Mechanisms of Change in Dialectical Behavioural Therapy: Theoretical and Empirical Observations (Lynch, T; Chapman, A; Rosenthal, M.Z.; Kuo, J.R. 7 Marsha M. Linehan – 2006).

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 62(4), 459–480 (2006).

Despite increased attention to treatment development for borderline personality disorder (BPD), very little research has examined the basic processes or mechanisms underlying
patient change.

it has demonstrated efficacy in RCTs for chronically depressed older adults (Lynch, Morse, Mendelson, & Robins, 2003) and eating disordered individuals (

reductions in several problems associated with
BPD, including self-injurious behavior, suicide attempts, suicidal ideation, hopelessness, depression, and bulimic behavior. (See Robins & Chapman, 2004, for a review.)

From Theory to Practice: Dialectical Philosophy and the Biosocial Theory
of Borderline Personality Disorder Philosophical Foundations

Marsha Linehan discovered an important shortcoming in standard cognitive and behavioral treatments: They focused almost exclusively on helping patients change their thoughts, feelings, and behaviors. A treatment solely focused on change often was not palatable to these patients, who often felt invalidated and criticized and dropped out of treatment. On the flip side, a treatment focused entirely on acceptance invalidated the seriousness of the patients’ suffering and the urgent need to produce change

As a worldview, dialectical philosophy
most often is associated with Marxist socioeconomic principles, but the philosophy of
dialectics actually extends back thousands of years

According to Hegel, the process by which a phenomenon, behavior, or argument is
transformed is the dialectic,

applied to the understanding of
human suffering, this ontological principle of interrelatedness and wholeness leads to a
systemic and contextual conceptualization of behavior. DBT treats the whole

the transaction
between a biological tendency toward emotional vulnerability and an invalidating rearing
environment produces a dysregulation of the patient’s emotional system.

invalidation is the critical socially mediated etiological process

emotional vulnerability is the key biological factor.

The invalidating environment is characterized by punishing,
ignoring, or trivializing the individual’s communication of thoughts and emotions as well
as self-initiated behaviors and may involve sexual, physical, and emotional abuse (Wagner
& Linehan, 1997).

the inevitable sequelae of dysregulated emotions,
or as maladaptive methods of altering emotional experiences. For example, impulsive
or self-destructive behaviors such as self-injury, suicide attempts, or disordered eating
may occur in direct response to or function to regulate

the ultimate goal is
not to achieve an objective “distance” from one’s experience, but rather to enter into,
participate in, and become “one with” experience (

learning to control the focus of attention, not the object

By allowing emotions to be experienced (exposure)
without judgment, new associations are acquired (the emotion “just is,” the thought “just
is,” the memory “just is”). With repeated practice,

in the patient’s life, DBT provides an opportunity to learn new associations with
stimuli that elicit intense emotional pain.

For instance, the socially anxious individual who avoids giving speeches
in response to a verbal rule (“If I publicly speak, I will be humiliated”) may fail to learn
that public speaking is nonthreatening, even if he or she gives a successful speech. Literal
belief in these types of verbal rules leads the individual to experience thoughts, feelings,
and situations as dangerous (i.e., “If I think X, a very bad thing will happen”) and to
evaluate certain thoughts as “bad” and/or equivalent to an unwanted action

observe a “thought as a thought”
without believing it is literally true

does not work by altering

it encourages the development

metacognitive awareness (i.e. seeing thoughts as thouhts, not literally true)

Indeed, BPD patients frequently describe a negative, shameful, or otherwise aversive
sense of self, which is likely maintained by literal belief in negative self-judgments.
Mindfulness may function to create a new sense of self

the difficulty individuals who have BPD
have in disengaging attention from emotional stimuli

DBT operationally defines the specific
behaviors involved in validation in a unique manner. As such, DBT involves six levels of
validation: (1) active listening, and awakeness to and interest in the patient; (2) accurate
reflecting of the patient’s feelings, thoughts, or behaviors; (3) articulating unverbalized
feelings or thoughts, or “mind reading”; (4) expressing that the patient’s dysfunctional
behavior is logical in view of past learning history or biological factors; (5) expressing
that the patient’s behavior is normative, wise, or expected given the current context; and
(6) acting in a manner that is genuine, or “radical genuineness.”

BPD individuals often suffer from identity disturbance, involving persistent and markedly
disturbed, distorted, or unstable self-image or sense of self (American Psychiatric
Association, 1994; Koenigsberg et al., 2001). Therefore, the ability to organize experiences,
predict future events, and engage in effective social interactions may be compromised
as well. Within

In turn, heightened arousal interferes with cognition and task performance

people tend to “gravitate toward and stay in environments that are compatible with their
self-conceptions” (Swann, 1983, p. 39).

to help the patient reduce emotion dysregulation
in the service of building a life worth living

For instance, many BPD patients engage in various behaviors
(i.e., self-injury) that they are rather averse to disclose and discuss, let alone in an
excruciatingly detailed chain analysis.

Shame has been described as a painful state that disrupts ongoing
behavior and cognition

The action tendencies
associated with shame include the urge to hide, withdraw, disappear, or avoid thinking
about aspects of the shameful behavior

Requiring the patient to talk in detail about shameful events or behaviors may work
very similarly to mindfulness or opposite action

The patient implements
emotion regulation skills to attenuate feelings of sadness and shame, discards her
razor blades, and seeks social contact and support or advice

Reducing Emotion Dysregulation and Building Skills:
Emotion Regulation Skills and Opposite Action

the biosocial theory that BPD is fundamentally a disorder of pervasive emotion dysregulation

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