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Dialectical Behavior Therapy

Practical No: Clinician:

Date: 28/02/2023 Client: J

Dialectical behavior therapy (DBT) is a modified type of cognitive behavioral therapy

(CBT). Its main goals are to teach people how to live in the moment, develop healthy ways to

cope with stress, regulate their emotions, and improve their relationships with others.

Marsha Linehan and her research team at the University of Washington developed DBT

during the 1980s as a treatment for the chronically suicidal patient who had a pattern of both

suicide attempts and/or non-suicidal self-injurious behaviors (i.e., parasuicidal behavior). DBT

was soon extended to treat individuals meeting criteria for borderline personality disorder (BPD),

a disorder often characterized by parasuicidal behaviors. DBT has since been standardized in

Linehan’s 1993 treatment manuals, and evaluated in randomized clinical trials. The data suggest

that it is more effective than usual psychotherapies offered in the community for treating women

with BPD with primary presenting problems of suicidal behavior and substance abuse. DBT has

also been adapted to the treatment of eating disorders and dissociative disorders, and to families

and adolescents. Settings in which DBT are often used include: group therapy, individual therapy

and phone coaching. The strategies and techniques that are used in DBT include the following:

Core Mindfulness

One important benefit of DBT is the development of mindfulness skills. Mindfulness

helps you focus on the present or “live in the moment.” This helps you pay attention to what is

happening inside you (your thoughts, feelings, sensations, and impulses) as well as using your

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senses to tune In to what’s happening around you (what you see, hear, smell, and touch) in

nonjudgmental ways.

Distress Tolerance

Distress tolerance skills help you accept yourself and your current situation. DBT teaches

several techniques for handling a crisis, including: distraction, improving the moment, self-

soothing, and thinking of the pros and cons of not tolerating distress. Distress tolerance

techniques help prepare you for intense emotions and empower you to cope with them with a

more positive long-term outlook.

Interpersonal Effectiveness

Interpersonal effectiveness helps you to become more assertive in a relationship (for

example, expressing your needs and be able to say "no") while still keeping a relationship

positive and healthy. You will learn to listen and communicate more effectively, deal with

challenging people, and respect yourself and others.

Emotion Regulation

Emotion regulation lets you navigate powerful feelings in a more effective way. The

skills you learn will help you to identify, name, and change your emotions. When you are able to

recognize and cope with intense negative emotions (for example, anger), it reduces your

emotional vulnerability and helps you have more positive emotional experiences.

In short, DBT is able to help people successfully improve their coping skills and develop

effective ways to manage and express strong emotions. Researchers have also found that DBT is

effective regardless of a person's age, sex, gender identity, sexual orientation, and race or

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ethnicity. DBT may also be useful in the treatment of children with disruptive mood

dysregulation disorder.

The component of interpersonal effectiveness is discussed further.

Interpersonal effectiveness
Dialectical behavioural therapy (DBT) teaches specific skills for developing strong roots

and establishing or maintaining healthier relationships. DBT's interpersonal effectiveness skills

aim to create and maintain positive relationships. The goal is to strengthen existing relationships,

create new and satisfying relationships, and end unhealthy or toxic relationships.It is important to

create and maintain balance in relationships, and balance change with acceptance. Learning to

get along with others while asserting your own needs is critical to maintaining healthy

relationships. It can be difficult to strike a balance between one's own needs and the needs of

others.

There are three sets of skills you will learn to help achieve this goal:

❖ Objective Effectiveness,

❖ Relationship Effectiveness

❖ Self-Respect Effectiveness

Objective Effectiveness (D.E.A.R. M.A.N.). The skill focuses on the goal of an interaction?

Objective effectiveness is about getting what you want out of a situation. The acronym

D.E.A.R. M.A.N. skill used to clearly express your needs or desires. It is the interpersonal

skill of asking for something in a respectful and effective manner that builds and maintains a

relationship, regardless of whether you get what you ask for.

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Describe. The situation in a simple way. If you want to go to the movies with your

friends, you could briefly describe the situation by saying, “My friends are going to see

the new comic book movie this weekend.”

Express. What you would like. “I would like to go to the movie with them.”

Assert. Why this is important to you in a way that is respectful, and not aggressive. “I

haven’t been able to spend much time with them since track season started, so it would be

really meaningful if I could spend time with them.”

Reinforce. When you do get what you asked for. “I promise I’ll have my room clean and

my homework is done before I leave for the movie.”

Mindful. Stay in that moment. Don’t worry about the past or future, such as what your

friends will say if you can’t go. Just be in that moment.

Appear Confident. Are you scared out of your mind to ask your boss for a raise? She

doesn’t need to know that. Approach the situation in a confident way.

Negotiate. When it doesn’t look like you’re going to get the result you were wanting, be

flexible. Negotiate to find a happy middle ground for both parties.

Relationship Effectiveness (G.I.V.E.). Relationships aren’t only about getting what we need—

they’re also about the other person. The skill G.I.V.E. will help to achieve relationship

effectiveness by fostering positive interactions.

Gentle. In your approach. When you’re gentle, you are being mindful of the other

person’s emotions. This will help the person with whom you’re communicating to feel

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loved instead of attacked. Communication is always better when no one is feeling

defensive.

Interested. In what the other person is saying. Interest can be conveyed through words

and/or body language. Using words, you can ask the person questions about what she is

saying or simple “uh-huh” “oh really?” responses. You can convey interest through body

language by maintaining eye contact, actually listening to what is being said, and making

a facial expression.

Validate. Confirm not only that you hear what the other person is saying, but that you

understand it by echoing the emotion back to her. If she is telling you that her friend

canceled their lunch date for the third time in a row, you might say “How frustrating!

You must feel so disappointed!”

Easy manner. Present yourself as being relaxed and comfortable throughout the

interaction. You will be more approachable.

Both verbal and nonverbal communication is essential in the GIVE skill. These actions

will set you up for effective interpersonal communication in each of your relationships.

Self-Respect Effectiveness (F.A.S.T.). Sometimes in relationships you might find yourself

betraying your own values and beliefs to receive approval or to get what you want. The skill

F.A.S.T. will help to achieve self-respect effectiveness. FAST is about maintaining your self-

respect during conflict.

Fair -to yourself and others. This includes both your thoughts and your actions. When

you’re being fair, you are not using dramatic or judgmental thoughts or statements such

as “I’m powerless in this situation” or “They’re the worst!” Instead, your thoughts may

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be along the lines of, “What’s going on for that person, and what’s going on for me?” or

“I didn’t agree with most of what he just said, but what were the elements of truth?”

(no) Apologies. This doesn’t mean you never apologize, apologizing can be incredibly

powerful in relationships. However, you don’t need to apologize when you haven’t done

anything wrong.

Stick to your values. Stand up for what you believe in. If you’re not sure what you

believe in, do some self-examination to determine your values. Be honest about what you

value. If you say you value family but you avoid them at all costs, then you’re not

valuing family. You may want to make a list of your current values, and what you hope

your values will be in the future.

Truthful. Be honest with yourself and others. Are you exaggerating the situation? Are

you minimizing it? Are your words true?

Using the four steps of FAST will allow you to maintain your dignity and come out of a

situation feeling good about yourself, regardless of how you feel about the outcome.

Case Summary

Jane was a 32-year-old heterosexual Caucasian female Army Veteran and medical

technician residing in a New Jersey apartment with her 7-year-old son, “Brandon.” Jane

presented as composed, intelligent, and competent. At intake, Jane was sexually active with

multiple male partners. She reported ongoing dissatisfaction with her various relationships. Jane

presented to treatment with symptoms of BPD. These symptoms included recurrent unstable and

intense relationships that alternated between idealization and devaluation, frantic efforts to avoid

abandonment, identity disturbance (e.g., fluctuating religious beliefs, changing conception of self

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in relationships), impulsivity (e.g., potentially damaging sexual behavior, substance use),

affective instability due to marked reactivity of mood, chronic feelings of emptiness, as though

her “inside is missing” , inappropriate, intense anger, sleeplessness, negative comparison and

competitive behavior with siblings. Jane additionally reported “very strong” suicidal ideation in

the past. She reported passive suicidal ideation at intake and during treatment.

Chief Complaints

 Recurrent unstable and intense relationships

 Frantic efforts to avoid abandonment

 Identity disturbance

 Impulsivity

 Affective instability due to marked reactivity of mood

 Chronic feelings of emptiness

 Inappropriate, intense anger

 Sleeplessness

 Negative comparison

 Competitive behavior with siblings

 Suicidal ideation

Provisional Diagnosis

Borderline Personality Disorder

Rationale

The client is diagnosed with BPD, based on the chief complaints. So the treatment plan is

to administer Dialectical Behavioral Therapy since it is a evidence based therapeutic approach

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for treating BPD exclusively. In the current session the treatment focus on interpersonal

effectiveness component of DBT as the client reported difficulty in maintaining relationship,

recurrent unstable and intense relationships, frequent breakups without appropriate reason, fear

of abandonment, dissatisfaction with ongoing various relationship, and lack of effective

interpersonal communication.

Procedure

Establish rapport with the client and psychoeducation is given about the interpersonal

effectiveness component of DBT. The current problematic behavior is identified in the initial

rapport session by asking about ‘what’s currently bothering you?’ and chain analysis was carried

out to understand the behavior further. The following questions could be asked:

 Vulnerability factors: What factors made you more vulnerable to the problem behavior?

 Precipitating event: What was the exact event that led to the problem behavior and when

did it happen?

 Thoughts and emotions: What thoughts did you have after the event occurred? What

feelings did you have after it happened / how did you feel during and after the problem

behavior?

 Dysfunctional link: What action followed? What was going on around you?

 Identification of targeted problematic behavior: What are the other problematic behaviors

associated with this?

 Effective behavior: What do you want instead? What are the possible ways you can do

that? In the case of Jane, ‘DEAR MAN’ is used.

‘DEAR MAN’ Skills

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In order to enhance their interpersonal skills, ‘DEAR MAN’ is used and the

following questions are asked.

Describe. (The current situation) What are the facts of the situation?

Express. (Your feelings and opinions about the situation) What are the feeling

and opinion about the situation? How do you express your feeling?

Assert. (Yourself by asking for what you want or saying “No” clearly) How will

you tell someone what you need?

Reinforce. (Reward) what you want or need? Positive effects of getting what you

want or need? The negative consequences of not getting what you want or need?

How will you reward the other person for responding well to you?

Mindful. (Keep your focus on your goals) What is the goal of your interaction?

What other topics might distract from the goal?

Appear. (Confident, effective, and competent) Describe the posture, eye contact,

and tone of voice you will use?

Negotiate. (Be willing to give to get) Offer and ask for other solutions to the

problem. What are the limits of what you are willing to accept?

Case Report

Jane was a 32-year-old heterosexual Caucasian female army veteran and medical

technician residing in a New Jersey apartment with her 7-year-old son. Jane presented the

complaints of having recurrent unstable and intense relationships, frantic efforts to avoid

abandonment, identity disturbance, impulsivity, affective instability due to marked reactivity of

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mood, chronic feelings of emptiness, inappropriate and intense anger, sleeplessness, negative

comparison, competitive behavior with siblings and suicidal ideation. Various assessment were

used to conform BPD like clinical interview and chain analysis and DEAR MAN were

administered as intervention to treat her interpersonal problems.

The goal of the treatment was to enhance the patient’s interpersonal effectiveness,

especially with her partner (boyfriend). In order to understand the current issue that the client

experiencing in her life, the therapist used behavioral chain analysis. Where the client discloses

the vulnerable and precipitating factors: for her the issue she faced in the job she wants to talk

with her boyfriend. But she called and, messaged him he doesn't pick up the call and didn't reply

to her which leads to the behavior of breakup. The patient reported that she was having the

frequent thought that whomever she loves left her and leave her alone. She believes all men are

similar because, in her previous relationship, she felt she was cheated by them. All these frequent

thoughts lead her to do self-harming behavior such as cutting the vein and hitting her head on the

wall. Due to the breakup, she was not able to trust others, not able to focus on her work, was not

able to take food properly and was not able to sleep well. Apart from these difficulties that the

patient was facing in her life, she wants to communicate her problem with her boyfriend and she

wants him throughout her life, instead of breaking up with him.

After doing chain analysis, the 'DEAR MAN' skill is administered to the patient. Here is

the first step “describe” she mentioned her current issue and which was breaking up with her

boyfriend. In the second step which was “express”, here patient mentioned that she constantly

felt that she was alone and no one is there to take care of her. Whomever she loves in the world

abandoned her. In the third step which is “assert”, here the patient mentions the expectation that

she has and she wants from her boyfriend. After the breakup, he tries to call her but she didn't tell

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him her exact problem with him whenever he calls her, she doesn’t respond to his call. So

exactly he doesn’t know what was the reason for her break up. The patient didn’t communicate

her problem with her boyfriend. From this step, she understood the need for communication. In

the step of “reinforce”, the patient wants her boyfriend’s presence and she wants to communicate

her problem with him whenever she is in trouble. Whenever her needs are met, she will be

feeling happy. In the “mindful” step, the patient set her goal to communicate effectively and

share her issues clearly with her partner. She clearly understood that her overthinking was

distracting her from effective communication. Overthinking such as losing his interest in her and

he might be having some other affair with others. In the step of “appear”, she mentioned that

whenever she is in trouble, she used to shout at him and she reported that from onwards she will

talk politely with him. In the last step of “negotiate”, in order to solve the problems, she will try

to consider and understand the situation that her partner is going through in his life such as his

work shift, and the busy schedule that he has to do each day.

After administering chain analysis and the ‘DEAR MAN’ skill, the client was taught how

to self-administer the ‘DEAR MAN’ skill and asked to continue practicing it every day for a

good result and the date for the next session was fixed.

The client was willing to change her behavior for reducing her interpersonal problems.

She co-operated adequately throughout the session and was willing to give details about her

interpersonal problems. Her support system was majorly her parents and boyfriend and they has

also shown adequate interest in the well-being of the client in the previous sessions. After the

current session, the client had good insight regarding the major cause of her interpersonal

problems, i.e, lack of communication and she was willing to start communicating patiently with

others, especially her boyfriend without being angry or arguing back. In the coming follow-up

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sessions, reviewing of the skills taught in the current session and her problems related to

emotional regulation would be addressed.

References

Hersen, M., & Sledge, W. (Eds.). (2002). Encyclopedia of psychotherapy. Academic

Press.

What Is Dialectical Behavior Therapy (DBT)? (2023, February 24). Verywell Mind.

https://www.verywellmind.com/dialectical-behavior-therapy-1067402

Interpersonal effectiveness. DBTSelfHelp.

https://dbtselfhelp.com/dbt-skills-list/interpersonal-effectiveness/

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