The Behavioral dialectical therapy Belongs to third generation therapies or contextual therapies, and has been in recent years one of the important contributions in cognitive behavioral therapy, as well as in the field of psychotherapy in general. It was the first psychotherapeutic treatment that demonstrated effectiveness in controlled clinical trials.
TDC was developed by Marsha M. Linehan And his team in the 1990s, with the aim of attending to the suicidal, suicidal and parasuicidal behaviors of people such as those with Borderline personality disorder , Where the constitutional basis of the disorder is high emotional reactivity and lack of regulation.
The difference between suicidal and parasuicidal behaviors is that the former are deliberate acts with fatal outcome that a person tries and carries out in full awareness of the definitive consequences of that act. And the second, are acts with a non-fatal outcome that attempts the individual without the intervention of others.
Limit patients present cognitive-behavioral deficits in several aspects such as interpersonal relationships, Control of emotions , And in the tolerance of suffering.
It is true that although this was the main objective, adaptations have now been made to apply it to other populations, to apply it to patients with other comorbid disorders, as well as Eating Disorders And chronic depression in the elderly, but these adaptations can only be considered in the experimental phase.
Differences between dialectical behavioral therapy with cognitive behavioral therapies
Although dialectical behavioral therapy picks up cognitive and behavioral techniques in its procedure, there are notable differences regarding the following aspects:
- The TDC attaches great importance to the acceptance and validation of the behavior of the patient and the therapist in the present moment (influences of third generation therapies).
- Work is done on behaviors that interfere with therapy.
- The therapeutic relationship plays a relevant role in the treatment and is considered crucial for the progression of BDD. This relationship combines acceptance with change, flexibility in limits, emphasis on skills and acceptance of deficit.
- Emphasis of radical acceptance of behavior and reality. This acceptance implies the absence of value judgment that is neither passive nor resigned, but committed to change.
Theoretical basis of behavioral dialectic therapy
Dialectical behavioral therapy, which includes a dialectical-cognitive-behavioral approach, moves away from the Beck And his Cognitive therapy Centered on the modification of the cognitive schemes and approaches a more behavioral approach.
It gives more importance to the reinforcing aspects of behavior and takes into account a diversity of theoretical and technical sources that justify its consideration as an integrative model, including behavioral science, dialectical philosophy and Zen practice ( Mindfulness ).
Dialectical philosophy refers to the dialectic / dialogue between nature, reality and human behavior. The fundamental principle is that established between change and acceptance. This is fundamental to understanding the borderline personality disorder, because the thinking, behavior and dichotomous emotions characteristic of these people are dialectical failures.
The center of action of the therapist is a function of dialectical processes. It plays with a balance between trying to change the patient, working on the goals of treatment, supporting the strengths and accepting the weak. This means validating your experience, understanding what you feel and doing, and not blaming your mistakes.
Linehan's theoretical approach is based on a biosocial approach, from which he conceptualizes borderline personality disorder. This is conceptualized as an emotionally vulnerable child, who presents a dysfunction of the emotional regulation system, product of the interaction between biological aspects and an environment that invalidates emotional expression.
The subject is very sensitive to emotional stimuli, and has a tendency to experience very intense emotions and difficulties with regard to returning to his emotional baseline. Difficulties in emotional modulation are related to that high reactivity, the deficit in regulating emotions causes them to present an exaggerated emotional reaction.
Over time, people develop an important fear of experiencing such emotions and resort to strategies of avoidance such as self-injurious behaviors (cut, burn), substance use or maladaptive eating behaviors, these serve to mitigate emotional and physical pain , And the momentary relief is a negative reinforcement for the patient, who will return to these behaviors in the future, keeping the pattern dysfunctional.
To this emotional vulnerability of biological origin, the psychosocial or environmental factor is united. For Linehan, the environment that surrounds us is crippling and has its effects on the development of personality that occurs in childhood and adolescence.
In the case of subjects with borderline personality disorder, who focused on this therapy, the environment is preceded by a parenting pattern that responds with inappropriate or non-contingent responses to the communication of intimate experiences.
If a person experiences intense emotion as sadness, the environment around him makes him see that he is mistaken in describing that emotion that he experiences, and that in reality this is based on his unacceptable character characteristics of personality, which make him To express oneself. For example, a child who starts crying because he has broken his favorite toy and the response of his parents is enough to make you cry. Or, a child, who is thirsty and asks his mother for water, and this one responds to you? You can not have thirst again, five minutes ago that you have drunk??.
The problem arises when the person is emotionally vulnerable, that is, when he has difficulty regulating his emotions and is told to control himself, that it is not right for him to express his affections as such, and that he does not know how to react to events. In such an environment, it is often necessary for the person to express an emotion with great intensity and in an extreme way, then the environment responds, and reinforces that intense expression, while punishing the expression of Negative emotions .
On the other hand, the message that launches the atmosphere of"do not express yourself, if you want one can get controlled", favors it is very difficult to tolerate discomfort, the individual does not trust their emotions and invalidate them.
Consequently, the difficulty in regulating the emotions gives rise to an interference in the social relations that the patient establishes, originating chaotic relations, based on the impulsivity and the outbursts of extreme negative emotions (example anger, sadness??).
Phases of dialectic-behavioral therapy
Dialectical behavioral therapy is developed in three phases, namely pretreatment, treatment and posttreatment.
The pretreatment phase is the most important, since it is the one where the structure of the program will be exposed, emphasizing the establishment of limits that will guide the therapy.
It will guide the patient about the therapy, the program and the importance that can have in his life. The therapeutic relationship will be established and the cohesion of the group will be built. Goals will be set, explaining the rules of operation of the program to respond to misconceptions that participants may have, and will be asked to approve and sign the treatment contract.
Some of the rules to follow are as follows:
- Those who leave therapy will not be able to re-enter it until it is over. And if they are late for the session or can not go to the session, they must call in advance.
- All participants should follow individual therapy apart from group therapy.
- If you go to therapy after having consumed alcohol or Drugs , Will not be able to participate in the session.
- All information obtained during sessions, as well as their names, must be confidential.
- It is forbidden to engage in private relationships between clients outside the training sessions, and those who have sex with each other, may not be part of the same training group.
- Patients will not be able to talk about past suicidal behaviors with others outside the session and if they have a suicidal tendency and call other people for help, they should be willing to receive such help.
The treatment phase consists of an individual and a group format a week, as well as telephone consultations between sessions to help patients to generalize the skills learned and use them in everyday life. I will then comment on the formats in the structure section.
Finally, the post-treatment phase includes the self-help groups, which are composed of patients in the advanced stages of the program and who are oriented towards helping them to reduce the probability of crisis and the achievement of vital objectives, maintenance of the achieved achievements and the Prevention of relapse.
Structure of the TDC
Individual therapy and group therapy are combined and there are also treatment manuals that allow standardization of interventions.
The TDC adopts strategies pertaining to cognitive-behavioral therapies such as exposure, contingency management, skills training, problem solving , Cognitive therapies, and pertaining to third-generation therapies such as mindfulness. In addition, acceptance is emphasized as the main goal for successful therapy. This acceptance must be compromised.
Group therapy is performed in sessions of two and a half hours, once a week, for a minimum of one year. The groups are composed of 6 to 8 patients and two therapists. It focuses on a psychoeducational approach, emphasizing the acquisition of behavioral skills such as interpersonal effectiveness, emotional regulation, tolerance to discomfort, meditation And self-control.
Individual therapy usually lasts one hour, and is done once a week. The motivation of the patient and the problems of post-traumatic stress are often worked. Telephone calls are intended to generalize skills to the specific situations of the patient's life.
The objectives of individual therapy are hierarchical and involve an order of priority. It is required that, to address a later goal, problem behaviors should not be given with a higher priority. For example, it would not be possible to intervene in quality of life Of a patient if the behavior has not been intervened the requirement that to deal with a later objective should not occur incidences of problem behaviors with a higher priority. The objectives are as follows:
- Decrease or elimination of suicidal or parasuicidal behaviors.
- Decrease or elimination of behaviors that interfere with therapy.
- Decrease or elimination of behaviors that interfere with the quality of living.
- Acquisition of behavioral skills, replacing previous ones.
- Reduction of the effects of posttraumatic stress To discover and reduce the effects of physical and emotional sexual infantile traumas.
- Increase self-respect.
- Obtaining the individual goals that the patient brings to the therapy.
Functions of the treatment program
The treatment program responds to five main functions:
- Strengthen the patient's ability by using different techniques such as skills training, modeling, behavioral testing??
- Increase the motivation of the patient by promoting the application of new learning to different situations, using contingency management, exposure??
- To promote generalization to other contexts, transferring the new skills to more difficult natural and social contexts, relying on live expositions, through telephone consultations?
- Structuring the environment, through the application of what is learned in bonding and family situations.
- Empowering the therapist, developing specific skills, supervising the level of being at work, supervising others.
Techniques used
To achieve the objectives proposed in this individual therapy different strategies are used that can be grouped into dialectical techniques, nuclear, stylistic, case management, integrators. These will be used to varying degrees and will be combined depending on the case. In its application, important elements are developed to achieve the objectives and help the therapist in his relationship with the patient.
Dialectical and nuclear strategies function as the organizing element of therapy and balance attempts at change with acceptance. On the other hand, the validation strategy is to look for the elements that make the maladaptive patient's response comprehensible and valid, even if it needs modification.
The stylistic ones are those referring to the communicative and interpersonal style necessary and suitable for the therapy. Case management specifies how the therapist interacts and responds to the social network in which the patient is immersed. And the integrators, focus on how to handle the problematic situations that arise when working with borderline personality disorder.
In group therapy other types of strategies are used such as mindfulness skills, malaise tolerance skills, emotional regulation skills and interpersonal effectiveness skills.
The former serve to enhance the learning of other skills; The latter are oriented to the person tolerating difficult and painful situations, without adding more discomfort; The third ones are oriented to the modulation of the emotions and the last ones are oriented to teach to apply specific abilities of resolution of interpersonal, social problems and of assertiveness To modify aversive environments and obtain their objectives in interpersonal encounters.
CONCLUSIONS
Within third-generation therapies, dialectical behavioral therapy is the one that has obtained the best results, fulfilling criteria to become a treatment with empirical support.
It is of great value to consider that a therapy with a point of view that is very different from traditional therapies, with more artistic characteristics, and perhaps less rigorous, is giving so much fruit in the field of personality disorders .
It is a matter of time for such therapies to be generalized to other disorders.
Bibliography
- Gómez, E. (2007). Dialectical Behavioral Therapy . Journal of Neuro-psychiatry. 70 (1-4).
- García Palacios, A. (2006). Behavioral dialectical therapy . EdyPsyckhé. Journal of Psychology and Psychopedagogy . Vol. 5, no. 2, 255-271.
- Ruíz, M.A., Díaz, M.I. And Villalobos, A. (2012). Manual of Cognitive Behavioral Intervention Techniques . Bilbao. UNED.
- Vallejo, M. A. (Dir.) Manual of behavior therapy. 2ª Ed. Madrid: Dykinson, 2012 (Vol. I).