Mechanisms of Change in Dialectical Behavior Therapy:
Theoretical and Empirical Obrvations
ᮢ
Thomas R.Lynch
Duke University and Duke University Medical Center
ᮢ
Alexander L.Chapman
University of Washington
ᮢ
M.Zachary Ronthal
Duke University Medical Center
ᮢ
Janice R.Kuo and Marsha M.Linehan
University of Washington
Dialectical behavior therapy(DBT)can be considered a well-established
treatment for borderline personality disorder(BPD)as evidenced by ven
well-controlled randomized clinical trials across four independent rearch
teams.The primary purpo of this article is to address a variety of poten-
tial mechanisms of change that may be associated with tho aspects of
DBT that are unique to the treatment and its theoretical underpinnings.
Bad on the biosocial theory of BPD,many of the mechanisms can be
distilled down to the following process:the reduction of ineffective action
tendencies linked with dysregulated emotions.Specifically we address the
following interventions and associated mechanisms of change:mindful-
ness,validation,targeting and chain analysis,and dialectics.Patient change
in BPD is conceptualized primarily as helping the patient to engage in
functional,life-enhancing behavior,even when inten emotions are prent.
Ultimately,our goal was to provide guidance for theoretically and empirically Work on this article was supported by NIMH K23MH01614–01A3(T.R.L.)and NIMH MH34486(M.M.L.). Alex Chapman,Ph.D.,is now at Simon Frar University,Department of Psychology(alchapma@sfu.ca). Correspondence concerning this article should be addresd to:Thomas R.Lynch,Ph.D.,Department of Psy-chiatry and Behavioral Sciences,Department of Psychology:Social and Health Sciences,Duke University Medical Center and Duke University,Box3026,Durham,NC27710;e-mail:lynch011@mc.duke.edu.
JOURNAL OF CLINICAL PSYCHOLOGY,Vol.62(4),459–480(2006)©2006Wiley Periodicals,Inc. Published online in Wiley InterScience(www.).DOI:
460Journal of Clinical Psychology,April2006
grounded rearch on the mechanisms of change in DBT.©2006Wiley
Periodicals,Inc.J Clin Psychol62:459–480,2006.
Keywords:dialectical behavior therapy;mechanisms of change;borderline
personality disorder;mindfulness;exposure therapy
Despite incread attention to treatment development for borderline personality disorder (BPD),very little rearch has examined the basic process or mechanisms underlying patient change.Dialectical behavior therapy(DBT)has garnered considerable evidence for its efficacy in treating BPD,warranting its designation as“well established”according to criteria outlined by Chambless and Hollon(1998).DBT has been evaluated and found to be efficacious for the treatment of BPD in ven well-controlled randomized clinical trials(RCTs)conducted by four independent rearch teams(Koons et al.,2001;Linehan, Armstrong,Suarez,Allmon,&Heard,1991;Linehan,Comtoi
s,et al.,2002;Linehan, Dimeff,et al.,2002;Linehan et al.,1999;Turner,2000;Verheul et al.,2003).In addition, it has demonstrated efficacy in RCTs for chronically depresd older adults(Lynch,Mor, Mendelson,&Robins,2003)and eating disordered individuals(Telch,Agras,&Line-han,2001)and has been examined for a variety of clinical problems in veral uncon-trolled or nonrandomized ,Bohus et al.,2000;Comtois,Elwood,Holdcraft,& Simpson,2002;Koons,Chapman,Betts,O’Rourke,&Robins,2006;Rathus&Miller, 2002).Across studies DBT has resulted in reductions in veral problems associated with BPD,including lf-injurious behavior,suicide attempts,suicidal ideation,hopelessness, depression,and bulimic behavior.(See Robins&Chapman,2004,for a review.) Now that DBT has garnered empirical support in treating BPD,rearchers have begun to turn their attention to the mechanisms of change associated with DBT.The esntial question here concerns how and why the treatment works,or“the process by which therapeutic change occurs”(Kazdin&Nock,2003,p.1117).Mechanisms of change are mediators(Baron&Kenny,1986),or tho variables that account for the relationship between the treatment intervention and the outcome.Delineating mechanisms of change is a critical step in the iterative process of treatment development and refinement and in the integration of basic science with clinical outcome rearch.Beyond functioning as mediators,rearchers have suggested,propod mechanisms of change also must be situated within and supported by a broade
r scientific knowledge ba(Kazdin&Nock, 2003).Although veral treatments have been thoroughly evaluated in efficacy studies, there has been substantially less emphasis on the process by which treatments produce change(Kazdin&Nock,2003),with the notable exception of studies on cognitive ther-apy for depression(Burns&Spangler,2001;Whisman,1993,1999).As a result,there is a notable gap between the rearch and the theories of therapeutic change on which empirically supported treatments are bad.
The primary purpo of this article is to outline potential mechanisms underlying changes in the patient that may mediate the effects of certain DBT interventions.The clear delineation of mechanisms of patient change can form the impetus for basic rearch on the process of behavior change in BPD,thus informing subquent modifications of DBT.It is important to note that the mechanisms have not been empirically tested,and that studies designed to isolate mechanisms of change in DBT currently are under way and will be published in the coming years.Conquently,the ultimate aim of this article is to provide a framework that encourages and guides rearchers in examining mecha-nisms of change in the context of clinical rearch on DBT.Given that this article cannot
Journal of Clinical Psychology DOI10.1002/jclp
Mechanisms in DBT461 Table1
Hypothesized Mechanisms of Dialectical Behavior Therapy:
Common and Unique Interventions
Interventions in Dialectical Behavior Therapy Common to All Behavior Therapies穆的拼音
Exposure and respon prevention
Skills training(including stimulus control)
Reinforcement
Cognitive restructuring
Therapist reciprocal vulnerability
Irreverence
关于冬天的散文Interventions Unique to Dialectical Behavior Therapy
Targeting:,suicidal,therapy interfering)and ,inhibited grieving)
Mindfulness as a t of skills
Dialectical focus
Emotion regulation and opposite action skills
Distress tolerance skills
医疗推广High degree of therapist lf-disclosure
Microanalytic chain analysis
Commitment strategies
Validation as an explicit therapist skill t
Telephone consultation
capture all potential mechanisms of change in a treatment as comprehensive as DBT(e Table1),th
e focus is on tho interventions and mechanisms that are unique to DBT and most clearly linked with rearch on emotions and emotion dysregulation,and with the biosocial theory underlying the treatment.
From Theory to Practice:Dialectical Philosophy and the Biosocial Theory of Borderline Personality Disorder Philosophical Foundations Dialectical Theory
In treating chronically suicidal patients who have BPD,Marsha Linehan discovered an important shortcoming in standard cognitive and behavioral treatments:They focud almost exclusively on helping patients change their thoughts,feelings,and behaviors.A treatment solely focud on change often was not palatable to the patients,who often felt invalidated and criticized and dropped out of treatment.On the flip side,a treatment focud entirely on acceptance invalidated the riousness of the patients’suffering and the urgent need to produce change.As a result,Dr.Linehan anchored DBT in a dialectical philosophy that encourages the balance and synthesis of both acceptance and change.
As a worldview,dialectical philosophy provides a foundation for DBT.Dialectics is evidenced not only in the prence of specific interventions but also in the style and manner in which interventions are d
elivered.As a worldview,dialectical philosophy most often is associated with Marxist socioeconomic principles,but the philosophy of dialectics actually extends back thousands of years(Bopp&Weeks,1984;Kaminstein, 1987).According to Hegel,the process by which a phenomenon,behavior,or argument is transformed is the dialectic,which involves three esntial stages:(1)the beginning,in which an initial proposition or statement(thesis)occurs;(2)the negation of the beginning phenomenon,which involves a contradiction or“antithesis”;and(3)the negation of the negation,or the synthesis of thesis and antithesis.Esntially,tension develops between thesis and antithesis,the synthesis between the two constitutes the next thesis,and the
Journal of Clinical Psychology DOI10.1002/jclp
462Journal of Clinical Psychology,April2006关于爸爸的歌曲
process is repeated ad infinitum.Dialectical philosophy also posits that reality is compod of interrelated parts that cannot be defined without reference to the system as a whole. Similarly,a whole system is compod of parts and cannot be defined without reference to its parts.The system and its parts constantly are in a state of change or flux,and changes in one influence changes in the other.When applied to the understanding of human suffering,this ontological principle of interrelatedn
白云奶奶
ess and wholeness leads to a systemic and contextual conceptualization of behavior.DBT treats the whole patient, rather than a discrete dia or disorder.Similarly,the whole emotion system is targeted in treatment,with the recognition that all elements of the system are interrelated,influ-encing both the patient’s behavior and the environmental context external to the patient.
The Biosocial Theory of BPD
The biosocial theory of BPD is dialectical,in that the theory propos that the transaction between a biological tendency toward emotional vulnerability and an invalidating rearing environment produces a dysregulation of the patient’s emotional system.In the context of biosocial theory,invalidation is the critical socially mediated etiological process,whereas emotional vulnerability is the key biological factor.Emotional vulnerability refers to a biologically mediated predisposition for heightened nsitivity and ,quick and strong reactions)to emotionally evocative stimuli,as well as a delayed return to baline emotional arousal.The invalidating environment is characterized by punishing, ignoring,or trivializing the individual’s communication of thoughts and emotions as well as lf-initiated behaviors and may involve xual,physical,and emotional abu(Wag-ner&Linehan,1997).The borderline individual’s inten emotional reactions elicit inval-idating behavior of caregivers,which then elicits further emotional dysregulation,and vice versa.This transact
ion between an emotionally vulnerable individual and an inval-idating rearing environment leads to dysregulation across the individual’s emotional sys-tem,characterized broadly by difficulty in up-and down-regulating physiological arousal as well as difficulty in turning attention away from emotional stimuli.As a result,indi-viduals who have BPD often experience considerable disruption of their cognitive,emo-tional,and behavioral systems when emotionally aroud.In this way,many of the behaviors associated with BPD are conceptualized as the inevitable quelae of dysregulated emo-tions,or as maladaptive methods of altering emotional experiences.For example,impul-sive or lf-destructive behaviors such as lf-injury,suicide attempts,or disordered eating may occur in direct respon to or function to regulate dysregulated emotional responding.
The biosocial theory has led to a treatment package largely focud on modifying var-ious aspects of the patient’s emotion system.Reductions in emotion dysregulation and increas in behavioral skills are framed as the primary controlling variables underlying or mediating treatment change.Within the following ctions,we discuss veral specific and unique interventions in DBT that target the central process(mindfulness and mindful-ness skills,validation,behavioral targeting and chain analysis,opposite action,and dia-lectics),outlining potential mechanisms of change associated with each class of intervention.
The Central Dialectic in DBT:Acceptance and Change
Beyond the dialectic between the emotionally vulnerable borderline individual and the invalidating environment there exists an acute tension or dialectic between acceptance and change in DBT.The verity of dysregulation en among BPD individuals often pulls for efforts by the therapist and others to change the patient’s behavior or emotions. However,Linehan(1993a)found that a purely change-bad approach was not palatable
Journal of Clinical Psychology DOI10.1002/jclp
旅游管理论文Mechanisms in DBT463
敲英语
to BPD patients,who often misd ssions or dropped out of treatment in respon to feeling invalidated.Indeed,an excessive focus on change may actually mirror the inval-idating environment en as pathogenic to the disorder.The thesis(behavior change) brought forth the antithesis(the need for acceptance),and both acceptance and change-bad strategies were integrated into the treatment package.Dialectical theory provides the theoretical undercurrent needed to balance and synthesize the strategies.Core acceptance-bad strategies derive from client-centered approaches and Zen practice and involve mindfulness skills,validation,and radical acceptance.
汽车牌照怎么拆
Enhancing Acceptance Through Mindfulness and Mindfulness Skills Although mindful practice has been incorporated into a variety of other treatment approaches(Hayes,Strosahl,&Wilson,1999;Kabat-Zinn,1990;Marlatt&Gordon, 1985;Segal,Williams,&Teasdale,2002)and already has garnered empirical support (for a review,e Baer,2003),the manner in which mindfulness is conceptualized and implemented in DBT distinguishes it from other approaches.Mindfulness is primarily related to the quality of awareness that an individual contributes to the prent experi-ence.Mindfulness in DBT was derived from Christian contemplative practices and Zen practice and can be thought of as a state or quality of awareness that involves“keeping one’s consciousness alive to the prent reality”(Hanh,1976).Influenced by Zen,mind-fulness practice often involves letting go of attachments and becoming“one”with cur-rent experience,without judgment or any effort to change“what is.”At the same time, mindfulness involves the u of skillful means and the finding of a middle path between extremes or polarities.For instance,in DBT the therapist teaches the patient that one goal of mindfulness skills is to achieve a wi state of ,“wi mind”),involving a synthesis of reason or logic(reasonable mind)and emotions and intuition(emotion mind) (Linehan,1993b).The esnce of mindful practice involves being fully awake to“what is”right now in the prent.Mindfulness in DBT differs from that of other approaches (i.e.,Hayes et al.,1999;Kabat-Zinn,1990;Segal et al.,2002)in that the ultimate goal is not to achieve an objective“distance”from one’s experience,but rather to ente
r into, participate in,and become“one with”experience(Chapman&Linehan,2005;Linehan, 1993a).Also uniquely to DBT,Linehan(1993a)has distilled the practice of mindfulness into veral discrete behavioral skills:obrving,describing,and participating fully in one’s actions and experiences,in a nonjudgmental and one-mindful ,attend-ing to one thing at a time),with a focus on effective behavior.Mindful practice also involves radically accepting a current situation,thought,emotion,or experience and maintaining a stance of willingness to enter into life with awakeness and effectiveness. Although the skills constitute mindful practice in DBT,mindfulness itlf is a state of awareness and awakeness given to each moment.The ultimate goals of mindfulness skills are to help patients(1)increa their conscious control over attentional process,(2) achieve a“wi”integration of emotional and rational thinking,and(3)experience a n of unity or oneness with themlves,others,and the univer.The following c-tion discuss some of the specific mechanisms of change that may be linked with mind-fulness,including behavioral exposure,emotion regulation,attentional control,and reducing the patient’s literal belief in rules.
Mechanisms of Change in Mindfulness
Behavioral Exposure and Learning New Respons
As an acceptance-bad strategy,mindfulness partly involves reducing the patient’s attempts to control his or her private ,emotions,cognitions,bodily states).In this
Journal of Clinical Psychology DOI10.1002/jclp
