Transdiagnostic Applications of DBT for Adolescents and Adults

By Ritschel, Lorie A.; Lim, Noriel E. et al. | American Journal of Psychotherapy, April 1, 2015 | Go to article overview

Transdiagnostic Applications of DBT for Adolescents and Adults


Ritschel, Lorie A., Lim, Noriel E., Stewart, Lindsay M., American Journal of Psychotherapy


INTRODUCTION

Dialectical Behavior Therapy ([DBT]; Linehan, 1993) is an evidence-based treatment that was originally developed for chronically suicidal adults. DBT is often associated with the treatment of borderline personality disorder (BPD), which is characterized by emotional, behavioral, cognitive, intrapersonal, and interpersonal dysregulation (Linehan, 1993a). Individuals with pervasive emotion regulation difficulties often engage in ineffective, harmful behaviors, including chronic suicidal ideation, non-suicidal self-injury (NSSI; e.g., cutting, burning), disordered eating, and substance use, as a way to modulate affect (Klonsky, 2009). As such, the treatment is designed to mitigate this pervasive dysregulation by teaching skills to disrupt and replace these harmful compensatory behaviors with more effective coping strategies.

Although DBT historically has been linked with BPD, two factors have led to the broader application of DBT to other clinical populations. First, individuals with BPD tend to meet criteria for at least one additional diagnosis; on average, a person diagnosed with BPD meets criteria for approximately four additional disorders (Hamed et al., 2008) Thus, the treatment was designed to target myriad presenting problems across a range of diagnoses. Moreover, the empirical evidence for DBT demonstrates that the treatment is effective not only for reducing the major treatment targets of suicide and NSSI, but also associated psychological difficulties, such as depression and trauma symptoms (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). Accordingly, in recent years DBT has become more strongly associated with pervasive emotion dysregulation, rather than with BPD specifically. Because other psychological difficulties can similarly be characterized as reflecting an inability to modulate painful negative affect without engaging in dysfunctional coping strategies, the treatment was thus expanded and modified to accommodate other presenting problems, such as eating disorders, substance use disorders, and trauma.

Dialectical behavior therapy offers a multi-modal, comprehensive, and flexible treatment approach that can be used transdiagnostically with both adults and adolescents who have a range of emotion regulation difficulties. Standard DBT is a principle-based treatment that includes weekly individual therapy, as-needed between-session coaching, weekly group-based skills training, and weekly consultation team meetings for therapists (for a description of modes, targets, and stages of treatment, see Linehan, this issue). The essence of DBT lies in the therapist's skillful blending of acceptance- and change-based strategies (Linehan, 1993). Acceptancebased strategies in DBT are based on the principles of Zen, wherein clients learn to observe and describe their behaviors, thoughts, emotions, and environments without judgment and without trying to change themselves or their situations. Change-based strategies in DBT are based on the principles of behaviorism and include interventions such as exposure, contingency management, problem solving, and cognitive restructuring. DBT therapists are able to weave acceptance- and change-based strategies together based on a well-formulated case conceptualization and target hierarchy, which combine to dictate the moment-by-moment focal point in therapy sessions. This blend of strategies is critical for individuals with severe emotion dysregulation because it is likely they will experience change without acceptance as invalidating of their difficulties, whereas acceptance without change is insufficient to moving them toward their goals.

DBT AS A TRANSDIAGNOSTIC TREATMENT APPROACH

The recent psychological literature has focused strongly on the construct of emotion dysregulation as the common element across most psychological disorders. Several treatments that have emerged in recent years have focused explicitly on transdiagnostic therapeutic applications, with emotion regulation as a primary treatment focus (e. …

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