Within this framework of stages, target hierarchies and modes of therapy a wide variety of therapeutic strategies and specific techniques is applied.
The core strategies in DBT are validation and problem solving. Attempts to facilitate change are surrounded by interventions that validate the patient’s behavior and responses as understandable in relation to her current life situation, and that show an understanding of her difficulties and suffering.
Problem solving focuses on the establishment of necessary skills. If the patient is not dealing with her problems effectively then it is to be anticipated either that she does not have the necessary skills to do so, or does have the skills but is prevented from using them. If she does not have the skills then she will need to learn them. This is the purpose of the skills training.
Having the skills, she may be prevented from using them in particular situations either because of environmental factors or because of emotional or cognitive problems getting in the way. To deal with these difficulties the following techniques may be applied in the course of therapy:
The principles of using these techniques are precisely those applying to their use in other contexts and will not be described in any detail. In DBT however they are used in a relatively informal way and interwoven into therapy. Linehan recommends that medication be prescribed by someone other than the primary therapist, although this may not always be practical.
Particular note should be made of the pervading application of contingency management throughout therapy, using the relationship with the therapist as the main reinforcer. In the session by session course of therapy care is taken to systematically reinforce targeted adaptive behaviors and to avoid reinforcing targeted maladaptive behaviors. This process is made quite overt to the patient, explaining that behavior which reinforced can be expected to increase. A clear distinction is made between the observed effect of reinforcement and the motivation of the behavior, pointing out that such a relationship between cause and effect does not imply that the behavior is being carried out deliberately in order to obtain the reinforcement. Didactic teaching and insight strategies may also be used to help the patient achieve an understanding of the factors that may be controlling her behavior.
The same contingency management approach is taken in dealing with behaviors that overstep the therapist’s personal limits in which case they are referred to as ‘observing limits procedures’. Problem solving and change strategies are again balanced dialectically by the use of validation strategies. It is important at every stage to convey to the patient that her behavior, including thoughts feelings and actions are understandable, even though they may be maladaptive or unhelpful.
Significant instances of targeted maladaptive behavior occurring since the last session (which should have been recorded on the diary card) are initially dealt with by carrying out a detailed behavioral analysis. In particular every single instance of suicidal or parasuicidal behavior is dealt with in this way. Such behavioral analysis is an important aspect of DBT and may take up a large proportion of therapy time.