Structure Modification Vs. Dialectical Behavoir Therapy

by Kathi Stringer

Modifying the patient’s internal structure has several advantages, the maximum of which mitigates the genesis of the deep buried pain and introduces a new modified world for the patient. To help put this into perspective, think of a patient’s source of pain deriving from earlier structures developed from experiencing sexual, verbal or physical abuse. These earlier structures shaped from abuse continue to unconsciously play-out through obsessive compulsiveness as a maladaptive defense hoping for a better ending. Since these earlier structures are a closed-system and only apparently semi-available to a trained professional, the patient’s repeated defenses are doomed to failure. That is until now, but first we will review a fairly new established complex theory before exploring this concept of exciting structure modification further.

Positioned at the opposite end of the structured spectrum is Linehan’s empirically successful Dialectical Behavioral Treatment for Borderline Personality Disorder (DBT). Linehan’s concept is Zen spirituality combined with western psychological theory. The concept is inviting since the emphasis is to accept the patient at her current level while introducing change. This becomes a mutual commitment that seems almost a paradox, but is defined as Dialectical because when two opposites exist to create the synthesis, a process of change takes place. Yet this dialectical change takes place as micro-formations, once one change is formed at each end, reality has evolved altering the properties, and again another synthesis is required, but with each synthesis less is geometrically required in the advancement toward the final goal. In other words, we accept you as you are as long as you commit to dialectical change.

Linehan explains that DBT is useful to modulate affect and control emotional dysregulation. The DBT model provides once weekly group ‘skills’ meetings and once weekly individual therapy sessions. The weekly skills groups are divided up into four 8-week skills training modules, which could be taken twice each over the year-required period. The target is to replace maladaptive, ineffective behavior with trained skilled responses.

Weekly Skills Group	Weekly Therapy Session
1. Core mindfulness skills 2. Interpersonal effectiveness skills 3. Emotional regulations skills 4. Distress tolerance skills, respectfully	1. Suicidal behaviors 2. Therapy-Interfering behaviors 3. Behaviors that interfere with the quality of life 4. Behavioral skill acquisition 5. Posttraumatic stress behaviors 6. Self-respect behaviors

To Linehan’s credit, she makes it absolutely clear the consequences concerning the invalidating environment toward the child. This is important because an invalidated child secures the child’s emotional reaction to her interpersonal world, or lack of it. See this example:

Child: ”Mom, I’m thirsty”

Mom: ”No, you just had a drink of water, you are not thirsty.”

Adult Version –

Patient: ”I’m hurting inside and I don’t know what to do”

Therapist: “I don’t know why you are hurting so much, I just went over my time limit with you for 30 minutes.”

The patient now reacts with emotional sensitivity and as the evening approaches her emotions become intense and she has patterns of perceiving herself as invalidated. She escalates her behavior toward suicidal ideation in frantic attempts for validation, which are now confused and uncontrolled.

As Linehan echoes throughout her work, a child that grows up in an invalidating environment will have poor reality testing skills as to what works and what does not work. (Linehan) “The invalidating environment contributes to emotions dysregulation by failing to teach the child to label and modulate arousal, to tolerate distress, or to trust her own emotional responses as valid interpretations of events.” Also, linked to poor reality testing is a confused identity of self, since a consistent validated mirror or feedback of self was unavailable. On moment the child is bright like her mother and the next instant, stupid, dirty and ugly like her drunken father, who in objective reality is not even a shadow of this biting description.

As you can see from this material, it generates incentive to accept and validate a patient’s current position when entering the DBT program, to break the invalidating cycle, and second, to apply the skills training modules beginning with Core Mindfulness to address emotional dysregulation and modulate affect and other therapy interfering behaviors. DBT also stress cheerleading, coaching, problem solving and homework though handouts. Below is an example of Mindfulness Handout #1, one of DBT’s capital declarations.

DBT illustrates three states of the mind

1. The Reasonable Mind (This is the logical part of the mind that takes cakes care of the day-to-day tasks)

2. The Emotional Mind (This part of the mind bases it decisions on reactions rather then response, or in other words decisions from feelings of the ‘heart’)

3. The Wise Mind (This part of the mind is a combination of the Reasonable Mind and the Emotional Mind, able to take appropriate actions based on good insight and good judgment)

When analyzing DBT as a treatment program and its functions to create self-regulatory repertoires to tolerate stress, impulsiveness, modulate affect; regulate emotional arousal and cognitive skills management to act as an internal gage, and all of its related functions, the operator of this system must be constantly alert and aware of impending movements of measurements, comparing, looking for signals, guidelines, sign-posts and warnings. This patient must be as the operator of a lighthouse, keeping the light burning in the night least the ships crash against the hidden rocks in the harbor. Measuring, monitoring and attempting to self-validate through weekly sessions. At a glance it seems a daunting, relentless task that would consume vast amounts of emotional energy. Through cogitation and skills training, it appears to be a single source to control pain. To quote Linehan (1993), “The distress tolerance module assumes that even though there may be a lot of pain, it can be tolerated, and life can be accepted and lived in spite of pain.”...

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