DBT: Dialectical Behaviour Therapy – Mental Health Matters

What is Personality Development Disorder?

Published on 11/24/2021 by Andrew MarshallLeave a comment

Introduction

A personality development disorder is an inflexible and pervasive pattern of inner experience and behavior in children and adolescents, that markedly deviates from the expectations of the individual’s culture.

Personality development disorder is not recognised as a mental disorder in any of the medical manuals, such as the ICD-10 or the DSM-IV, nor the more recent DSM-5. DSM-IV allows the diagnosis of personality disorders in children and adolescents only as an exception. This diagnosis is currently proposed by a few authors in Germany. The term personality development disorder is used to emphasize the changes in personality development which might still take place and the open outcome during development. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.

Adults usually show personality patterns over a long duration of time. Children and adolescents however still show marked changes in personality development. Some of these children and adolescents have a hard time developing their personalities in an ordinary way. DSM-IV states, for example, that children and adolescents are at higher risk to develop an antisocial personality disorder if they showed signs of conduct disorder and attention deficit disorder before the age of 10. This led Adam & Breithaupt-Peters (2010) to the idea that these children and adolescents need to be looked at more carefully. The therapy which these children and adolescents need might be more intense and maybe even different from looking at the disorders traditionally. The concept of personality development disorders also focuses on the severity of the disorder and the poor prognosis. An early diagnosis might help to get the right treatment at an early stage and thus might help to prevent a personality disorder outcome in adulthood.

Description

Similar to the adult diagnosis personality disorder these children display enduring patterns of inner experience and behaviour deviating markedly from the expectations of the individual’s culture. These patterns are inflexible and pervasive across a broad range of personal and social situations, lead to clinically significant distress or impairment in social, occupational or other important areas of functioning and they are stable and of long duration (more than a year).

The term personality development disorder (Persönlichkeitsentwicklungsstörung) was first used in German by Spiel & Spiel (1987). Adam & Breithaupt-Peters (2010) adapted the term to a more modern concept and suggested the below definition.

Cause

Similar to adult personality disorders there are multiple causes and causal interactions for personality development disorders. In clinical practice it is important to view the disorder from multiple perspectives and from an individual perspective. Biological and neurological causes need to be observed just as much as psychosocial factors. Looking at the disorder from only one perspective (e.g. (s)he had a bad childhood) often results in ignorance of important other factors or causal interactions. This might be one of the main reasons why traditional treatment methods often fail with these disorders. Only a multi-perspective view can provide for a multi-dimensional treatment approach which seems to be the key for these disorders.

Diagnosis

The diagnosis personality development disorder should only be given carefully and after a longer period of evaluation. Also a thorough diagnostic evaluation is necessary. Parents should be questioned separately and together with the child or adolescent to evaluate the severity and duration of the problems. In addition standardised personality tests might be helpful. It is also useful to ask the family what treatment approaches they have already tried so far without success.

Definition

According to Adam und Breithaupt-Peters personality development disorders are defined as complex disorders:

Which show similarity to a certain type of personality disorder in adulthood.
Which persist over a long period of time (more than a year) and show a tendency towards being chronic.
Which have a severe negative impact on more than one important area of functioning or social life.
Which show resistance to traditional educational and therapeutic treatment methods.
Which result in a reduced insight into or ignorance of the own problem behaviour. The family usually suffers more than the child or adolescent and has a hard time dealing with the diminished introspection.
Which make positive interactions between the children/adolescents and other people merely impossible. Instead social collisions are part of everyday life.
Which threaten the social integration of the young person into a social life and might result in an emotional disability.

Treatment

Personality development disorders usually need a complex and multi-dimensional treatment approach (Adam & Breithaupt-Peters, 2010). Since the problems are complex, treatment needs to affect the conditions in all impaired functional and social areas. Both educational and therapeutic methods are helpful and problem and strength based approaches work hand in hand. Parents need to be included as well as the school environment. Treatment methods need to be flexible and adjustable to the individual situation. Even elements of social work can be helpful when supporting the families and in some cases medication might be necessary. When suicidal behaviours or self-injuries are prominent treatment might best be done in a hospital.

For some personality development disorders (e.g. borderline personality disorder) treatment methods from adults can be adapted (e.g. dialectical behaviour therapy, Miller et al., 2006).

References

Adam, A. & Breithaupt-Peters, M. (2010). Persönlichkeitentwicklungsstörungen bei Kindern und Jugendlichen. Stuttgart: Kohlhammer Verlag.

What is Dialectical Behaviour Therapy?

Published on 11/08/2021 by Andrew Marshall7 Comments

Introduction

Dialectical behaviour therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders, ADHD, and interpersonal conflicts.

There is evidence that DBT can be useful in treating mood disorders, suicidal ideation, and for change in behavioural patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies, and ultimately balance and synthesize them, in a manner comparable to the philosophical dialectical process of hypothesis and antithesis, followed by synthesis.

This approach was developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviours to help avoid undesired reactions.

Linehan developed DBT as a modified form of cognitive behavioural therapy (CBT) in the late 1980s to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviours associated with spectrum mood disorders, including self-injury. Work also suggests its effectiveness with sexual-abuse survivors and chemical dependency.

DBT combines standard cognitive-behavioural techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from contemplative meditative practice. DBT is based upon the biosocial theory of mental illness and is the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. The first randomised clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalisations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.

Overview

DBT is considered part of the “third wave” of cognitive-behavioural therapy, and DBT adapts CBT to assist patients to deal with stress.

Linehan developed DBT as a modified form of cognitive behavioural therapy (CBT) in the late 1980s to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviours associated with spectrum mood disorders, including self-injury. Recent work also suggests its effectiveness with sexual-abuse survivors and chemical dependency.

DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the client’s feelings at any given time, while, nonetheless, informing the client that some feelings and behaviours are maladaptive, and showing them better alternatives. DBT focuses on the client acquiring new skills and changing their behaviours, with the ultimate goal of achieving a “life worth living”, as defined by the patient.

In DBT’s biosocial theory of BPD, clients have a biological predisposition for emotional dysregulation, and their social environment validates maladaptive behaviour.

DBT skills training alone is being used to address treatment goals in some clinical settings, and the broader goal of emotion regulation that is seen in DBT has allowed it to be used in new settings, for example, supporting parenting.

Four Modules

Mindfulness

Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations.

The concept of mindfulness and the meditative exercises used to teach it are derived from traditional contemplative religious practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one’s emotions and senses fully, yet with perspective. The practice of mindfulness can also be intended to make people more aware of their environments through their five senses: touch, smell, sight, taste, and sound. Mindfulness relies heavily on the principle of acceptance, sometimes referred to as “radical acceptance”. Acceptance skills rely on the patient’s ability to view situations with no judgment, and to accept situations and their accompanying emotions. This causes less distress overall, which can result in reduced discomfort and symptomology.

Acceptance and Change

The first few sessions of DBT introduce the dialectic of acceptance and change. The patient must first become comfortable with the idea of therapy; once the patient and therapist have established a trusting relationship, DBT techniques can flourish. An essential part of learning acceptance is to first grasp the idea of radical acceptance: radical acceptance embraces the idea that one should face situations, both positive and negative, without judgment. Acceptance also incorporates mindfulness and emotional regulation skills, which depend on the idea of radical acceptance. These skills, specifically, are what set DBT apart from other therapies.

Often, after a patient becomes familiar with the idea of acceptance, they will accompany it with change. DBT has five specific states of change which the therapist will review with the patient:

Precontemplation is the first stage, in which the patient is completely unaware of their problem.
In the second stage, contemplation, the patient realises the reality of their illness: this is not an action, but a realisation.
It is not until the third stage, preparation, that the patient is likely to take action, and prepares to move forward. This could be as simple as researching or contacting therapists.
Finally, in stage 4, the patient takes action and receives treatment.
In the final stage, maintenance, the patient must strengthen their change in order to prevent relapse.

After grasping acceptance and change, a patient can fully advance to mindfulness techniques.

There are six mindfulness skills used in DBT to bring the client closer to achieving a “wise mind”, the synthesis of the rational mind and emotion mind: three “what” skills (observe, describe, participate) and three “how” skills (nonjudgementally, one-mindfully, effectively).

Distress Tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by person-centred, psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behaviour therapy emphasizes learning to bear pain skilfully. This module outlines healthy coping behaviours intended to replace harmful ones, such as distractions, improving the moment, self-soothing, and practicing acceptance of what is.

Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and non-judgemental fashion, both oneself and the current situation. Since this is a non-judgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.

Emotion Regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. DBT skills for emotion regulation include:

Identify and label emotions.
Identify obstacles to changing emotions.
Reduce vulnerability to emotion mind.
Increase positive emotional events.
Increase mindfulness to current emotions.
Take opposite action.
Apply distress tolerance techniques.

Emotional regulation skills are based on the theory that intense emotions are a conditioned response to troublesome experiences, the conditioned stimulus, and therefore, are required to alter the patient’s conditioned response. These skills can be categorised into four modules: understanding and naming emotions, changing unwanted emotions, reducing vulnerability, and managing extreme conditions:

Learning how to understand and name emotions:
- The patient focuses on recognising their feelings.
- This segment relates directly to mindfulness, which also exposes a patient to their emotions.
Changing unwanted emotions:
- The therapist emphasizes the use of opposite-reactions, fact-checking, and problem solving to regulate emotions.
- While using opposite-reactions, the patient targets distressing feelings by responding with the opposite emotion.
Reducing vulnerability:
- The patient learns to accumulate positive emotions and to plan coping mechanisms in advance, in order to better handle difficult experiences in the future.
Managing extreme conditions:
- The patient focuses on incorporating their use of mindfulness skills to their current emotions, to remain stable and alert in a crisis.

Interpersonal Effectiveness

The three interpersonal skills focused on in DBT include self-respect, treating others “with care, interest, validation, and respect”, and assertiveness. The dialectic involved in healthy relationships involves balancing the needs of others with the needs of the self, while maintaining one’s self-respect

Tools

Specially formatted diary cards can be used to track relevant emotions and behaviours. Diary cards are most useful when they are filled out daily. The diary card is used to find the treatment priorities that guide the agenda of each therapy session. Both the client and therapist can use the diary card to see what has improved, gotten worse, or stayed the same.

Chain Analysis

Chain analysis is a form of functional analysis of behaviour but with increased focus on sequential events that form the behaviour chain. It has strong roots in behavioural psychology in particular applied behaviour analysis concept of chaining. A growing body of research supports the use of behaviour chain analysis with multiple populations.

Efficacy

Borderline Personality Disorder

DBT is the therapy that has been studied the most for treatment of borderline personality disorder, and there have been enough studies done to conclude that DBT is helpful in treating borderline personality disorder. A 2009 Canadian study compared the treatment of borderline personality disorder with dialectical behaviour therapy against general psychiatric management. A total of 180 adults, 90 in each group, were admitted to the study and treated for an average of 41 weeks. Statistically significant decreases in suicidal events and non-suicidal self-injurious events were seen overall (48% reduction, p=0.03; and 77% reduction, p=0.01; respectively). No statistically-significant difference between groups were seen for these episodes (p=.64). Emergency department visits decreased by 67% (p<0.0001) and emergency department visits for suicidal behaviour by 65% (p<0.0001), but there was also no statistically significant difference between groups.

Depression

A Duke University pilot study compared treatment of depression by antidepressant medication to treatment by antidepressants and dialectical behaviour therapy. A total of 34 chronically depressed individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically-significant differences were noted in remission rates between groups, with a greater percentage of patients treated with antidepressants and dialectical behaviour therapy in remission.

Complex Post-Traumatic Stress Disorder (CPTSD)

Exposure to complex trauma, or the experience of traumatic events, can lead to the development of complex post-traumatic stress disorder (CPTSD) in an individual. CPTSD is a concept which divides the psychological community. The American Psychological Association (APA) does not recognise it in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental illness), though some practitioners argue that CPTSD is separate from post-traumatic stress disorder (PTSD).

CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive, emotional, and biological domains, among others. CPTSD differs from PTSD in that it is believed to originate in childhood interpersonal trauma, or chronic childhood stress, and that the most common precedents are sexual traumas. Currently, the prevalence rate for CPTSD is an estimated 0.5%, while PTSD’s is 1.5%. Numerous definitions for CPTSD exist. Different versions are contributed by the World Health Organisation (WHO), The International Society for Traumatic Stress Studies (ISTSS), and individual clinicians and researchers.

Most definitions revolve around criteria for PTSD with the addition of several other domains. While The APA may not recognise CPTSD, the WHO has recognized this syndrome in its 11th edition of the International Classification of Diseases (ICD-11). The WHO defines CPTSD as a disorder following a single or multiple events which cause the individual to feel stressed or trapped, characterised by low self-esteem, interpersonal deficits, and deficits in affect regulation. These deficits in affect regulation, among other symptoms are a reason why CPTSD is sometimes compared with borderline personality disorder (BPD).

Similarities between CPTSD and Borderline Personality Disorder

In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit splitting, mood swings, and fears of abandonment. Like patients with borderline personality disorder, patients with CPTSD were traumatised frequently and/or early in their development and never learned proper coping mechanisms. These individuals may use avoidance, substances, dissociation, and other maladaptive behaviours to cope. Thus, treatment for CPTSD involves stabilising and teaching successful coping behaviours, affect regulation, and creating and maintaining interpersonal connections. In addition to sharing symptom presentations, CPTSD and BPD can share neurophysiological similarities, for example, abnormal volume of the amygdala (emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital prefrontal cortex (personality). Another shared characteristic between CPTSD and BPD is the possibility for dissociation. Further research is needed to determine the reliability of dissociation as a hallmark of CPTSD, however it is a possible symptom. Because of the two disorders’ shared symptomatology and physiological correlates, psychologists began hypothesising that a treatment which was effective for one disorder may be effective for the other as well.

DBT as a Treatment for CPTSD

DBT’s use of acceptance and goal orientation as an approach to behaviour change can help to instil empowerment and engage individuals in the therapeutic process. The focus on the future and change can help to prevent the individual from becoming overwhelmed by their history of trauma. This is a risk especially with CPTSD, as multiple traumas are common within this diagnosis. Generally, care providers address a client’s suicidality before moving on to other aspects of treatment. Because PTSD can make an individual more likely to experience suicidal ideation, DBT can be an option to stabilize suicidality and aid in other treatment modalities.

Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious behaviours (such as cutting or burning) and increases interpersonal functioning but neglects core CPTSD symptoms such as impulsivity, cognitive schemas (repetitive, negative thoughts), and emotions such as guilt and shame. The ISTSS reports that CPTSD requires treatment which differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing on traumatic memories. The recommended multiphase model consists of establishing safety, distress tolerance, and social relations.

Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT discuss the time required for the therapy to be effective. Individuals seeking DBT may not be able to commit to the individual and group sessions required, or their insurance may not cover every session.

A study co-authored by Linehan found that among women receiving outpatient care for BPD and who had attempted suicide in the previous year, 56% additionally met criteria for PTSD. Because of the correlation between borderline personality disorder traits and trauma, some settings began using DBT as a treatment for traumatic symptoms. Some providers opt to combine DBT with other PTSD interventions, such as prolonged exposure therapy (PE) (repeated, detailed description of the trauma in a psychotherapy session) or cognitive processing therapy (CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories).

For example, a regimen which combined PE and DBT would include teaching mindfulness skills and distress tolerance skills, then implementing PE. The individual with the disorder would then be taught acceptance of a trauma’s occurrence and how it may continue to affect them throughout their lives. Participants in clinical trials such as these exhibited a decrease in symptoms, and throughout the 12-week trial, no self-injurious or suicidal behaviours were reported.

Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is low. Biosocial theory posits that emotion dysregulation is caused by an individual’s heightened emotional sensitivity combined with environmental factors (such as invalidation of emotions, continued abuse/trauma), and tendency to ruminate (repeatedly think about a negative event and how the outcome could have been changed).

An individual who has these features is likely to use maladaptive coping behaviours. DBT can be appropriate in these cases because it teaches appropriate coping skills and allows the individuals to develop some degree of self-sufficiency. The first three modules of DBT increase distress tolerance and emotion regulation skills in the individual, paving the way for work on symptoms such as intrusions, self-esteem deficiency, and interpersonal relations.

Noteworthy is that DBT has often been modified based on the population being treated. For example, in veteran populations DBT is modified to include exposure exercises and accommodate the presence of traumatic brain injury (TBI), and insurance coverage (i.e. shortening treatment). Populations with comorbid BPD may need to spend longer in the “Establishing Safety” phase. In adolescent populations, the skills training aspect of DBT has elicited significant improvement in emotion regulation and ability to express emotion appropriately. In populations with comorbid substance use, adaptations may be made on a case-by-case basis.

For example, a provider may wish to incorporate elements of motivational interviewing (psychotherapy which uses empowerment to inspire behaviour change). The degree of substance use should also be considered. For some individuals, substance use is the only coping behaviour they know, and as such the provider may seek to implement skills training before target substance reduction. Inversely, a client’s substance use may be interfering with attendance or other treatment compliance and the provider may choose to address the substance use before implementing DBT for the trauma.

What is Experiential Avoidance?

Published on 10/14/2021 by Andrew Marshall1 Comment

Introduction

Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences – even when doing so creates harm in the long-run.

The process of EA is thought to be maintained through negative reinforcement – that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the behaviour will persist. Importantly, the current conceptualisation of EA suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings (and the associated avoidance and inhibition of these experiences) is thought to be linked to a wide range of problems.

Background

EA has been popularised by recent third-wave cognitive-behavioural theories such as acceptance and commitment therapy (ACT). However, the general concept has roots in many other theories of psychopathology and intervention.

Psychodynamic

Defence mechanisms were originally conceptualised as ways to avoid unpleasant affect and discomfort that resulted from conflicting motivations. These processes were thought to contribute to the expression of various types of psychopathology. Gradual removal of these defensive processes are thought to be a key aspect of treatment and eventually return to psychological health.

Process-Experiential

Process-experiential therapy merges client-centred, existential, and Gestalt approaches. Gestalt theory outlines the benefits of being fully aware of and open to one’s entire experience. One job of the psychotherapist is to:

“explore and become fully aware of [the patient’s] grounds for avoidance” and to “[lead] the patient back to that which he wishes to avoid”.

Similar ideas are expressed by early humanistic theory:

“Whether the stimulus was the impact of a configuration of form, color, or sound in the environment on the sensory nerves, or a memory trace from the past, or a visceral sensation of fear or pleasure or disgust, the person would be ‘living’ it, would have it completely available to awareness…he is more open to his feelings of fear and discouragement and pain…he is more able fully to live the experiences of his organism rather than shutting them out of awareness.”

Behavioural

Traditional behaviour therapy utilises exposure to habituate the patient to various types of fears and anxieties, eventually resulting in a marked reduction in psychopathology. In this way, exposure can be thought of as “counter-acting” avoidance, in that it involves individuals repeatedly encountering and remaining in contact with that which causes distress and discomfort.

Cognitive

In cognitive theory, avoidance interferes with reappraisals of negative thought patterns and schema, thereby perpetuating distorted beliefs. These distorted beliefs are thought to contribute and maintain many types of psychopathology.

Third-Wave Cognitive-Behavioural

The concept of EA is explicitly described and targeted in more recent CBT modalities including acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), functional analytic psychotherapy (FAP), and behavioural activation (BA).

Associated Problems

Distress is an inextricable part of life; therefore, avoidance is often only a temporary solution.
Avoidance reinforces the notion that discomfort, distress and anxiety are bad, or dangerous.
Sustaining avoidance often requires effort and energy.
Avoidance limits one’s focus at the expense of fully experiencing what is going on in the present.
Avoidance may get in the way of other important, valued aspects of life.

Empirical Evidence

Laboratory-based thought suppression studies suggest avoidance is paradoxical, in that concerted attempts at suppression of a particular thought often leads to an increase of that thought.
Studies examining emotional suppression and pain suppression suggest that avoidance is ineffective in the long-run. Conversely, expressing unpleasant emotion results in short-term increases in arousal, but long-term decreases in arousal.
Exposure-based therapy techniques have been shown to be effective in treating a wide range of psychiatric disorders.
Numerous self-report studies have linked EA and related constructs (avoidance coping, thought suppression) to psychopathology and other forms of dysfunction.

Relevance to Psychopathology

Seemingly disparate forms of pathological behaviour can be understood by their common function (i.e., attempts to avoid distress). Some examples can be seen in the Table below.

Diagnosis	Example Behaviours	Target of Avoidance
Major Depressive Disorder	Isolation/suicide	Feelings of sadness, guilt, and/or low self-worth.
PTSD	Avoiding trauma reminders, hypervigilance	Memories, anxiety, concerns of safety.
Social Phobia	Avoiding social situations	Anxiety, concerns of judgement from others.
Panic Disorder	Avoiding situations that might induce panic	Fear, physiological sensations.
Agoraphobia	Restricting travel outside of home or other ‘safe areas’	Anxiety, fear of having symptoms of panic.
Obsessive-Compulsive Disorder	Checking/rituals	Worry of consequences (e.g. contamination).
Substance Use Disorders	Abusing alcohol/drugs	Emotions, memories, withdrawal symptoms
Eating Disorders	Restricting food intake, purging	Worry about becoming ‘overweight’, fear of losing control.
Borderline Personality Disorder	Self-harm (e.g. cutting)	High emotional arousal.

Relevance to Quality of Life

Perhaps the most significant impact of EA is its potential to disrupt and interfere with important, valued aspects of an individual’s life. That is, EA is seen as particularly problematic when it occurs at the expense of a person’s deeply held values. Some examples include:

Putting off an important task because of the discomfort it evokes.
Not taking advantage of an important opportunity due to attempts to avoid worries of failure or disappointment.
Not engaging in physical activity/exercise, meaningful hobbies, or other recreational activities due to the effort they demand.
Avoiding social gatherings or interactions with others because of the anxiety and negative thoughts they evoke.
Not being a full participant in social gatherings due to attempts to regulate anxiety relating to how others are perceiving you.
Being unable to fully engage in meaningful conversations with others because one is scanning for signs of danger in the environment (attempting to avoid feeling “unsafe”).
Inability to “connect” and sustain a close relationship because of attempts to avoid feelings of vulnerability.
Staying in a “bad” relationship to try to avoid discomfort, guilt, and potential feelings of loneliness a break-up might entail.
Losing a marriage or contact with children due to an unwillingness to experience uncomfortable feelings (e.g. achieved through drug or alcohol abuse) or symptoms of withdrawal.
Not attending an important graduation, wedding, funeral, or other family event to try to avoid anxiety or symptoms of panic.
Engaging in self-destructive behaviours in an attempt to avoid feelings of boredom, emptiness, worthlessness.
Not functioning or taking care of basic responsibilities (e.g. personal hygiene, waking up, showing up to work, shopping for food) because of the effort they demand and/or distress they evoke.
Spending so much time attempting to avoid discomfort that one has little time for anyone or anything else in life.

Measurement

Self-Report

The Acceptance and Action Questionnaire (AAQ) was the first self-report measure explicitly designed to measure EA, but has since been re-conceptualised as a measure of “psychological flexibility”. The 62-item Multidimensional Experiential Avoidance Questionnaire (MEAQ) was developed to measure different aspects of EA. The Brief Experiential Avoidance Questionnaire (BEAQ) is a 15-item measure developed using MEAQ items, which has become the most widely used measure of experiential avoidance.

Book: DBT Skills Training Manual

Published on 03/19/2021 by Andrew Marshall1 Comment

Book Title:

DBT Skills Training Manual.

Author(s): Marsha M Linehan.

Year: 2015.

Edition: Second (2nd).

Publisher: Guildford Press.

Type(s): Hardcover, Paperback, and Kindle.

Synopsis:

From Marsha M. Linehan – the developer of dialectical behaviour therapy (DBT) – this comprehensive resource provides vital tools for implementing DBT skills training. The reproducible teaching notes, handouts, and worksheets used for over two decades by hundreds of thousands of practitioners have been significantly revised and expanded to reflect important research and clinical advances. The book gives complete instructions for orienting clients to DBT, plus teaching notes for the full range of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills. Handouts and worksheets are not included in the book; purchasers get access to a Web page where they can download and print all the handouts and worksheets discussed, as well as the teaching notes. The companion volume is available separately: DBT Skills Training Handouts and Worksheets, Second Edition.

New to This Edition

Handouts and worksheets (available online and in the companion volume) have been completely revised and dozens more added – more than 225 in all.
Each module has been expanded with additional skills.
Multiple alternative worksheets to tailor treatment to each client.
More extensive reproducible teaching notes (provided in the book and online), with numerous clinical examples.
Curricula for running skills training groups of different durations and with specific populations, such as adolescents and clients with substance use problems.
Linehan provides a concise overview of “How to Use This Book.”

See also DBT Skills Training Handouts and Worksheets, Second Edition, a spiral-bound 8 1/2″ x 11″ volume containing all of the handouts and worksheets and featuring brief introductions to each module written expressly for clients.

Book: The Dialectical Behaviour Therapy Skills Workbook

Published on 03/19/2021 by Andrew MarshallLeave a comment

Book Title:

The Dialectical Behaviour Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.

Author(s): Matthew McKay and Jeffrey C. Wood.

Year: 2019.

Edition: Second (2nd).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

A clear and effective approach to learning evidence-based DBT skills-now in a fully revised and updated second edition.

Do you have trouble managing your emotions? First developed by Marsha M. Linehan for treating borderline personality disorder, dialectical behaviour therapy (DBT) has proven effective as treatment for a range of other mental health problems, and can greatly improve your ability to handle distress without losing control and acting destructively.

However, to make use of these techniques, you need to build skills in four key areas: distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness.

The Dialectical Behavior Therapy Skills Workbook, a collaborative effort from three esteemed authors, offers
evidence-based, step-by-step exercises for learning these concepts and putting them to work for real and lasting change. Start by working on the introductory exercises and, after making progress, move on to the advanced-skills chapters.
Whether you’re a mental health professional or a general reader, you’ll benefit from this clear and practical guide to better managing your emotions.

This fully revised and updated second edition also includes new chapters on cognitive rehearsal, distress tolerance, and self-compassion. Once you have completed the exercises in this book and are ready to move on to the next level, check out the authors’ new book, The New Happiness Workbook.

Book: DBT Skills Training Handouts and Worksheets

Published on 03/19/202103/19/2021 by Andrew Marshall1 Comment

Book Title:

DBT Skills Training Handouts and Worksheets.

Author(s): Marsha M Linehan.

Year: 2014.

Edition: Second (2nd).

Publisher: Guildford Press.

Type(s): Paperback and Kindle.

Synopsis:

Featuring more than 225 user-friendly handouts and worksheets, this is an essential resource for clients learning dialectical behaviour therapy (DBT) skills, and those who treat them. All of the handouts and worksheets discussed in Marsha M. Linehan’s DBT Skills Training Manual, Second Edition, are provided, together with brief introductions to each module written expressly for clients.

Originally developed to treat borderline personality disorder, DBT has been demonstrated effective in treatment of a wide range of psychological and emotional problems. No single skills training programme will include all of the handouts and worksheets in this book; clients get quick, easy access to the tools recommended to meet their particular needs. The 8 1/2″ x 11″ format and spiral binding facilitate photocopying. Purchasers also get access to a Web page where they can download and print additional copies of the handouts and worksheets.

Mental health professionals, see also the author’s DBT Skills Training Manual, Second Edition, which provides complete instructions for teaching the skills. Also available: Cognitive-Behavioural Treatment of Borderline Personality Disorder, the authoritative presentation of DBT, and Linehan’s instructive skills training videos for clients – Crisis Survival Skills: Part One, Crisis Survival Skills: Part Two, From Suffering to Freedom, This One Moment, and Opposite Action.

Refer to DBT Skills Training book.

Book: Cognitive-Behavioural Treatment of Borderline Personality Disorder

Published on 03/19/2021 by Andrew MarshallLeave a comment

Book Title:

Cognitive-Behavioural Treatment of Borderline Personality Disorder (Diagnosis and Treatment of Mental Disorders).

Author(s): Marsha M. Linehan.

Year: 1993.

Edition: First (1st).

Publisher: Guildford Press.

Type(s): Hardcover and Kindle.

Synopsis:

For the average clinician, individuals with borderline personality disorder (BPD) often represent the most challenging, seemingly insoluble cases. This volume is the authoritative presentation of dialectical behaviour therapy (DBT), Marsha M. Linehan’s comprehensive, integrated approach to treating individuals with BPD. DBT was the first psychotherapy shown in controlled trials to be effective with BPD. It has since been adapted and tested for a wide range of other difficult-to-treat disorders involving emotion dysregulation. While focusing on BPD, this book is essential reading for clinicians delivering DBT to any clients with complex, multiple problems.

Companion volumes: The latest developments in DBT skills training, together with essential materials for teaching the full range of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills, are presented in Linehan’s DBT Skills Training Manual, Second Edition, and DBT Skills Training Handouts and Worksheets, Second Edition. Also available: Linehan’s instructive skills training videos for clients – Crisis Survival Skills: Part One, Crisis Survival Skills: Part Two, From Suffering to Freedom, This One Moment, and Opposite Action.

Book: Emotion Efficacy Therapy

Published on 02/23/2021 by Andrew MarshallLeave a comment

Book Title:

Emotion Efficacy Therapy: A Brief, Exposure-Based Treatment for Emotion Regulation Integrating ACT and DBT.

Author(s): Matthew McKay (PhD) and Aprilia West (PSyD, MT).

Year: 2016.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

If you treat clients with emotion regulation disorders – including depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder, and borderline personality disorder (BPD) – you know how important it is for these clients to take control of their emotions and choose their actions in accordance with their values. To help, emotion efficacy therapy (EET) provides a new, theoretically-driven, contextually-based treatment that integrates components from acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT) into an exposure-based protocol. In doing so, EET targets the transdiagnostic drivers of experiential avoidance and distress intolerance to increase emotional efficacy.

This step-by-step manual will show you how to help your clients confront and accept their pain, and learn to apply new adaptive responses to emotional triggers. Using a brief treatment that lasts as little as eight weeks, you will be able to help your clients understand and develop a new relationship with their emotions, learn how to have mastery over their emotional experience, practice values-based action in the midst of being emotionally triggered, and stop intense emotions from getting in the way of creating the life they want.

Using the transdiagnostic, exposure-based approach in this book, you can help your clients manage difficult emotions, curb negative reactions, and start living a better life. This book is a game changer for emotion exposure treatment!

Book: Pocket Therapy for Emotional Balance

Published on 02/11/2021 by Andrew MarshallLeave a comment

Book Title:

Pocket Therapy for Emotional Balance: Quick DBT Skills to Manage Intense Emotions (New Harbinger Pocket Therapy).

Author(s): Matthew McKay (PhD), Jeffrey C. Wood (PSyd), and Jeffrey Brantley (MD).

Year: 2020.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

In Pocket Therapy for Emotional Balance, three clinical psychologists and authors of The Dialectical Behaviour Therapy Skills Workbook offer quick, evidence-based tips and tools for managing intense emotions in the moment. Using this handy, take-anywhere guide, readers will find freedom from overwhelming thoughts and feelings, find a sense of calm, and live a more balanced life.

Bite-sized, evidence based tips and tools for managing intense emotions in the moment-from the authors of The Dialectical Behaviour Therapy Skills Workbook! Sometimes emotions can feel like a big, powerful tidal wave that will sweep you away. And the more you try to suppress or put a lid on these emotions, the more overwhelming they get. So, how can you feel better when difficult emotions threaten to wash over you?

In this take-anywhere pocket guide, clinical psychologists and authors Matt McKay, Jeffrey Wood, and Jeffrey Brantley offer quick and simple strategies based in dialectical behaviour therapy (DBT) to help you take charge of your emotions and start living the life you want. Using this handy little book, you’ll find freedom from overwhelming thoughts and feelings, discover a sense of lasting calm, improve your relationships, and feel more at peace with the world and yourself. If you are looking for small, easy ways to manage your emotions on the go, put this compact guide in your coat pocket, your purse, on your nightstand, or anywhere for quick and soothing relief.

Book: The Mindfulness Solution for Intense Emotions

Published on 03/04/2020 by Andrew MarshallLeave a comment

Book Title:

The Mindfulness Solution for Intense Emotions: Take Control of Borderline Personality Disorder with DBT.

Author(s): Cedar R. Koons.

Year: 2016.

Edition: First.

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

If you suffer from intense emotions, you are not alone. Millions of Americans are diagnosed with emotion regulation disorders, such as borderline personality disorder (BPD) and other co-morbid conditions like post traumatic stress disorder (PTSD), and severe depression.

Developed by Marsha Linehan, DBT is a clinically proven, evidence-based treatment for intense emotions that can help you start feeling better right away.

This is the first consumer-friendly book to offer Linehan’s new mindfulness skills to help you take control of your emotions, once and for all.

In this book, you will learn seven powerful skills that highlight the unique connection between mindfulness and emotion regulation.

Each skill is designed to help you find focus in the present moment, reduce impulsive behaviour, and increase a sense of connection to your true self, even during times of extreme stress or difficulty.

You can feel calmer, more grounded, and centred. If you are ready, the mindfulness practices in this book will help you move away from a chaotic, emotion-driven life and cultivate a focused, intentional one.