Tuesday, July 27, 2010

Stephen I. Deutsch & Richard B. Rosse - Dialectical Behavior Therapy: Evidence-Based Psychotherapeutic Strategies for the Difficult-to-Treat Patient


This article was first published in Psychiatry Weekly.com, Volume 5, Issue 18, on July 26, 2010. I like the dialectical part of DBT, or the mindfulness part. Not yet convinced by the behavior therapy aspect, except for short-term symptom management.

You can learn more about DBT at Marsha Linehan's site, or at DBT Self Help.


Dialectical Behavior Therapy: Evidence-Based Psychotherapeutic Strategies for the Difficult-to-Treat Patient

July 26, 2010

Stephen I. Deutsch, MD, PhD

Ann Robinson Endowed Chair in Psychiatry, Professor and Chairman, Department of Psychiatry, Eastern Virginia Medical School

Richard B. Rosse, MD

Chief of Psychiatry, Mental Health Service Line, Department
of Veterans Affairs Medical Center, Washington, DC; Professor of Psychiatry, Georgetown University School of Medicine

First published in Psychiatry Weekly.com, Volume 5, Issue 18, on July 26, 2010


Intense displays of affect, self-injurious behaviors, persistent threats of suicide and other treatment challenges presented by patients with borderline personality disorder (BPD) are bewildering and often fearful for psychiatric residents, whereas these patients can put senior psychiatrists at-risk of burnout. Given the complexity of these patients and the negative counter-transference that they elicit, it can very easy for the therapeutic relationship to deteriorate into an adversarial one and to regard the patient as manipulative, splitting and noncompliant.

Fortunately, an evidence-based therapeutic strategy has emerged, known as dialectical behavior therapy (DBT), that can provide clinicians with a doctor’s bag of useful skills to impart to patients, such as the “mindfulness” skills of non-judgmentally observing and describing a situation, thus overriding “emotion-mind”-based thinking. Teaching patients these skills can facilitate, at least some of the time, collaborative work between therapist and patient. DBT was developed by the psychologist Marsha M. Linehan of the University of Washington, is based on a “blending” of principles of cognitive control of emotional regulation and Eastern meditative practices, and has been shown to be efficacious with sustained benefit in controlled clinical trials with longitudinal follow-up. Importantly, formal exposure to DBT should be incorporated into the curriculum of the psychiatric resident.

How DBT Can Help

Empirically, the authors have found two therapeutic strategies of DBT to be very helpful in quickly establishing rapport and constructive collaborative relationships with diagnostically-heterogeneous groups of difficult patients. The first is “validation and acceptance,” which is a perspective adopted by the therapist and a powerful message conveyed to the patient. Most simply, validation/acceptance means that a patient’s behavioral repertoire is a logical outcome of the interaction of the disordered biological/genetic endowments and what may have been chaotic social-rearing experiences. Thus, the feelings and behaviors of the patient with BPD have legitimacy and are understandable. The experience of validation is a powerful message that can prevent premature eruption of intense hostile feelings towards the therapist. The second therapeutic strategy involves the invitation to work collaboratively on the patient becoming more “effective”—helping the patient achieve their desired outcomes.


Some aspects of DBT are clearly complex, but there are some simple principles that have wide and almost immediate applications, including prioritizing safety (all initial therapeutic efforts should be focused on keeping the patient safe, and moving on to dealing with Treatment Interfering Behaviors (TIBs). These principles are implemented pragmatically and with common sense, including the notion that the patient’s relationship with the therapist is not unconditional, and that there are limits to clinicians’ availability and what they can do for the patient. Perhaps, DBT (or application of some of its therapeutic principles) is indicated whenever a resident refers in a pejorative fashion to a patient as manipulative or when a senior staff psychiatrist complains, “This patient is burning me out!”

Disclosure: Drs. Deutsch and Rosse report no affiliations with, or financial interests in, any organization that may pose a conflict of interest.

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