ABSTRACT
DBT flexibly applies the treatment principles within a highly structured and comprehensive treatment programme as applying traditional cognitive-behavioural treatment to clients with a diagnosis of borderline personality disorder (BPD) and other complex presentations, which presents several challenges (Linehan, 1993a). Frequently, clients present varied problems from week to week, each of which may require a different CBT treatment protocol. For example, one week the client may report extensive panic attacks and avoidance of social activities; the following week, the presented problems are bingeing and vomiting; the week after the client presents with an acute suicidal crisis. The extent of comorbidity within the client population makes adhering to the procedure of any single traditional cognitive-behavioural treatment problematic and may account, in part, for the impaired effectiveness of such treatments for clients with a personality disorder diagnosis (Shea et al., 1990; Steiger & Stotland, 1996). Following a highly structured treatment protocol, with a clear and consistent therapeutic focus and a unified formulation, in the face of multiple and varied problems is almost impossible. Furthermore, clients diagnosed with BPD and other complex difficulties frequently present with therapy-interfering behaviours (e.g. not attending sessions, complaints, hostility towards the therapy, therapist, or both) that add to the challenge of delivering therapy. Under these circumstances, many therapists report a “war of attrition” occurring between the client and the therapist. The therapist persistently attempts and fails to implement the protocol, and the client deems the therapist’s efforts more and more irrelevant. Eventually, the therapist delivers the antithesis of a structured, focused intervention and instead follows the client impulsively, adding whatever strategy he or she thinks may prove helpful as a problem whizzes by. DBT endeavours to steer a dialectical course between these two extremes.
