Dialectical Thinking – The Forgotten Part of DBT

Dialects and DBT
Dialectical behavior therapy (DBT) is a therapeutic approach which combines elements of western cognitive behavior therapy (CBT) with mindfulness practice associated with Zen Buddhism. It has proven to be extremely useful in treating patients with Borderline Personality Disorder, depression, and other psychiatric conditions in which patients have difficulty managing strong emotional responses and intense interpersonal relationships. Among other areas of focus, DBT teaches specific skills for better managing emotional life in four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

Marsha Linehan developed DBT based on the paradoxical principle that patients need to be validated because they are doing the very best they can do with their lives and their therapy. At the very same time, they need to learn to do better. Therapists need to send the message that they accept their patients for who they are and, simultaneously, insist that they change.

Much of the excitement around the therapeutic effectiveness of DBT focuses on the skills training. Parasuicidal behaviors (e.g. – self cutting, threatening overdose, bingeing and purging, drinking to excess) and other ineffective methods of coping with emotional stress are carefully analyzed in order to understand the precipitants and decision making that goes on just beneath the patient’s awareness. Patients are taught how to be more mindful and less reactive, giving them opportunities to make better decisions that have more desirable consequences. Specific strategies are devised to help patients deal more effectively with emotional states (e.g. – rage, despair, hopelessness) and interpersonal situations (e.g. – asking to have a need met, arguing with a person one cares about) that have been problematic in their lives.

However, the attitude of the therapist is also critical for success. The therapist must hold contradictory positions in balance, with the understanding that both are true. This keeps the therapist and patient from prematurely going down a one-sided path, which likely has been tread before many times with a poor outcome. Staying with the “dialectical dilemma” gives both therapist and patient the psychological space to work together on problems that have been impossible to solve up to that point. For this to come about, the therapist must be able to guide and structure the therapy sessions. This may involve methodically completing a behavioral chain analysis through the guidance of the patient’s diary card. This provides a framework so that therapy is not swept up in a series of unrelenting crises. The focus stays on resolving the life threatening behaviors (and therapy interfering behaviors) before all others. Frequently, the therapist must switch between validating and irreverent styles of communication. This technique allows the therapist to keep both poles of the dialectic on the table – the patient is doing her best and she also needs to change. When the dialectical poles are held long enough in therapeutic tension, a synthetic solution can emerge.

For example, a patient with Borderline Personality Disorder finds the pain of rejection intolerable, leading to wishes to die and the behavior of cutting herself to “feel alive” again. In analyzing this with the patient, the therapist learns that she feels hopeless and powerless at the height of her misery. At other times, when she is not immersed in this emotional state, the patient is capable of creative and effective action to get things done in her life. The patient’s cutting can be seen as a move towards “effective action” that gets her out of the powerless position. The therapist needs to validate the experience of hopelessness AND the creative action (cutting) the patient has learned gets her out of it. She can then help the patient look at other strategies that have some of the same elements of turning a passive/powerless experience into one of action/empowerment, but this time with more desirable consequences. If the therapist does not acknowledge the patient’s despair and her best efforts to overcome it, she dismisses the patient’s experience (which likely has happened many times in her life.) On the other hand, if the therapist simply sits with the patient’s pain, she misses the opportunity to enlist the patient in coming up with a better solution.

There are many “dialectical dilemmas” that the therapist must engage if she is to help her patient face them. Many of these are familiar from more traditional psychodynamic psychotherapy practice, but may not be in full awareness. DBT frames them in dialectical format (thesis – antithesis – leading to synthesis), which is very helpful in keeping them in mind. In addition, the therapist and patient can learn to hold these dilemmas in balanced tension with the help of mindfulness training.

A New Look at Transference
One central dilemma that troubles many patients (and troubles therapists as they try to work with these patients) involves the search for the right emotional distance. Therapy needs to be intense enough to be emotionally meaningful, but with enough distance to make sense of what is going on. (In psychodynamic psychotherapy, this is the problem of dealing with the transference and countertransference.)

Some examples of how this shows up in DBT-informed work are listed below:

- Thesis: I need to be close in order to feel loved. If I am not close enough, I feel unloved and unlovable.
- Antithesis: When I am close, I feel terribly vulnerable to being hurt (e.g.-abandoned, suffocated, scorned.)

- Thesis: I want my therapist to love me in a special way (which may be maternal, paternal, sexual or in some other way.)
- Antithesis: I need my therapist to maintain objectivity so she can help me with the problems I came to therapy with.

- Thesis: My feelings for my therapist are real and deserve to be recognized as such.
- Antithesis: My feelings for my therapist are a repetition of past relationships that have not worked well for me in my adult life. I need to understand these patterns and master them.

The focus on dialectical thinking in therapy can be very useful in engaging these dilemmas in ways that eventually lead to productive work. Both thesis and antithesis are true, yet both need to be recognized in relationship to the other to get a more complete picture. Taking only one side is a pathway towards acting out, fleeing treatment, or stalemate. The work towards creative synthesis of these and similar dilemmas, along with the development of practical skills in managing emotional and interpersonal life, is the essence of all good therapy.

Don Ross, MD
Medical Director
Kelly Shannon, LCSW-C
Coordinator of DBT Programs

The Retreat at Sheppard Pratt
01-06-2010

Early Findings Positive for Combination Treatment

Sheppard Pratt is among the early adopters of Transcranial Magnetic Therapy (TMS), offering psychiatrists another tool to treat depression. Dr. Scott Aaronson, director of clinical research programs at Sheppard Pratt, Associate Medical Director of the Retreat and medical director of TMS Services, uses NeuroStar TMS Therapy® for patients who have not responded to other types of depression treatment. It is offered in conjunction with a stay on The Retreat at Sheppard Pratt and on an outpatient basis.

During TMS, magnetic field pulses are generated and aimed at the left dorsal lateral prefrontal cortex, an area of the brain that has been demonstrated to function abnormally in patients with depression. During the clinical trials in which Dr. Aaronson was involved, TMS was used only as a monotherapy for individuals who had failed one to four antidepressant treatments in their lifetime.

Now, Dr. Aaronson is using TMS more frequently as an add-on treatment to antidepressants on patients who are, on average, sicker patients who have failed antidepressant treatment more than what was acceptable for the clinical trial. Dr. Aaronson says the hope is to provide a different paradigm to treat depression, no longer just dealing with serotonin or norepinephrine reuptake inhibitors, but instead offering antidepressant support by electric means.

Outside of the clinical trials, Dr. Aaronson is finding a larger percentage of patients responding to TMS treatment. Whereas it was about 50% of clinical trial subjects responding to TMS monotherapy, now about 60 to 65% of patients show good evidence of response to combination treatment.

Dr. Aaronson cites a 50-year-old male patient who was disabled from his profession because of his depression, and who had not previously responded to aggressive pharmacologic treatment as an outpatient. The man received TMS treatment and is now back to work and functioning again. A woman in her early 30s was able to return to work for the first time in five years after receiving TMS treatments.

A typical course of TMS therapy consists of 20 to 30 consecutive sessions, each lasting about 45 minutes for five days a week. No anesthesia or sedation is needed and there are no cognitive side effects. Currently, two patients are receiving maintenance treatments, a woman who has failed alternative treatments over the past five years and a man who has had a recurrence of his depression three months after a good response to TMS.

The original TMS technology was developed as exploratory means to investigate what different parts of the brain do — a way to activate or slow down areas of the brain through magnetic stimulation. Dr. Aaronson says this is a new tool and sees it as just the beginning of using this new technology. Currently, TMS is used with unipolar depression, but it may also have usefulness in bipolar depression or other illnesses, like schizophrenia.

Additionally, Dr. Aaronson says side effects have been minimal and, generally speaking, most patients have tolerated treatment well. The first few treatments have been uncomfortable for some patients, Dr. Aaronson says, who are sensitive to the tapping sensation at the treatment site. He says patients then get used to the stimulation and it becomes less bothersome as treatment continues.

Although TMS therapy is not currently covered by insurance, the parent company, Neuronetics, is working to get third party payers to support the treatment. Current costs for treatment range from about $6,000 to $9,000. Dr. Aaronson says he believes insurers would be more likely to cover costs once they become aware of the successes that come from using the technology along with antidepressants.

Dr. Aaronson stresses that TMS treatment is not a last chance for patients, but yet another tool for providers to use. He hopes mental health providers accept the technology, and that there will be an increased understanding of its utility for a variety of psychiatric conditions.