The Application and Efficacy of Skills Training in Dialectical Behavioral Therapy


Dialectical Behavior Therapy (DBT) is recognized by the American Psychiatric Association as one of the non-drug recommended treatments for borderline personality disorder (BPD)/repeated suicide and self-injury cases. Standard DBT treatment has four In the treatment system of a treatment module, the patient must receive treatment that lasts for one year; in recent years, there have been more and more modified versions of DBT abroad, many of which are designed from the perspective of skill training, and these therapeutic interventions are also It shows certain effects; this article will briefly explain DBT, and focus on the introduction of skills training groups and the application of skills training in related modified versions. It is expected that domestic experts and practitioners can more creatively apply DBT Technology is used in related treatments.

The connotation and efficacy of dialectical behavior therapy

Dialectical Behavior Therapy (DBT) is a comprehensive treatment model developed by Linehan in the 1900s specifically to assist patients with repeated self-injury (especially those with a diagnosis of Borderline Personality Disorder (BPD)). , such cases often incorporate complex issues, including:

  1. Severe functional impairment, they are often unable to maintain functional performance in work, interpersonal relationships, finances and health.
  2. There is a very high suicide rate. 69% to 80% of BPD cases have committed suicide, and 5% to 10% of them will commit suicide, which is more than 50 times the suicide mortality rate of the average person.
  3. There is a very high proportion of comorbidities with other mental disorders. It is possible that more than 83.5% of BPD cases also have other psychiatric diagnoses, including depression or other personality diagnoses.
  4. Extensive use of treatment resources and very high social treatment costs, including the treatment of suicidal behavior and the cost of treatment dropout.

DBT believes that the multiple problems of BPD cases stem from their original emotional vulnerability (emotional vulnerability). When encountering stressful events, they produce excessive emotional arousal (emotional arousal) and slow recovery speed, which is emotional dysregulation ( emotional dysregulation), which is accompanied by the occurrence of extreme, evaluative, and even distorted thoughts (cognitive dissonance) and troublesome problem-solving practices (behavioral dysregulation). Emotional dysregulation is also related to instability of their self (ego dysregulation). It is also related to unstable interpersonal relationships (interpersonal maladjustment) (see Figure 1); among these disorders, the most easily observed by others are behavioral disorders, including self-injury and various impulsive behaviors, etc. However, for BPD, these behaviors The purpose is not necessarily to cause damage or harm, nor to manipulate others, but to quickly reduce extreme emotional arousal and control painful emotions. In fact, research does show that many cases of self-injurious behavior state that, Self-injurious behavior has the function of relieving the stress of negative emotions.

It is no longer easy to help these patients who are extremely prone to overwhelmed emotion learn to regulate their emotions. Frequent unexpected life events and crises make treatment more complicated. The process is like helping a mountain guide to help A mountaineer who is exhausted or even injured, who lacks equipment and lacks experience, has to climb a narrow mountain road with occasional rockfalls. Therefore, standard DBT has designed a careful treatment system, including:

  1. Through weekly individual therapy, behavioral chain analysis, validation strategies, and contingency management are used to increase the patient’s willingness to change.
  2. Through a two-hour group once a week, various techniques are taught to increase the target-oriented and appropriate skillful behavior of the case.
  3. Use telephone personal care and case management to help clients use the learned skills in their daily lives.
  4. Maintain the therapist’s motivation to continue treatment and use appropriate techniques to help the patient through weekly therapist consultation team.

In 1990, Linehan published the first Randomized controlled Trial (RCT) study, which found that compared with the treatment as usual (TAU) group, cases in the DBT group had a lower number of hospitalization days after one year of treatment. Significantly reduced (Fang Junkai, 2007); in 1993, Linehan published “Cognitive-Behavioral Treatment of Borderline Personality Disorder” (Linehan, 1993a) and its technique manual (Linehan, 1993b) in the United States ), Dialectical Behavior Therapy has more and more related studies published in Europe and the United States. There are simple pre- and post-treatment comparison studies as well as rigorous randomized control studies (RCT). There are large sample studies and a few individual case studies. Most of the research results are It has been shown that within one year of standard dialectical behavioral therapy, the dropout rate of cases was reduced, suicidal or quasi-suicidal behaviors were reduced, and anger and depression were significantly reduced. Even one year after the end of treatment, the treatment effects were still obvious. Better than other treatments.

Categories and contents of dialectical behavioral skills

DBT regards an individual’s thoughts, behaviors/actions and physical arousal as part of the behavior. The reaction of any part will produce a series of rapid chain effects. For example, when you are angry, you will feel the excitement of the body and muscles at the same time. Becoming tense, cognitive interpretations are more harmful, and impulsive aggressive behavior may occur; therefore, individuals who learn skills to change any of these components may change the behavioral results, such as by taking prescribed medications steadily or Exercise can reduce an individual’s aggressive behavior by changing the patient’s level of physiological agitation, or using cognitive changes to modify aggressive interpretations into neutral thoughts, or training oneself to leave the scene of possible conflict; that is, learning and applying skills To replace the original maladaptive behaviors, including reducing suicidal, self-injurious behaviors or various behaviors that interfere with the quality of life, and increasing self-control behaviors, is the main goal of skill training.

There are more than fifty DBT techniques, which can be roughly divided into four major categories:

  1. Mastering mindfulness
    It is a core technique in therapy. By teaching the client wisdom, what is clarity practice, and how to practice clarity practice, it helps the client practice accepting and paying attention to every current environment and experience.
  2. Emotional regulation skills
    Including techniques such as clarifying emotional myths, clarifying various emotions, and reducing emotional vulnerability, helping patients understand their own emotions and actively regulate emotions. The negative side is to reduce the problem behaviors caused by emotions, and the positive side is to work hard. Accumulate positive emotions and move towards long-term goals.
  3. Distress tolerance skills
    Techniques specifically targeted at patients who are prone to impulsive and destructive behaviors, and taught to patients how to avoid causing more harm and distress when excessive emotional arousal is about to lose control.
  4. interpersonal effectiveness skills
    Including the prioritization of complex goals in interpersonal relationships, the mechanism of interpersonal self-affirmation, how to improve interpersonal relationships by validating others (Validate), how to establish new relationships, etc. Each group session lasts for two hours. The first hour is a homework discussion to help clients apply the skills they learn each week in their daily lives, and the second hour is spent teaching new skills. It takes a total of half a year for a patient to fully learn these skills. In a standard DBT treatment of one year, all skills will be learned twice in a cycle.

Neacsiu, Rizvi and Linehan (2010) combined and analyzed data from two DBT RCT studies on BPD cases. There were a total of 106 participants (52 in the DBT group and 54 in other treatment models). All cases participated for one year. Treatment, physical and mental status was assessed every four months. Analysis of multi-level models using a hierarchical linear modeling approach showed that the extent to which patients in the DBT group self-reported learning and using skills played a significant role in reducing suicidal behavior and reducing suicidal behavior. Depressive symptoms and increased anger control were fully mediated, and the reduction in suicidal behavior was partially mediated. The learning of display skills does have an important influence on the change of individual problem behaviors and emotional distress.

Intervention study of different dialectical behavioral therapy skills training (DBT-ST)

There are many different DBT Skills Training (DBT-ST) intervention programs, most still conducted in a group format, but there are quite a few variations, from simplified versions of standardized DBT for treating BPD cases, to applying these techniques to treat other diagnoses. For individual cases or situations, a single skills training intervention, or adding other skills to DBT skills training, this article will summarize several different types of research to illustrate its use:

The RCT study designed by Soler et al. (2009) is the intervention closest to standard DBT, using a simple DBT skills training group (DBT-ST) and a general treatment group (standard group therapy, referred to as SGT) for emergency and BPD cases referred from the outpatient clinic were given group therapy for two hours each time for thirteen times (three months). The results showed that such a short-term intervention, DBT-ST was more effective than the SGT group, including lower dropout rate, depression, Anxiety, irritability, anger and emotional instability were significantly reduced.

Koons et. al (2006) designed approximately four hours of group skills training per week (including two hours of DBT skills and 90 minutes of group diary card review, Teach behavior chain analysis and behavior drills, the latter is somewhat similar to individual DBT treatment in a group), and the change goal of the treatment is set at problem behaviors that affect continued work; at the end of one year of treatment, and the sixth follow-up After months of follow-up, it was found that the 8 cases who had completed the treatment had significantly reduced anger expressions, had better anger control, were more satisfied with their work roles, and could maintain their anger for a longer period of time at the sixth-month follow-up. There is a working status.

DBT-ST has also been used in the treatment of family members of patients. In 1999, Hoffman et al. designed “Dialectical Behavior Therapy – Family Skills Training” for 110 family members of patients. Through a 1.5-hour skills training course per week for 24 weeks, It is obviously helpful in improving family members’ understanding of patients, family members’ assistance to patients, and patients’ compliance with treatment (indirectly quoted from Fang Junkai, 2006). Hoffman et al. (2005) also designed a group course that only takes 12 weeks, including: 1. Instructions on the disease and treatment of BPD; 2. DBT coping skills; 3. Family skills; 4. Establishing a support system Opportunities and other four contents, that is, in the knowledge part, in addition to BPD-related information, it also integrates the introduction of family functions, and the skill teaching part, in addition to selecting important skills from DBT, also trains some from the family perspective. Some of the techniques, there are practical exercises and assignments in each group. After the group ended, 34 family members from 34 families experienced a significant decrease in sadness and burden, and an increased sense of competence. This effect was still visible six months after the group ended.

Since many high-risk suicide cases in the United States did not receive appropriate treatment and intervention before committing suicide, in order to effectively assist high-risk cases of suicidal behavior who do not want to receive treatment but hope not to commit suicide, WardCiesielski (2013) developed a The single assessment and intervention model recruits cases with suicidal ideation (Beck’s Suicide Scale score >10) by posting posters in the community. The cases are then asked to fill in a DBT ways of Coping Checklist. DBT-WCCL), after giving feedback to the patient on the questionnaire, it takes about an hour to teach five DBT skills, including two clarity skills (teaching the patient what it is to live in the present and how to live in the present), and two emotional regulation skills. skills (understanding current emotions and acting contrary to emotions), and two pain tolerance skills (distracting from painful things and improving the present moment). In the dependent-sample t test, 18 cases showed a significant decrease in suicidal ideation during the telephone follow-up one month later.

In Taiwan, there is a poster paper published at the European Society for Suicide Prevention and Treatment in 2014 (Chen, 2014), which aims at a six-week, 50-minute DBT skills training course for nursing staff in psychiatric wards. Fill out the Suicide Behavior Attitude Questionnaire (Suicide Behavior Attitude Questionnaire) during the first week and the last course. This scale is divided into three subscales: negative feelings toward suicides, feelings of competence in caring for suicide cases, and whether patients have the right to commit suicide. Due to the large number of affairs in the ward, it is difficult for nursing staff to fully participate in the course. Therefore, ten staff who participated more than or equal to three times were finally selected for post-test data analysis. The average number of course participations was 4.2 times. Comparison of the pre- and post-test results showed that nursing After attending the class, the staff’s negative feelings when faced with suicide cases were reduced. For example: The score for “I feel powerless” when faced with suicide cases was reduced. However, their sense of competence in taking care of suicide cases and their thoughts on whether patients have the right to commit suicide have not changed much. Among the skills learned, pain tolerance skills are the skills that nurses find most helpful.

In addition to the studies mentioned above, intervention studies on pure DBT-ST include DBT group training for adolescents with BPD traits (Miller et. Al., 2000), and DBT group training for adolescents with oppositional and defiant traits (Nelson-Gray et. Al ., 2006), treatment of patients with refractory major depression (Harley, Sprich, Safren, Jacobo, & Fava, 2008), cases of women with bulimia (Telch, Agras, & Linehan, 2000), DBT for women who have suffered domestic violence Skill Groups (Inverson, Shenk, Frizzetto, 2009) (indirectly cited from Neacsiu, et. al., 2010)

In conclusion

Although there are currently no comparative studies of standard DBT and DBT-ST, the benefits of DBT skills-only group intervention in reducing treatment costs and increasing the feasibility of implementation compared to standardized DBT are attractive; in addition, dialectical behavior Research on treatment efficacy factors shows that skill learning plays an important role in treatment, and short-term group training studies that select appropriate combinations of DBT skills for different cases or purposes have indeed seen therapeutic effects; perhaps DBT skills can be used It is regarded as a general collection of techniques. Among the more than fifty techniques, after understanding the connotation and effect of each technique, the therapist can use his or her clinical sensitivity and understanding of the target object to creatively combine them. And the application of teaching these skills, the breadth of its application is worth looking forward to.

Taiwan has become quite curious about DBT in recent years, but its practical use is still quite limited. On the one hand, there are still only a few therapists who have a full understanding of this school of therapy. Another reason is that there are no suitable Chinese textbooks on the market. However, , there are at least three translation manuals introducing DBT skills. If suitable skill design groups can be selected for some specific cases with emotional difficulties, I believe it will be easier to use DBT in the existing environment or professional restrictions. .

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