Relational dialectics

From Wikipedia, the free encyclopedia

Relational dialectics is an interpersonal communication theory about close personal ties and relationships that highlights the tensions, struggles and interplay between contrary tendencies. The theory, proposed respectively by Leslie Baxter and Barbara Montgomery in 1988, defines communication patterns between relationship partners as the result of endemic dialectical tensions.

When making decisions, desires and viewpoints that often contradict one another are brought up and lead to dialectical tensions. Leslie A. Baxter and Barbara M. Montgomery exemplify these contradictory statements that arise from individuals experience dialectal tensions using common proverbs such as "opposites attract", but "birds of a feather flock together"; as well as, "two's company; three's a crowd" but "the more the merrier". This does not mean these opposing tensions are fundamentally troublesome for the relationship; on the contrary, they simply bring forward a discussion of the connection between two parties.

The relational dialectic is an elaboration on Mikhail Bakhtin's idea that life is an open monologue and humans experience collisions between opposing desires and needs within relational communications. Baxter includes a list of dialectical tensions that reminds us that relationships are constantly changing, and that successful and satisfying relationships require constant attention. Although Baxter's description of relational dialectics is thorough, it by no means is exact or all inclusive since we all experience different tensions in different ways.

History

Relational dialectics is the emotional and value-based version of the philosophical dialectic. It is rooted in the dynamism of the yin and yang. Like the classic yin and yang, the balance of emotional values in a relationship is always in motion, and any value pushed to its extreme contains the seed of its opposite.

In the Western world, these ideas hark back to the Greek philosopher Heraclitus, who held that the world was in constant flux (like fire), with creative and destructive forces on both sides of every process. Mikhail Bakhtin, a Russian scholar most known for his work in dialogism, applied Marxist dialectic to literary and rhetorical theory and criticism. He illustrated the tensions that exists in the deep structure of all human experience. For example, he identified that the tension that exists between unity and difference. Bakhtin conceived the human dialectic as two forces analogous to the physical forces centripetal (emotional forces tending towards unity) and centrifugal (emotional forces tending towards divergence). Like the Yin and Yang, Bakhtin's forces have no ultimate resolution.

Baxter took the deep structural analysis of Bakhtin and applied it to communication theory. She found a T-Bangha of axes where this dynamic tension operated. Later authors have added other axes.

Approaches to Relational Dialectics

The monologic approach frames contradictions as either/or, the dualistic approach frames contradictions as two separate entities, and the dialectic approach contends that multiple points of view play off one another in every contradiction (both/and).

Core concepts and assumptions

There are four main concepts that form the backdrop of relational dialectics, as well as four major assumptions. Relational dialectics assumes that "(1.) relationships are not linear, (2.) relational life is characterized by change, (3.) contradiction is the fundamental fact of relational life, and (4.) communication is central to organizing and negotiating relational contradictions".

The four core concepts of relational dialectics include: contradiction, totality, process, and praxis.

Contradictions are the core concept of relational dialectics. It is the dynamic interplay between unified oppositions. A contradiction is formed "whenever two tendencies or forces are interdependent (unity) yet mutually negate one another (negation)". For example, in a relationship one can simultaneously desire intimacy and distance. 

Totality suggests that contradictions in a relationship are part of a unified whole and cannot be understood in isolation. In other words, the dialectics cannot be separated and are intrinsically related to each other. For example, the tension between dependence and interdependence cannot be separated from the tension between openness and privacy — both work to condition and define the other.

Process Relational dialectics must be understood in terms of social processes. Movement, activity, and change are functional properties (Rawlins,1989). For example, instances such as an individual fluctuating between disclosure and secretiveness. In addition, the individual may move between periods of honest and open communication (Miller, 2002, 2005).

Praxis is a philosophical term for the concept of 'practical behavior' or sometimes 'the experience of practicing'. In praxis the dialectic tensions are created and re-created through the active participation and interaction. In other words, the practical experience of having a relationship exposes one to the imposition of the needs and value of another. As the relationship endures one's own needs and values become apparent. Praxis focuses on the practical choices individuals make in the midst of the opposing needs and values (dialectical tensions). In turn, the choices and actions themselves create, re-create, and change the nature of the relationship and hence the dialectical tensions themselves.

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Research has recommended theories which further dialectical understanding in relationships, such as in the marriage, in the workplace, etc. Relational dialectics further includes the idea of Contextual Dialectics, or rather, the idea that every relationship exists within a specific place within a specific culture. From there we also see the raise of public and private/real and ideal dialectics and the interplay between what we see on television in public life, versus what experience within our private lives. Examples of this include politicians as well as TV shows. According to West and Turner, "the tension of the real and ideal dialectic is featured when we think of television shows like Leave It to Beaver: We receive an idealized message of what family life is like, and then when we look at the families we live in, we have to contend with the troublesome realities of family life. The tension between these two images forms this dialectic".

Dialectics

According to the original relational dialectic model, there were many core tensions (opposing values) in any relationship. These are autonomy and connectedness, favoritism and impartiality, openness and closedness, novelty and predictability, instrumentality and affection, and finally, equality and inequality. 

Autonomy and connectedness refers to the desire to have ties and connections with others versus the need to separate oneself as a unique individual. An example of autonomy and connectedness would be an athlete, who wants to feel like they are part of a team but also wanting to highlight their individual talents. Favoritism and impartiality refers to the desire to be treated fairly and impartially versus the desire to be seen and known as "special". For instance, a professor may want to be impartial by creating an attendance policy but makes exceptions for students who participate in class and have good grades, demonstrating favoritism. Openness and closedness refers to the desire to be open and divulge information versus the desire to be exclusive and private. When chatting with a boss about one's weekend, there is the desire to be open, however, closedness is also at play, as certain details are often left out, because of the context. Novelty and predictability suggest that there is a desire for the relationship to be predictable versus the desire for it to be original and new. When creating scheduled meetings for board members, the predictability may lie in a fixed schedule, however the novelty may be in scheduling a varying number of locations to peak interests as well as inspiration. Instrumentality and affection, is the desire for affection to be genuine versus the desire for affection to be motivated by benefits and perceived advantages of the relationship. An example of this would be being in a romantic relationship based on love and affection, but maintaining it for benefits such as financial security. Finally, equality and inequality refers to the desire to be considered as equals versus the desire to develop levels of superiority. A female in the military may seek treatment equivalent to that received by her male colleagues, but requires special barracks and adjusted assignments.

According to the theory, while most of us may embrace the ideals of closeness, certainty, and openness in our relationships, the communication is not a straight path towards these goals. Conflicts often produce the exact opposites.

	Internal dialect (within the relationship)	External dialect (between couple and community)
Integration–Separation	Connection–Autonomy	Inclusion–Seclusion
Stability–Change	Certainty–Uncertainty	Conventionality–Uniqueness
Expression–Nonexpression	Openness–Closedness	Revelation–Concealment

The table shows typical dialectical tensions experienced by relational partners based on research done by Baxter and Montgomery showing contrasting efforts in two different ways. The column that displays examples of Internal Dialect shows "ongoing tensions played out within a relationship". The column that displays examples of External Dialect shows "ongoing tensions between a couple and their community".

Integration–separation is "a class of relational dialectics that includes connection–autonomy, inclusion–seclusion, and intimacy–independence." Some individual autonomy must be given up to connect to others.

Stability–change is "a class of relational dialectics that includes certainty–uncertainty, conventionally–uniqueness, predictability–surprise, and routine–novelty." Things must be consistent but not mundane. There must be a balance between the expected and unexpected in order to keep a relationship.

Expression–nonexpression is "a class of relational dialectics that includes openness–closedness, revelation–concealment, candor–secrecy, and transparency–privacy". In a relationship, it is important to keep some things between the two parties, while other parts of the relationship are okay to allow the public to know about.

Dialectics in relationships

According to Michaela Meyer, "relational dialectics theory exposes tensions within interpersonal relationships while at the same time it assumes a continual maintenance and repair of these tensions. As a result, relational dialectics theory is incredibly useful for defining how tensions are managed within relationships." Extensive research has been done regarding the role dialectical tensions play in relationships, as well as the various factors that influence the tensions and the degree to which they affect the relationship. Through studies of romantic relationships, long distance relationships, friendships, and family relationships, researchers have observed the existence and frequency of certain dialectical tensions within various types of relationships.

According to Marsha Linehan, founder of DBT or Dialectical Behavior Therapy, some people have great difficulty resolving the dialectic tensions that arise in relationships. Many people with personality disorders, potentially caused or made worse by dysfunctional upbringing, especially Borderline Personality Disorder (BPD) and some others, perpetually vascilate between the poles of the dialectic conflict, with resulting instability causing problems in living that are not mediated by other therapy modalities. In DBT's biosocial theory, some people "have a biological predisposition for emotional dysregulation, and their social environment validates maladaptive behavior. 

Romantic relationships

A study of 25 heterosexual married couples was designed to determine what types of dialectical tensions were most prevalent in antagonistic conflicts between spouses. Larry Erbert found that the Openness v. Closedness dialectic was most commonly referenced through examples by participants. Research conducted by Baxter and Montgomery confirmed this finding, and broke the dialectic down into four subcategories to further analyze its existence in romantic relationships.

• Openness with: Refers to an individual's self-disclosure of information to another. In this idea, three types of information are shared: information deemed to be personal, the individuals feelings or personal opinions, and information regarding one individual's relationship with the other.
• Openness To: Often this form of openness is labeled as being attentive or responsive. People respond in cognitive, affective, and behavioral ways.
• Closedness with: Describes the type of nondisclosive talk that occurs between individuals. It is most often identified as "small talk", being primarily superficial. The talk is oriented around conversation that requires little or no self-disclosure, allowing for a controlled level informational privacy.
• Closedness to: Some people experience stress and discomfort when listening to others' problems. In response to this, some individuals attempt to distance themselves in order to discourage others from confiding in them.

Research has been conducted to examine the autonomy-connection dialectic when dealing with termination of romantic relationships. In Erin Sahlestein and Tim Dun's study they found that, "participants' joint conversations and their breakup accounts reflect the two basic forms of contradiction. Both antagonistic and non-antagonistic struggles were evident in these data". Furthermore, the study discovered that while normally break-ups are retroactively studied, the autonomy-connection dialectic is actually in full swing throughout the termination process as opposed to previous thought of as a move from connection to autonomy.

A study measuring the display of symbols by lesbian couples, revealed that while same-sex couples experience similar challenges that opposite-sex partners do, there are unique challenges that arise to these same-sex couples. These unique problems in turn give rise to unique dialectical tensions within the relationship.

Re-marriage

In a study that focused on dialectics in second marriages, six tensions unique to remarriages emerged.

Three tensions related to the remarried dyad:

• Old-new - Many participants found that within their new marriage, the individuals brought with them ideas and expectations based on their previous, or "old," marriages. However, participants recognized that they had since entered a "new" marriage, which would not necessarily carry over the previous old expectations or experiences.
• Emotional closeness-distance - Participants expressed feelings of both emotional closeness and emotional distance with their new partners. While participants found that they experienced emotional closeness with their second spouse, they also found that either they or their new spouse had other close friends or family with whom they were close to.
• Past-present - Many participants found that they do not discuss prior relationships, or other things that relate to the past, with their new partners. Yet, the new couples remained open about issues and topics related to their present life.

Three tensions also emerged from the remarried dyad and their social networks:

• Their time frame-our time frame - Many participants expressed feeling tensions between adhering to a time frame that felt right to the individual, while acknowledging the expectations that they sensed from their friends and family members in regards to what an appropriate relationship and re-marriage time frame would be.
• Dyadic revelation-network revelation - Participants found that they desired to share information with their social network, however, sometimes their partner did not desire them to share such information with that particular network, resulting in tensions among participants to decide between revealing to their partner and revealing information to their social network.
• Old-new - Participants identified the tension that was created through interactions with friends and family from the "old" marriage while being in the "new" marriage. Participants managed this tension primarily through recalibration and reaffirmation, where participants recognized that both sides had to be present in order for the relationship to exist.

Long distance relationships

Based on research by Sahlstein, the uncertainty v. certainty dialectic is the most prevailing dialectic found in long-distance relationships. Her work exposed uncertainty v. certainty as a competing yet complementary need. In interviews conducted with couples engaged in long distance relationships, contradictions emerged. For example, couples were found to plan interactions in order to obtain a level of spontaneity. Within this, three different forms of the praxis of relational dialectics emerged:

• Segmentation - referred to the partners' ability to live separate, independent lives when they were not together.
• Balance - referred to the couple's ability to plan conversations about the future of the relationship.
• Denial - referring to the couple's refusal to admit the effect distance is having on the relationship.

Friendships

William Rawlins has examined the role of relational dialectics in regard to friendships. The tension of instrumentality v. affection was found to be the most central to this type of relationship. Within friendships, importance is placed on the ability to discern the level of affection for "real" friendships opposed to instrumentality for "fake" friendships. Aristotle's "friendship of virtue" notion of caring for friends without instrumental purposes exemplifies this point. The dichotomy of instrumentality v. affection cannot be ignored within friendships, as affection may be offered in order to receive instrumental aid from friends. This interweaving of concepts is what distinguishes different types of friendships. While this remains true, the subjectivity of the friends in question ultimately determines the outcome of how heavily instrumentality v. affection is applied.

In the workplace

Blended Relationships are close friends that are a part of the same work environment. Dialectical tensions occur in organizations as individuals attempt to balance their roles as employees while maintaining established friendships within their occupations. It is not necessary, however, to have a friend in organizations to experience dialectical contradictions. Stress occurs frequently on the individual level as human needs and desires oppose.

• Impartiality vs. Favoritism: Friends within organizations desire to provide each other with special support and assistance but organizations strive for equitable treatment and discourage bias.
• Openness vs. Closedness: It is a tendency of close friends to be open and honest with one another, but organizations often expect a level of confidentiality that places strain on friendships that value the sharing of information.
• Novelty and Predictability: Feeling excited about a restructuring of your organization but anxious since it may interrupt your routine and put stress on your current relationships.
• Instrumentality and Affection: Inviting a coworker to lunch with the intention of asking for support on a project at work.

Family relationships

Sibling relationships  

Relational dialectics can be applied when considering the significant change in family life that siblings experience when one sibling moves out of the family home for the first time as part of the transition into adulthood. As one sibling begins a new phase of life, this change is often accompanied by new friendships or romantic relationships that occur in his/her new lifestyle, along with a new geographic separation, both of which result in a change in communication. As the newly absent sibling begins a new lifestyle beyond his/her home, the pre-existing sibling relationship goes through various changes and transitions.

In a study conducted on discursive struggles among siblings experiencing transition, all participants acknowledged that moving away from their sibling(s) resulted in a discursive struggle between the old and new meanings in the sibling relationship. Two specific discursive struggles were identified:

• Old relationship-new relationship - For many siblings, family rituals were not continued upon moving out, resulting in a change in relationship and a feeling of missing out, emphasizing the changes that occur during the transition from an old relationship into new ones.
• Certainty-uncertainty - Participants found that the change from seeing a sibling regularly to not seeing him/her often resulted in feelings of uncertainty, resulting in an identity shift in the relationship and supporting the discursive struggle of certainty-uncertainty.

While participants addressed the varying tensions involved with lifestyle transitions, 8 of the 19 participants in the study expressed that moving away from their sibling strengthened their connection and appreciation for their brother(s) and/or sister(s).

Children and stepparents

In a study focusing on the adult stepchild perceptions of communication in the stepchild-stepparent relationship, three contradictions were found to be experienced by the stepchildren participants:

• Dialectics of emotional distance-closeness - While many stepchildren expressed feelings of emotional distance, the participants had varying reasons for keeping the distance. Some participants who still had a positive relationship with their nonresidential parent kept an emotional distance from their stepparent as an act of loyalty that they felt toward their nonresidential parent. Other participants equated emotional distance to the fact that they had little in common with their stepparent. However, many participants expressed feeling some closeness with a stepparent while maintaining an amount of emotional distance. Participants reported that they upheld a relationship with the stepparent that contained honesty, respect, and trust, yet they kept an emotional distance by continuing to address the stepparent by his/her first name, or simply claiming that each individual was very different from the other, causing tension in an effort to promote emotional closeness.
• Stepparent status - Many of the stepchildren in the study also experienced a dialectical tension between desiring for the family authority position to be designated to their one residential parent along with a desire for both the residential parent and the stepparent to share parenting authority. Many participants felt that legitimating their stepparent as a parent would result in the formation of closeness.
• Expression - The participants expressed a desire for open communication with their stepparent, while at the same time, expressing resistance to openness and instead favoring a more careful form of communication due to the fact that the participants often sensed a lack of familiarity with their stepparent.

In another study, researchers aimed to identify the contradictions that were perceived by stepchildren when characterizing the ways that familial interactions caused them to feel caught in the middle between parents. The participants expressed that they wanted to be centered in the family while, at the same time, they hoped to avoid being caught in the middle of two opposing parents. The main contradiction identified in the study was similar to the autonomy-connection dialectic; stepchildren desired the freedom to communicate and enact the desired relationship with their parents. However, these stepchildren also felt the need to manage the constraints that resulted from parental communication, particularly when both parents did not cooperate with one another. While the stepchildren wanted to know what was happening, at the same time, they also wanted to be protected, resulting in a second dialectic of control-restraint. Through this study, the researchers believe that openness-closeness dialectic between parents and their children is important to building functional step-family relationships. 

One study, focused on the relationship and communication between college-aged stepchildren and their nonresidential parents, found two underlying contradictions: parenting and not parenting, and openness and closeness. Many participants expressed that they wanted their nonresidential parent to be actively involved in parenting them but did not desire it once they were. Participants also expressed that while they wanted open and intimate communication with their nonresidential parents, they felt that they could not closely communicate because of the nonresidential parent's lack of familiarity with the child's everyday life.

Theory applications

End of life care

Relational dialectics theory can be applied to the context of health care, specifically end-of-life care, providing a system for caregiver communication that contains tensions and challenges. The quality of the end-of-life journey is influenced by how these tensions are managed. Relational dialectics theory is an applicable framework for investigating the ongoing communication between physicians and their patients/family members during the process of end-of-life care.

When making choices about end-of-life medical care, family members, friends, or surrogate decision makers often experience feelings of tension and burden. Decision-makers must deal with the relational and moral tensions that come with such decision-making. Family members in charge of making end-of-life decisions often face conflicting emotions between holding on and letting go; recognizing the need to let a patient go while wanting to continue fighting to keep a loved one alive.

In a study that focused on the communication tensions perceived among the Maori culture during the end-of-life journey, it was found that despite the culture's focus on collectivism and its emphasis on harmony, four communication tensions existed between caregivers (family and friends) and patients: autonomy and connection, conflict and connection, isolation and connection, and balancing the needs of self and other.

Grief

The human grieving process is marked by relational dialectics. After the death of a child, bereaved parents often experience tension between presence and absence by grieving their child's permanent absence while still experiencing an emotional bond toward the deceased child. Bereaved parents may also experience tension between openness and closeness, where they desire to discuss their feelings with friends or family, yet they are hesitant to share because of the potentially negative reactions they could receive.

One study, aimed at focusing on how families make sense of contradictory discourses, found two discursive contradictions: family members' wishes vs. patient's wishes, and emotionality vs. rationality. Through interviews with participants who had experienced the loss of a loved one, researchers concluded that many of the end of life decisions made by family members, patients, and doctors were centered on making sense of the simultaneous desires to hold on and to let go. Participants recognized that they experienced tension between their own preferences and the preferences of a loved one, and with that, experienced the tension between desiring to make decisions based on emotions versus making decisions based on rationality.

Dialectical contradictions have also been found among parents who have lost a child. One study found that two primary dialectical contradictions occurred for parents who had experienced the death of a child: openness-closeness, and presence-absence. Parents experienced openness-closeness when they desired to talk about their child and their loss, yet they perceived the outcome as risky, especially if they sensed that friends and family wished for the parents to move on. Participants explained that they were able to manage this contradiction by being selective with their disclosure and taking control over the communicative situation. When dealing with the presence-absence dialectic, bereaved parents experienced tensions between the ongoing bond that they experienced with their child, and the physical absence of the child. Participants expressed that when people were not willing to remember their dead child, the physical absence of the child was deeply felt. However, when people chose to remember the deceased child, the parent experienced feelings of comfort and continual bonding with the child.

Understanding Autistic Communication

As relational dialects’ aim is to analyze competence during interaction, it can suggest an approach to researching on communication competence among people which are with autism spectrum disorders. Applying relational dialects theory to studying interactions of autistic individuals starts from approaching autistic individual as an actor during the interaction and deeming competence a result of the interaction. This approach can delve into how social contexts, expectations, and roles contribute to the autistics’ competent communication. The investigation of dialects includes integration-separation, expression-privacy, and stability-change enhance the understanding of the communication between people with autism spectrum disorders.

Dialogue

Dialogue is typically a conversation between two or more people. These conversations are what constitute relationships, as communication is the very foundation of any relationship. According to Cools, "the four important concepts that form the foundation of dialogism 1) the self and the other situated in contradictory forces, 2) unfinalizability, 3) the chronotope and the carnivalesque, and 4) heteroglossia and utterance". Similarity, in dialogue the following components are the most important: constitutive dialogue, utterance chains, dialectical flux, aesthetic moment, and critical sensibility.

'Constitutive dialogue'

While some theorists, along with Baxter, may argue that communication is simply a feature in a relationship, examining constitutive dialogue suggests that communication is actually what creates and maintains a relationship instead. According to Baxter, "a constitutive approach to communication asks how communication defines, or constructs, the social world, including our selves and our personal relationships. From a constitutive perspective, then, persons and relationships are not analytically separable from communication; instead, communication constitutes these phenomena" When initial researchers studied relationships, they found that similarities, backgrounds, and interests are usually what hold people together while self-disclosure is the root of these components. Dialogic researchers would argue that differences are just as important as similarities and they are both discovered through dialogue.

'Utterance chains'

To understand utterance chains, we must know that an utterance is what a person says in one turn of a conversation. When utterances are "linked to competing discourses", they are considered utterance chains. Baxter believes that there are "four links on the chain where the struggle of competing discourses can be heard." These are: cultural ideologies, relational history, non-yet spoken response of partner or utterance, and normative evaluation of third party to utterance. Baxter also suggest that to understand an utterance, we must also understand the discourse. She posits "in the broadest sense, a discourse is a cultural system of meaning that circulates among a group's members and which makes our talk sensical. for example in the United States the discourse of individualism helps us to understand and value an utterance such as, 'I need to find myself first before I commit to a serious relationship with another person'".

'Dialectical flux'

A dialectical flux is "the unpredictable, unfinalizable, indeterminate nature of personal relationships". Relationships are complicated and intertwined with dialectical tensions. Spiraling inversion and segmentation are two strategies that Baxter and Montgomery have established to respond to this complexity. Spiraling inversion is generally a no-win situation; a struggle between two different thought processes. For example, if you were to do something your parents did not approve of, you could lie about it, but your parents might yell at you for lying. And on the other hand, you could tell them upfront, and they could be completely quiet in shock. Segmentation is pertaining to more than one role in a relationship that must be altered depending on the situation. For example, if you were working at your father's shop as a part-time job, he would be considered your father AND your boss. This could mean that he has different expectations of you in different circumstances and his attitude towards you might change between roles.

'Aesthetic moment'

Aesthetic moments are brief incidents in a relationship that bring participants together through the use of dialogue. There is a temporary feeling of wholeness felt between partners involved in this dialogue. It is easy to see examples of aesthetic moments in romantic relationships, such as a first kiss or a reciting of wedding vows, but these moments can be experienced by anyone.

'Critical sensibility'

According to Griffin, critical sensibility is "an obligation to critique dominant voices, especially those that suppress opposing viewpoints; a responsibility to advocate for those who are muted". This means that both sides of a dialogue are equal to one another. No one person is more powerful or dominant than the other, and they are able to communicate without these imbalances interfering. This does not mean that the dialogue is free of competing discourses as listed in Utterance Chains.

Ethics

When communicating, we must understand that morals do not apply for all people. Sometimes lying can be entirely minor in communication, but there are oftentimes that lying can majorly affect the perspective of those being lied to. There are several times where most people would justify a "white lie", or a lie that causes no harm. For instance, if your mother was in the hospital, you could tell her she still looked beautiful, even if her appearance was far from it because it would make her feel better. Other actions that are only followed through based on whether they have a positive or negative outcome are called "consequential ethics". According to Sissela Bok, "lies drag around an initial negative weight that must be factored into ethical equations". Bok believes in the "principle of veracity" which says that truthful statements are preferable to lies in the absence of special circumstances that overcome the negative weight.

Critiques

According to theorist Leslie Baxter, there are three major limitations in the work of relational dialectics theory. Baxter claims that her work has been "too distanced from naturally occurring talk between relating parties", and claims that the theory needs a firmer empirical base when applied to talk between relating parties. Baxter also believes that more future work needs to include multiple voices instead of focusing on the more popular research on the dialectics between "two voices". Lastly, Baxter has stated that future research should focus on discourse through time, such as studying dialogue and how it transforms over a longer period of time.

Dialectical behavior therapy

From Wikipedia, the free encyclopedia

The stages used in dialectical behavior therapy

 

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy designed to help people suffering from borderline personality disorder (BPD). It has also been used to treat mood disorders as well as those who need to change patterns of behavior that are not helpful, such as self-harm, suicidal ideation, and substance abuse. This approach is designed to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions.

A modified form of cognitive behavioral therapy (CBT), DBT was developed in the late 1980s by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviors associated with spectrum mood disorders, including self-injury. Recent work also suggests its effectiveness with sexual abuse survivors and chemical dependency.

DBT combines standard cognitive behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is based upon the biosocial theory of mental illness and is the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.

Overview

Linehan observed "burn-out" in therapists after coping with "non-motivated" patients who repudiated cooperation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments, and, therefore, required a climate of loving-kindness and somewhat unconditional acceptance (not Carl Rogers' positive humanist approach, but Thích Nhất Hạnh's metaphysically neutral one), in which to develop a successful therapeutic alliance. Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction. 

DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the client's feelings at any given time, while, nonetheless, informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives. DBT focuses on the client acquiring new skills and changing their behaviors, with the ultimate goal of achieving a "life worth living", as defined by the patient.

In DBT's biosocial theory of BPD, clients have a biological predisposition for emotional dysregulation, and their social environment validates maladaptive behavior.

Linehan and others combined a commitment to the core conditions of acceptance and change through the principle of dialectics (in which thesis and antithesis are synthesized) and assembled an array of skills for emotional self-regulation drawn from Western psychological traditions, such as cognitive behavioral therapy and an interpersonal variant, "assertiveness training", and Eastern meditative traditions, such as Buddhist mindfulness meditation. One of her contributions was to alter the adversarial nature of the therapist-client relationship in favor of an alliance based on intersubjective tough love. 

All DBT can be said to involve 4 components:

1. Individual – The therapist and patient discuss issues that come up during the week (recorded on diary cards) and follow a treatment target hierarchy. Self-injurious and suicidal behaviors, or life-threatening behaviors, take first priority. Second in priority are behaviors which, while not directly harmful to self or others, interfere with the course of treatment. These behaviors are known as therapy-interfering behaviors. Third in priority are quality of life issues and working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
2. Group – A group ordinarily meets once weekly for two to two and a half hours and learns to use specific skills that are broken down into four skill modules: core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.
3. Therapist Consultation Team – A therapist consultation team includes all therapists providing DBT. The meeting occurs weekly and serves to support the therapist in providing the treatment.
4. Phone Coaching – Phone coaching is designed to help generalize skills into the patient's daily life. Phone coaching is brief and limited to a focus on skills.

No one component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context. DBT skills training alone is being used to address treatment goals in some clinical settings, and the broader goal of emotion regulation that is seen in DBT has allowed it to be used in new settings, for example, supporting parenting.

Four modules

Mindfulness

A diagram used in DBT, showing that the Wise Mind is the overlap of the emotional mind and the reasonable mind.

 

Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one's emotions and senses fully, yet with perspective. The practice of mindfulness can also be intended to make people more aware of their environments through their 5 senses: touch, smell, sight, taste, and sound. Mindfulness relies heavily on the principle of acceptance, sometimes referred to as "radical acceptance". Acceptance skills rely on the patient’s ability to view situations with no judgment, and to accept situations and their accompanying emotions. This causes less distress overall, which can result in reduced discomfort and symptomology.

Acceptance and Change

The first few sessions of DBT introduce the dialectic of acceptance and change. The patient must first become comfortable with the idea of therapy; once the patient and therapist have established a trusting relationship, DBT techniques can flourish. An essential part of learning acceptance is to first grasp the idea of radical acceptance: radical acceptance embraces the idea that one should face situations, both positive and negative, without judgment. Acceptance also incorporates mindfulness and emotional regulation skills, which depend on the idea of radical acceptance. These skills, specifically, are what set DBT apart from other therapies. 

Often, after a patient becomes familiar with the idea of acceptance, they will accompany it with change. DBT has five specific states of change which the therapist will review with the patient: precontemplation, contemplation, preparation, action, and maintenance. Precontemplation is the first stage, in which the patient is completely unaware of their problem. In the second stage, contemplation, the patient realizes the reality of their illness: this is not an action, but a realization. It is not until the third stage, preparation, that the patient is likely to take action, and prepares to move forward. This could be as simple as researching or contacting therapists. Finally, in stage 4, the patient takes action and receives treatment. In the final stage, maintenance, the patient must strengthen their change in order to prevent relapse. After grasping acceptance and change, a patient can fully advance to mindfulness techniques.

"What" skills:

Observe

This is used to nonjudgmentally observe one's environment within or outside oneself. It is helpful in understanding what is going on in any given situation.

DBT recommends developing a "teflon mind", the ability to let feelings and experiences pass without sticking in the mind.

Describe

This is used to express what one has observed with the observe skill. It is to be used without judgmental statements. This helps with letting others know what one has observed. Once the environment or inner state of mind has been observed with 5 senses, the individual can put words to observations and thus better understand the environment.

Participate

This is used to become fully focused on, and involved in, the activity that one is doing.

"How" skills (How to do Mindful Meditation):

There are many "scripted" meditations available on YouTube; for example: The 3 Minute Meditation; or The Body Scan. How to do it (The Body Scan): You listen to the body scan and you allow your mind to focus on each aspect of your physical self, usually starting at your toes and ending at the top of your head. As you listen to the body scan and allow your mind to focus in on the body, you will notice your "busy mind" will come into consciousness. You will notice that thoughts and feelings will attempt to distract you from focusing on each part of your body. You will notice that some of the thoughts and feelings may be distressing to you. You may want to stop the meditation because it might be very painful emotionally or physically or because you are having negative or busy thoughts. Sometimes memories may surface and they may also be difficult emotionally to accept. How to do Mindful Meditation involves learning to acknowledge the thoughts, feelings and memories without needing to fight them or chase them away. The paradox: If we try to fight them, they seem to get bigger; but when we move into acceptance, they seem to get smaller. We enter the mindfulness meditation body scan, 3 minute meditation or other meditation sessions with no goals and with a non-striving stance. Again, if we enter with a goal to "fix my problems by meditating", that goal and pressure to fix something tends to make the problems bigger. To enter the meditation with a non-goal/non-striving attitude, so having no expectations, paradoxically, usually results in a reduction of stress, pain and other symptoms.

Nonjudgmentally

This is the action of describing the facts, and not thinking in terms of "good" or "bad," "fair," or "unfair." These are judgments, not factual descriptions. Being nonjudgmental helps you to get your point across in an effective manner without adding a judgment that someone else might disagree with.

One-mindfully

This is used to focus on one thing. One-mindfully is helpful in keeping one's mind from straying into "emotion" by a lack of focus.

Effectively

This is simply doing what works. It is a very broad-ranged skill and can be applied to any other skill to aid in being successful with said skill.

Distress tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by person-centered, psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.

Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Since this is a non-judgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.

Distract with ACCEPTS 

This is a skill used to distract oneself temporarily from unpleasant emotions.

Activities – Use positive activities that you enjoy.

Contribute – Help out others or your community.

Comparisons – Compare yourself either to people that are less fortunate or to how you used to be when you were in a worse state.

Emotions (other) – cause yourself to feel something different by provoking your sense of humor or happiness with corresponding activities.

Push away – Put your situation on the back-burner for a while. Put something else temporarily first in your mind.

Thoughts (other) – Force your mind to think about something else.

Sensations (other) – Do something that has an intense feeling other than what you are feeling, like a cold shower or a spicy candy.

Self-soothe

This is a skill in which one behaves in a comforting, nurturing, kind, and gentle way to oneself. You use it by doing something that is soothing to you. It is used in moments of distress or agitation. New York Jets wide receiver Brandon Marshall, who was diagnosed with BPD in 2011 and is a strong advocate for DBT, cited activities such as prayer and listening to jazz music as instrumental in his treatment.

IMPROVE the moment

This skill is used in moments of distress to help one relax.

Imagery – Imagine relaxing scenes, things going well, or other things that please you.

Meaning – Find some purpose or meaning in what you are feeling.

Prayer – Either pray to whomever you worship, or, if not religious, chant a personal mantra.

Relaxation – Relax your muscles, breathe deeply; use with self-soothing.

One thing in the moment – Focus your entire attention on what you are doing right now. Keep yourself in the present.

Vacation (brief) – Take a break from it all for a short period of time.

Encouragement – Cheerlead yourself. Tell yourself you can make it through this and cope as it will assist your resilience and reduce your vulnerability.

Pros and cons

Think about the positive and negative things about not tolerating distress.

Radical acceptance

Let go of fighting reality. Accept your situation for what it is.

Turning the mind

Turn your mind toward an acceptance stance. It should be used with radical acceptance.

Willingness vs. willfulness

Be willing and open to do what is effective. Let go of a willful stance which goes against acceptance. Keep your eye on the goal in front of you.

Emotion regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:

• Identify and label emotions
• Identify obstacles to changing emotions
• Reduce vulnerability to emotion mind
• Increase positive emotional events
• Increase mindfulness to current emotions
• Take opposite action
• Apply distress tolerance techniques

Emotional regulation skills are based on the theory that intense emotions are a conditioned response to troublesome experiences, the conditioned stimulus, and therefore, are required to alter the patient’s conditioned response. These skills can be categorized into four modules: understanding and naming emotions, changing unwanted emotions, reducing vulnerability, and managing extreme conditions:

• Learning how to understand and name emotions: the patient focuses on recognizing their feelings. This segment relates directly to mindfulness, which also exposes a patient to their emotions.
• Changing unwanted emotions: the therapist emphasizes the use of opposite-reactions, fact-checking, and problem solving to regulate emotions. While using opposite-reactions, the patient targets distressing feelings by responding with the opposite emotion.
• Reducing vulnerability: the patient learns to accumulate positive emotions and to plan coping mechanisms in advance, in order to better handle difficult experiences in the future.
• Managing extreme conditions: the patient focuses on incorporating their use of mindfulness skills to their current emotions, in order to remain stable and alert in a crisis situation.

Story of emotion

This skill is used to understand what kind of emotion one is feeling.

• Prompting event
• Interpretation of the event
• Body sensations
• Body language
• Action urge
• Action
• Emotion name, based on previous items on list

PLEASE

This skill concerns ineffective health habits that can make one more vulnerable to emotion mind. This skill is used to maintain a healthy body, so one is more likely to have healthy emotions.

PhysicaL illness (treat) – If you are sick or injured, get proper treatment for it.

Eating (balanced) – Make sure you eat a proper healthy diet, and eat in moderation.

Avoid mood-altering drugs – Do not take other non-prescribed medication or drugs. They may be very harmful to your body, and can make your mood unpredictable.

Sleep (balanced) – Do not sleep too much or too little. Eight hours of sleep is recommended per night for the average adult.

Exercise – Make sure you get an effective amount of exercise, as this will both improve body image and release endorphins, making you happier.

Build mastery

Try to do one thing a day to help build competence and control.

Opposite action

This skill is used when you have an unjustified emotion, one that doesn't belong in the situation at hand. You use it by doing the opposite of your urges in the moment. It is a tool to bring you out of an unwanted or unjustified emotion by replacing it with the emotion that is opposite.

Problem solving

This is used to solve a problem when your emotion is justified. It is used in combination with other skills.

Letting go of emotional suffering

Observe and experience your emotion, accept it, then let it go.

Interpersonal effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict. 

Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing their own situation. 

The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person's goals in a specific situation will be met, while at the same time not damaging either the relationship or the person's self-respect.

DEEAR MAN – conveying one's needs to another person

This acronym is used to aid one in getting what one wants when asking.

• Describe one's situation using specific factual statements about a recent situation.
• Express the emotions experienced when the situation occurred, why this is an issue and how one feels about it.
• Empathy acknowledge what the other person experienced and their emotions
• Assert one's self by asking clearly and specifically for what behavior change the person seeks.
• Reinforce one's position by offering a positive consequence if one were to get what one wants.
• Mindful of the situation by focusing on what one wants and disregard distractions through validation/empathy and redirecting back to the point.
• Appear confident and assertive, even if one doesn't feel confident.
• Negotiate with a hesitant person and come to a comfortable compromise on one's request.

GIVE – giving something

This skill set aids one maintaining one's relationships, whether they are with friends, co-workers, family, romantic partners, etc. It is to be used in conversations.

• Gentle: Use appropriate language, no verbal or physical attacks, no put downs, avoid sarcasm unless one is sure the person is alright with it, and be courteous and non-judgmental.
• Interested: When the person one is speaking to is talking about something, act interested in what is being said. Maintain eye contact, ask questions, etc. Avoid the use of a cell phone during an in-person conversation.
• Validate: Show understanding and sympathy of a person's situation. Validation can be shown through words, body language and/or facial expressions.
• Easy Manner: Be calm and comfortable during conversation; use humor; smile.

FAST – keeping self-respect

This is a skill to aid one in maintaining one's self-respect. It is to be used in combination with the other interpersonal effectiveness skills.

• Fair: Be fair to both oneself and the other person.
• Apologies (few): Don't apologize more than once for what one has done ineffectively or for something that was ineffective.
• Stick to One's Values: Stay true to what one believes in and stand by it. Don't allow others to encourage action against one's own values.
• Truthful: Don't lie. Lying can only pile up and damage relationships and one's self-respect.

This list does not include the "problem solving" module, the purpose of which is to practice being one's own therapist.

Tools

Diary cards

Specially formatted cards for tracking therapy interfering behaviors that distract or hinder a patient's progress. Diary cards can be filled out daily, 2–3 times a day, or once per week.

Chain analysis

Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining. A growing body of research supports the use of behavior chain analysis with multiple populations.

Milieu

The milieu, or the culture of the group involved, plays a key role in the effectiveness of DBT.

Efficacy

Borderline personality disorder

DBT is the therapy that has been studied the most for treatment of borderline personality disorder, and there have been enough studies done to conclude that DBT is helpful in treating borderline personality disorder. A 2009 Canadian study compared the treatment of borderline personality disorder with dialectical behavior therapy against general psychiatric management. A total of 180 adults, 90 in each group, were admitted to the study and treated for an average of 41 weeks. Statistically significant decreases in suicidal events and non-suicidal self-injurious events were seen overall (48% reduction, p=0.03; and 77% reduction, p=0.01; respectively). No statistically-significant difference between groups were seen for these episodes (p equal .64). Emergency department visits decreased by 67% (p less than 0.0001) and emergency department visits for suicidal behavior by 65% (p less than 0.0001), but there was also no statistically significant difference between groups.

Depression

A Duke University study of compared treatment of depression by antidepressant medication to treatment by antidepressants and dialectical behavior therapy. A total of 34 chronically depressed individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically-significant differences were noted in remission rates between groups, with a greater percentage of patients treated with antidepressants and dialectical behavior therapy in remission.

Complex Posttraumatic Stress Disorder

Exposure to Complex trauma, or the experience of traumatic events, can lead to the development of Complex Posttraumatic Stress Disorder (CPTSD) in an individual. CPTSD  is a concept which divides the psychological community. The American Psychological Association (APA) does not recognize it in the DSM-5 (Diagnostical and Statistical Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental illness), though some practitioners argue that CPTSD is separate from Posttraumatic Stress Disorder(PTSD). CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive, emotional, and biological domains, among others. CPTSD differs from PTSD in that it is believed to originate in childhood interpersonal trauma, or chronic childhood stress, and that the most common precedents are sexual traumas. Currently, the prevalence rate for CPTSD is an estimated .5%, while PTSD's is 1.5%. Numerous definitions for CPTSD exist. Different versions are contributed by the World Health Organization (WHO), The International Society for Traumatic Stress Studies (ISTSS), and individual clinicians and researchers. Most definitions revolve around criteria for PTSD with the addition of several other domains. While The APA may not recognize CPTSD, the WHO has recognized this syndrome in its 11th edition of the International Classification of Diseases (ICD-11). The WHO defines CPTSD as a disorder following a single or multiple events which cause the individual to feel stressed or trapped, characterized by low self-esteem, interpersonal deficits, and deficits in affect regulation. These deficits in affect regulation, among other symptoms are a reason why CPTSD is sometimes compared with Borderline Personality Disorder (BPD).  

Similarities Between CPTSD and Borderline Personality Disorder

In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit Splitting, mood swings, and fears of abandonment. Like patients with Borderline Personality Disorder, patients with CPTSD were traumatized frequently and/or early in their development and never learned proper coping mechanisms. These individuals may use avoidance, substances, dissociation, and other maladaptive behaviors to cope. Thus, treatment for CPTSD involves stabilizing and teaching successful coping behaviors, affect regulation, and creating and maintaining interpersonal connections. In addition to sharing symptom presentations, CPTSD and BPD can share neurophysiological similarities. For example, abnormal volume of the amygdala (emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital prefrontal cortex (personality). Another shared characteristic between CPTSD and BPD is the possibility for dissociation. Further research is needed to determine the reliability of dissociation as a hallmark of CPTSD, however it is a possible symptom. Because of the two disorders’ shared symptomatology and physiological correlates, psychologists began hypothesizing that a treatment which was effective for one disorder may be effective for the other as well.

DBT as a Treatment for CPTSD

DBT’s use of acceptance and goal orientation as an approach to behavior change can help to instill empowerment and engage individuals in the therapeutic process. The focus on the future and change can help to prevent the individual from becoming from overwhelmed by their history of trauma. This is a risk especially with CPTSD, as multiple traumas are common within this diagnosis. Generally, care providers address a client’s suicidality before moving on to other aspects of treatment. Because PTSD can make an individual more likely to experience suicidal ideation, DBT can be an option to stabilize suicidality and aid in other treatment modalities.

Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious behaviors (such as cutting or burning) and increases interpersonal functioning but neglects core CPTSD symptoms such as impulsivity, cognitive schemas (repetitive, negative thoughts), and emotions such as guilt and shame. The ISTSS reports that CPTSD requires treatment which differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing on traumatic memories. The recommended multiphase model consists of establishing safety, distress tolerance, and social relations. Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT discuss the time required for the therapy to be effective. Individuals seeking DBT may not be able to commit to the individual and group sessions required, or their insurance may not cover every session.

Approximately 56% of individuals diagnosed with Borderline Personality Disorder also meet criteria for PTSD. Because of the correlation between Borderline Personality Disorder traits and trauma, some settings began using DBT as a treatment for traumatic symptoms. Some providers opt to combine DBT with other PTSD interventions, such as Prolonged Exposure Therapy (PE) (repeated, detailed description of the trauma in a psychotherapy session) or Cognitive Processing Therapy (CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories). For example, a regimen which combined PE and DBT would include teaching mindfulness skills and distress tolerance skills, then implementing PE. The individual with the disorder would then be taught acceptance of a trauma's occurrence and how it may continue to affect them throughout their lives. Participants of clinical trials such as these exhibited a decrease in symptoms, and throughout the 12-week trial, no self-injurious or suicidal behaviors were reported.

Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is low. Biosocial theory posits that emotion dysregulation is caused by an individual’s heightened emotional sensitivity combined with environmental factors (such as invalidation of emotions, continued abuse/trauma), and tendency to ruminate (repeatedly think about a negative event and how the outcome could have been changed). An individual who has these features is likely to use maladaptive coping behaviors. DBT can be appropriate in these cases because it teaches appropriate coping skills and allows the individuals to develop some degree of self-sufficiency. The first three modules of DBT increase distress tolerance and emotion regulation skills in the individual, paving the way for work on symptoms such as intrusions, self-esteem deficiency, and interpersonal relations.

Noteworthy is that DBT has often been modified based on the population being treated. For example, in veteran populations DBT is modified to include exposure exercises and accommodate the presence of traumatic brain injury (TBI), and insurance coverage (ie shortening treatment).  Populations with comorbid BPD may need to spend longer in the “Establishing Safety” phase. In adolescent populations, the skills training aspect of DBT has elicited significant improvement in emotion regulation and ability to express emotion appropriately. In populations with comorbid substance abuse, adaptations may be made on a case-by-case basis. For example, a provider may wish to incorporate elements of Motivational Interviewing (psychotherapy which uses empowerment to inspire behavior change). The degree of substance abuse should also be considered. For some individuals, substance use is the only coping behavior they know, and as such the provider may seek to implement skills training before target substance reduction. Inversely, a client’s substance abuse may be interfering with attendance or other treatment compliance and the provider may choose to address the substance use before implementing DBT for the trauma.