains how symptoms arise and how problems continue not just with borderline personality disorder but in a variety of different psychopathologies within DBT.
Biosocial model, the bio part of biosocial model involves the idea that emotional sensitivity is inborn.
We all have different sensitivities in terms of our skin. We are more or less sensitive to the sun, more or less sensitive to detergents, perfumes, etc. We have biologically born sensitivities when it comes to our digestion, what we can eat and what causes us more difficulty. The same is thought to be true with our emotions.
We are born more or less sensitive emotionally and that is not something that can be necessarily changed. That’s something that is part of your genetic makeup. That alone is not enough to cause difficulties.


So in DBT, the idea is it’s the transactions over time with what is referred to as an invalidating environment that causes the trouble.
An invalidating environment is one in which the individual doesn’t fit. An invalidating environment can be abusive, but doesn’t have to be abusive.


When you have a person who is biologically born to be emotionally sensitive and you have them in an environment in which they don’t fit, the transactions that happen over time lead to emotion dysregulation due to the reinforcement patterns that occur.
The core issue in DBT is pervasive emotion dysregulation. One of the ways that you can identify a patient that DBT is going to benefit is if their core characteristic is that they have emotion dysregulation.
I think of emotion dysregulation as being a thermostat that wouldn’t hold steady, so particularly sensitive to distressing circumstances, seem to feel things more intensely than others. When a person is an invalidating environment, it’s almost like being born gluten intolerant and being born into a family of bakers. That would be a very difficult situation to be in. The person could not help that they were gluten intolerant or gluten sensitive. And the bakers, they’re not abusive or there’s no problem with being a family of bakers. But the problem comes in the combination of the two.


When we have families or spouses who would ask, “Whose fault is it? Or why is it this way?” DBT considers it a no-blame model.It’s not the person who is coming in for treatment that’s to blame. It’s not the family that’s to blame. It is the transactions between the two that cause a problem.Invalidation in the environment maintains and may exacerbate the biological sensitivity of the individual. And patterns tend to arise between the two so that when they come in to treatment part of the treatment itself involves identifying and changing up these patterns that have led to the exacerbation of symptoms.


The key points for this talk are that DBT’s biosocial model is the theory of how symptoms arise and are maintained. It is a no-blame model.The equation for the biosocial model is emotional sensitivity plus an invalidating environment equals pervasive emotion dysregulation.
Emotional sensitivity is inborn. An invalidating environment is one in which a person does not fit. An invalidating environment does not have to be an abusive one.
The biosocial model is transactional in nature.


History of DBT

Dialectical behavior therapy (DBT) emerged from attempts to apply standard behavior therapy to the treatment of highly suicidal individuals. In essence, DBT was a trial-and-error clinical effort based on the application of behavioral principles (Bandura, 1969) and social learning theory (Staats & Staats, 1963 Staats, 1975) to suicidal behaviors (Linehan, 1981). In the first randomized controlled trial (RCT), Linehan and colleagues actively recruited the most severe, highly suicidal clients from local area hospitals (Linehan et al., 1991). From the beginning the focus of DBT has been to build a “life worth living.” The first complete draft of the treatment manual focused primarily on ameliorating suicidal behaviors however, federal grant funding required that treatment outcome research identify a mental disorder diagnosis. As a result, the first clinical trials conducted were focused on treating chronically suicidal who also met criteria for borderline personality disorder (BPD), a population known for being at risk for suicide (Leichsenring, Leibing, Kruse, New, & Leweke, 2011).

Initially, treatment focused on teaching clients effective problem-solving strategies. However, treating such a high-risk and complex population moved the therapists to apply treatment strategies that required clients to make very difficult life changes. This focus on problem solving was experienced as extremely invalidating by clients. Often, clients responded with hostility by lashing out, often at their therapist, or dropping out of treatment altogether. In response, treatment shifted dramatically to focus on warmth and acceptance. Clients were equally frustrated by this treatment, saying it was not doing enough to solve their problems. It became clear was that there was a need for new therapist strategies that could encompass a synthesis of

a technology of change and a technology of acceptance,

spaciousness of the therapist’s mind to “dance” with movement, speed and flow,

radical acceptance by the therapist of the client as is, with slow and episodic rate of progress and the constant risk of suicide, and

therapist humility to see the transactional nature of the enterprise. This led to a synthesis of both acceptance and change—accepting

clients where they are while pushing for progress and combining a range of change strategies aimed at problem solutions and acceptance strategies with a core emphasis on validation.

However, this synthesis of acceptance and change was troubling for clients as well. Given the complexity of the clients’ problems, asking them to temporarily tolerate distressing experiences to focus on other treatment goals proved difficult if not impossible. For many clients, the pain from the past was intolerable and elicited dysfunctional behaviors. What was needed was a new set of client targets that focused on teaching

radical acceptance of what each of us has to accept our past, the present and realistic limitations on the future and

skills to tolerate distress without impulsively or destructively reducing it.

Dialectical behavior therapy is rooted in behaviorism, and at the time DBT was created, behavioral treatments focused primarily on changing distressing experiences rather than on temporally tolerating them. This prompted an alteration to traditional behavioral treatment.

The problem was where to find an acceptance-based practice that did not focus on change. Acceptance-based treatments (e.g. client centered therapy Rogers, 1946) used positive acknowledgement as a vehicle to enact change, and thus were ultimately change focused. A search for practices that were purely acceptance based, and for individuals who could teach acceptance without linking it to change, led to the study of both Eastern (Zen) and Western contemplative practices (Aitken, 1982 Jager, 2005). Fundamental to these practices is the concept of radical acceptance of the present moment without attempts to change it. Integrating Zen and contemplative practices into behavioral therapy also created challenges. Both Zen and contemplative prayer spring from spiritual practices, and clients presented from the entire spectrum from no spirituality to intense spirituality and religious convictions. An inclusive approach had to be developed. Many individuals struggled with meditating in silence and focusing their attention on their breath and inner sensations. At the time, meditation did not exist in psychotherapy. The idea of meditation was viewed as weird, threatening, and out of reach to individuals whose avoidance of emotions and inner sensations was a strong pattern. Thus, basic Zen practices, along with aspects of other contemplative practices, were translated into a set of behavioral skills that could be taught to both clients and therapists. The spiritual and religious overtones in Zen had to be parceled out as well, at least at first pass. Thus, the term mindfulness was used to describe the skills translated from Zen. The term was adopted from the work of both Ellen Langer (1989) and Thich Nhat Hanh (1976). The skills translating contemplative practices were labeled “reality acceptance skills” and drew heavily from the work of Gerald May (1987).

Another problem to solve was to develop a model for BPD. Such a model would have to be capable of guiding effective therapy, nonpejorative for the client, and compatible with current research data. Thus, the model that was developed was the biosocial theory, which states that BPD is a pervasive disorder of the emotion regulation system. Taken further, BPD criterion behaviors function to regulate emotions or are a natural consequence of emotion dysregulation (Linehan, 1993).

Dialectical behavior therapy required a theoretical framework that could integrate the principles of Zen and other contemplative practices with behaviorism. That framework emerged with a chance encounter with the philosophical concept of dialectics, which highlights the process of synthesizing oppositions. After dialectics was adopted, the treatment was scrutinized to insure that it was consistent with the underlying philosophy and the treatment manual was published (Linehan, 1993a Linehan, 1993b). Dialectics continues to provide a framework from which the treatment evolves continual tensions between theory and research versus clinical experience and between Western psychology versus Eastern practice drives the evolution that is consistent with the theoretical integration model described by psychotherapy integration researchers (Arkowitz, 1989 Arkowitz, 1992 Prochaska & Diclemente, 2005 Ryle, 2005 Norcross & Goldfried, 2005).

Stages of Treatment

Clients coming into treatment ordinarily met criteria for BPD, were at high risk for suicide, had a wide range of co-occuring axis I disorders (e.g., depression, multiple anxiety disorders, eating disorders, substance abuse disorders, etc.), had a difficult time managing negative emotions, and were engaged in behaviors antithetical to treatment (e.g., avoidance of appointments, poor time management skills), all of which made conducting effective therapy difficult. At the time there were no guidelines on how to treat clients with severe multiple disorders and high-risk behaviors, and therapists needed guidance on what and how to prioritize problems within sessions. To organize treatment, a set of priorities were developed based on the concept of level of disorder, which included imminent life threatening risk, severity, pervasiveness, and complexity of disorder and, disability.

The guidelines provide a hierarchy of what to treat and when to treat it for a particular client. It also enables the clinician to treat individuals with varying complexities and problems. Targets can be grouped into recommended stages of treatment. In stage 1, the focus of treatment is to stabilize the client and achieve behavioral control. Stage 1 is broken into the following behavioral targets: to decrease imminent life interfering behaviors (e.g. suicide attempts, non-suicidal self-injury), reduce therapy interfering behaviors (e.g. missing treatment, behaviors that are burning out the therapist, refusal to collaborate with necessary steps for desired change), decrease client-guided, quality-of-life interfering behaviors (e.g. substance use, unemployment, homelessness), and increase skillful behaviors to replace dysfunctional behaviors (this is called DBT skills training). Stage 2 is called the stage of “quiet desperation.” Action is controlled but emotional suffering is not. In stage 2, the goal of treatment is for the client to experience to full range of emotions also PTSD is treated in stage 2. Stage 3 is to reduce ordinary problems in living. Stage 4 is designed to increase a sense of completeness, to find joy, and/or achieve transcendence.

Modularity

As previously mentioned, DBT was developed for clients with complex, multi-diagnostic, high-risk disorders, and resultantly, the clinical problems that emerged were very complicated. It was clear that in order for DBT to be effective, treatment had to be flexible and based on principles rather than on highly structured protocols. Strategies for approaching and resolving complex problems are modularity and hierarchy. Modularity can be used to separate the functions of a treatment/intervention into independent modules such that each module contains everything necessary to carry out one specific aspect of the desired treatment. This inherent modularity to DBT enables various aspects of disorder-specific protocols to be included or withdrawn from the treatment as needed. Hierarchy is built into the treatment by having predetermined levels of disorder, which are addressed in order from most to least severe.

Dialectical behavior therapy was developed for individuals entering stage 1 of treatment. However, DBT has a modular and flexible structure, which allows for the treatment to be scaled to treat clients with simpler clinical presentations. Disorders are treated depending on a treatment hierarchy with protocols within DBT or protocols brought in from other treatments for specific problems (for example, formal exposure for specific phobias).

Team as a Part of Treatment

Dialectical behavior therapy was developed and applied initially within a graduate training program that evolved into a research environment. After completion of formal DBT training and supervision, all research therapists attended a weekly consultation team meeting to insure the maintenance of fidelity to the model during the study. Because this was and is the model used in all of the early DBT studies it, the treatment, when defined, included this focus on team consultation as part of the treatment. The primary functions of consultation team are to focus on therapist treatment fidelity, manage burnout, and provide support to those treating clients at imminent suicide risk and/or engaging in significantly more dysfunctional behavior. In DBT, the emphasis of consultation team reinforced and/or shaped therapist behavior, with the aim to improve fidelity and treatment. The essence of team is to prioritize topics based on severity and acuity. Therapists are also encouraged to cheerlead and validate each other and to maintain a non-judgmental tone. Consequently, DBT is defined as the treatment of a community of clients by a community of therapists, and the treatment of the therapists by the community of therapists.

Between-Session Coaching

The primary rationales for providing between-session telephone coaching is that 1) suicidal individuals often need more contact than weekly individual sessions, especially during crises, and 2) allowing phone calls only when suicidal is likely to reinforce suicidality for many clients. Another reason for phone coaching between sessions is that most clients desperately needed to learn how to interact with people in ways that make others want to help them rather than making others angry or frustrated. Thus a focus of phone calls is to teach clients phone skills and to provide effective consequences for dysfunctional social interactions. Phone skill coaching is used to aid in skill generalization in different contexts and environments. Lastly, phone coaching can be used to repair damage done to the therapeutic relationship when having to wait until the next session is unnecessarily painful.

DBT Skills

In developing the treatment it became apparent that it was extraordinarily difficult, if not impossible, in 60 minutes to focus simultaneously on problem solving a range of crises, dysfunctional behaviors, emotional distress and high emotion dysregulations while teaching a set of behavioral skills that required practice to be useful. Accordingly, treatment was separated into two parts serving differing roles, one that focused primarily on skill training and one that focused primarily on solving current problems and motivational issues, (e.g. staying alive, abstaining from drug use, reducing depression and/or stay in therapy). In DBT skills the primary emphasis is to help clients learn behaviors that can be used in place of ineffective or maladaptive behavior. Some attention to motivational issues occurs in DBT skills training, particularly with the weekly skills practice homework assignments, but the fundamental emphasis in DBT skills training is on acquiring and strengthening skills.

Skills training is didactically focused, with a heavy emphasis on skills training procedures, including modeling, instructions, stories, behavioral rehearsal, feedback and coaching, and homework assignments. Skills for each module are transcribed on handouts, and various worksheets are provided for each skill. There are four skills modules

Skills are separated into “change skills” (interpersonal effectiveness and emotion regulation) and “acceptance skills” (mindfulness and distress tolerance). The inherent modularity of DBT allows for skills to be added, modified, or deleted depending on the curriculum or need. Many of the DBT skills are developed from research in social psychology, spiritual teachings, or are adaptations of instructions given to clients in various evidence-based treatments targeting specific problems. The original skills package was developed for individuals who were highly suicidal and diagnosed with BPD since then, DBT has been implemented with differing populations and with individuals presenting with differing problem behaviors. New skills have been developed and/or modified due to clinical need and/or advancement in research such as treatment outcomes or mechanisms. Further, the development of DBT was and continues to be an iterative process—as new research comes in, skills will naturally adapt to improve treatment or address new challenges.

Mindfulness is central to DBT, and thus mindfulness skills are labeled the “core” skills. These skills (going within to wise mind, wordless observing, describing what is observed, participating, being non-judgmental, one mindfulness, and effectiveness) are behavioral translations of common instructions given across Eastern and Western contemplative practices. Each skills module has at least one mindfulness skill, e.g., mindfulness of others in interpersonal skills, mindfulness of current emotions in emotion regulation, and mindfulness of current thoughts in distress tolerance. The mindfulness skills of “observe and describe” are part of every worksheet.

Emotion regulation training teaches a range of behavioral and cognitive strategies for reducing unwanted emotional responses and increasing desired emotions. Skills focus on teaching how to identify and describe emotions, how to change emotional responses, how to reduce vulnerability to negative emotions, and how to manage difficult emotions. Dialectical behavior therapy emotion regulation skills training first teaches that emotions are brief, involuntary, full-system, patterned responses to internal and external stimuli (Eckman & Davidson, 1994). Also emphasized in skills training is the importance of the evolutionary adaptive value of emotions in understanding them (Tooby & Cosmides, 1990). The first task of emotion regulation skills training is presenting the model of emotion which identifies

emotional vulnerability to cues,

internal and/or external events that, when attended to, serve as emotional cues (e.g., prompting events),

appraisal and interpretations of the cues,

response tendencies, including neurochemical and physiological responses, experiential responses and action urges,

non-verbal and verbal expressive responses and actions, and

after-effects of the initial emotional “firing” which can include secondary emotions.

Many DBT skills target specific components of the emotional system because we believe that if someone wants to change her emotions, including emotional actions, it can be done by targeting any part of the system of emotions. Once a model is formed, skills to change emotions largely come from existing treatment manuals. Exposure based procedures are found in the skill of “Opposite Action,” where clients explicitly do the opposite of what their emotions and/or action urges dictate (e.g. approach a feared stimulus). Since the original publication of the skills manual (Linehan 1993b), new research emerged for the treatment of depression (e.g. behavioral activation [BA] Dimidjian et al., 2006) and post-traumatic stress disorder (e.g. prolonged Exposure [PE] Foa, Hembree, & Rothbaum, 2007). Subsequent research trials on BA and PE provided further research support for opposite action for emotions like sadness or fear respectively. New emotion regulation skills emerged to target specific aspects of the model of emotions. For example, Nezu, Nezu, and Perri’s (1989) problem solving therapy was repurposed to “Problem Solving,” where solutions are generated to solve problems causing justified emotional distress. Cognitive modification (e.g. Meichenbaum, 1979) became the new skill of “check the facts” where unjustified emotions are challenged and events are reinterpretated to fit the facts. Imaginal rehearsal was repurposed into “Cope Ahead,” where individuals imagine coping effectively to a feared and/or distressing situation. Imaginal rehearsal is also applied in the nightmare protocol (Krakow et al., 2001). In addition to changing emotional response, emotion regulation skills also teach clients to reduce vulnerability to negative emotions. Dialectical behavior therapy is referred as a treatment that helps clients build a “life worth living.” To emphasize that point, skills were added that taught accumulating positives in both the short-term (e.g. adding pleasant events) and in the long-term (e.g. developing goals that fit one’s values). Both skills fit within the behavioral activation treatment model for depression and are also similar to the emphasis on values in acceptance and commitment therapy ([ACT] Hayes, Strosahl, & Wilson, 1999).

Individuals with difficulty regulating their emotions often experience difficulties in interpersonal relationships for example, jealousy and anger can damage close relationships, fear and shame can lead to avoidance of interpersonal contact, and even depression can inhibit efforts to interact with others. Thus interpersonal effectiveness training is a collection of skills that teach individuals to manage interpersonal conflict, develop new friendships and/or end destructive ones, and reinforce the environment effectively. Many of the interpersonal effectiveness skills came from research in assertiveness training (Linehan & Egan, 1979) for example, the skill of DEARMAN (see figure 2) teaches individuals how to make requests effectively. This is balanced by skills on how/when to effectively say no. Interpersonal effectiveness skills have broadened to include skills in dialectics, validation, and contingency management procedures. These skills were added to address different interpersonal dynamics. For example, “Walking the Middle Path,” was originally designed for family skills training with adolescents and their care givers. In walking the middle path, individuals are taught dialectics, more in depth validation (see Linehan 1997), and behavior change procedures. This includes a skill on behaviorism, which teaches clients how positive and negative reinforcement can be strategically implemented to shape goal directed behavior.

When DBT was developed, there were no existing treatment manuals that targeted temporarily tolerating distressing events or circumstances. Available behavioral treatment focused on changing behavior, while distress tolerance teaches clients to accept, find meaning, and tolerate distress. Distress tolerance training teaches a number of “delay of gratification” and self-soothing techniques aimed at surviving crises without making things worse (e.g. avoiding using drugs, attempting suicide, or engaging in other dysfunctional behavior). For example, the TIP skill (see figure 3) was developed by translating research on how to activate the body’s physiological nervous system for decreasing arousal either through temperature (Jay, Christensen, & White, 2006 & Foster & Sheel, 2005), exercise (Tate & Petruzzello, 1995), effective breathing, and muscle relaxation (Linehan, 2005). Also, in distress tolerance are a set of skills focused on reality acceptance, which aim to reduce suffering and increase freedom when painful facts cannot be changed immediately (if ever). The skill of “radical acceptance,” for example emerged from the extensive literature on survivors of Nazi concentration camps, particularly the work by Viktor Frankl (1985). Luck plus radical acceptance of the facts of the present moment were essential to survival.

Figure 2 DEARMAN ACRONYM FROM INTERPERSONAL EFFECTIVENESS MODULE

Figure 3 TIP ACRONYM FROM DISTRESS TOLERANCE MODULE

The skill of willingness, contrasted with willfulness, was taken from Gerald May’s (1982) book and it teaches clients to be wholeheartedly ready to respond to life’s challenges, doing what is necessary, and throwing one’s self into the community as a whole. Among the reality acceptance skills are ones that are accepting reality with the body—these are half smiling and willing hands. Half smiling came from research that showed that emotions are influenced by facial expressions (Ekman et al., 1987 & Ekman, 1993). For the treatment of substance abuse, a new set of skills that highlighted drug addiction were added to the distress tolerance module. These skills integrate community reinforcement, alternative rebellion, and the concept of “dialectical abstinence,” which is a synthesis of an abstinence approach with a harm reduction approach. Very recently, the TIP skill within the distress tolerance module was modified to include a skill called “paired muscle relaxation.” Adapted from stress management for collegiate and professional athletes (Smith, 1980), paced muscle relaxation pairs induced affect, cognitive modification, and relaxation.

Future Directions

Beyond treating clients with BPD, DBT has demonstrated efficacy with different conditions, such as eating disorders (Safer & Jo, 2010 Safer & Joyce, 2011), depression in older adults (Lynch et al., 2007 Lynch Morse, Mendelson, & Robins, 2003), and a cluster B personality disorder (Feigenbaum et al., 2011). In addition, there has been an effort to implement DBT skills as a stand-alone treatment. A number of articles have identified that the DBT skills component alone (without the individual therapy) to be efficacious for a variety of populations including incarcerated women with histories of trauma (Bradley & Follingstad, 2003), ADHD (Hirvikoski et al., 2011), and for intimate partner violence (Iverson, Shenk, & Fruzzetti, 2009) among others. More research is needed to identify which skills are effective for which problem area and for whom though, DBT skill use as a whole has been found to be effective at reducing emotion dysregulation (Neacsiu, Rizvi, & Linehan, 2010). Dialectical behavior therapy skills training has been applied to focus on building resilience and it can be applied across work or school settings for example, DBT skills lesson plans are now being used in school systems to teach middle and high school students (Mazza, Mazza, Murphy, Miller, & Rathus, in press). A relative recent advance to psychotherapy is the integration of technology to psychotherapy. For example, computerized psychotherapy treatments have been found to reduce depression (Richards & Richardson, 2012 Proudfoot et al., 2003) and anxiety (Marks, Kenwright, McDonough, Whittaker, & Mataix-Cols, 2004). In some cases, the computerized interventions have been found to be as efficacious as face-to-face interventions (Selmi, Klein, Greist, Sorrell, & Erdman, 1990). Dialectical behavior therapy, with its established efficacy in face-to-face interventions for a variety of clinical problems and populations and its structured skills training format, is an ideal candidate for dissemination as a computerized intervention.

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What Is an Invalidating Environment?

An invalidating environment isn’t necessarily one in which a child is abused or neglected. Even the most well-intentioned families can be invalidating by ignoring, ridiculing, denying, or judging a child’s feelings. Making a child believe their thoughts or feelings are just plain wrong without being understanding of them is invalidating.

People who grow up in an invalidating environment learn to believe that their actions, thoughts, and feelings don’t matter. This can hinder their ability to recognize and label their emotions, and cause them to distrust their emotions. It can also cause them to later turn to substance abuse or self-harm as a way to better cope with and control their emotions.

The biosocial theory of BPD, posited by Marsha Linehan, Ph.D., who developed Dialectical Behavior Therapy (DBT) to treat the disorder, is that BPD is a dysfunction in how bodies regulate emotions. It is a combination of this emotional sensitivity and an invalidating environment that can ultimately trigger BPD.


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