ایجاد قابلیت ها با احتمالات: تکنیک های درمان مکمل در رفتار درمانی دیالکتیکی که منجر به تقویت تغییر رفتار می شود

Dialectical behavior therapy (DBT) has been shown to be effective in the treatment of borderline personality disorder (BPD), a disorder associated with poor functional outcomes and high utilization of behavioral health services. Contingency management strategies are one of the four primary change procedures in DBT. This paper provides an overview of the use of contingency management strategies in DBT with a particular focus on how adjunctive treatments can be utilized as a reinforcer for positive behavior change. We focus specifically on two adjunctive DBT treatments with evidence of efficacy, including the DBT Prolonged Exposure protocol (DBT PE), which targets PTSD, and DBT–Accepting the Challenges of Exiting the System (DBT-ACES), which targets getting off of psychiatric disability by obtaining and maintaining employment. This paper describes how contingency management strategies are used to help clients make the changes necessary to become eligible to receive these adjunctive treatments, as well as the process of clarifying and managing contingencies to maintain and increase adaptive behaviors as these treatments are implemented. Considerations for how DBT therapists and larger health systems can apply contingency management strategies to enhance behavioral capabilities in the treatment of individuals with BPD are discussed.

.

DBT PE and DBT-ACES are adjunctive treatments of DBT that make the availability of treatment contingent on behavior change. This appears to create significant positive changes in the lives of individuals with BPD, the most important of which is the quicker and more complete reduction of life-threatening behaviors in order to start these adjunctive treatments. Both treatments place emphasis on the benefit of exposure, the importance of not reinforcing phobic avoidance, utilizing skills in the client’s environment, and on creating more naturalistic environmental reinforcers. By employing more strategic and planned reinforcers in therapy, this leads the client to increase natural reinforcers in their life to enhance behavioral capabilities (i.e., planning for and accomplishing a DBT-ACES Career Development task will increase capabilities to plan for and accomplish a task at work). As in DBT, DBT-ACES and DBT PE therapists create an environment rich in reinforcement, with positive reinforcers delivered in response to behavior that indicates clinical progress, rather than provide reinforcers indiscriminately or immediately following maladaptive behaviors that are often maintained by their tendency to elicit validation or other reinforcing responses from the environment (Linehan, 1997). This is in contrast to the pattern seen in many health systems of providing extra therapy sessions or contact with providers following maladaptive client behaviors, such as suicide crisis behaviors, which often serves to inadvertently reinforce these behaviors (Koerner, 2012). This illustrates a primary dialectical tension within the DBT treatment model of working with the client to create a warm and supportive relationship that validates the client’s emotional experience while being careful to guard the therapeutic process from mood-dependent reactions that unintentionally reinforce maladaptive behaviors. The DBT therapist uses CM strategies frequently in session by identifying client behaviors as adaptive versus maladaptive as they occur in the moment, followed by a quick response involving positive reinforcement whenever possible. More formal contingency plans are identified and applied in a collaborative manner with the goal of shaping the client into becoming more active in creating and implementing their own behavioral plans. The DBT-ACES Career Development deadline is an example of a formal contingency plan to set up the client to build a life that is motivated by reinforcement instead of variable punishment and short-term relief with no long-term change. Individuals with BPD have a chronic pattern of engaging in mood-dependent behavior, which is often accompanied with a belief that one is unable to follow through with many steps to achieve greater quality of life. Both clients themselves, and others in their social network, are often surprised that if the client is held to task using contingencies, it can be possible to remain consistent in treatment, gradually tolerate increased stressors, block avoidance responses, and build in natural reinforcers into life outside of therapy. Clients whose behavior is shaped by CM and who find environments that reinforce them for being effective achieve more. Contingencies create capabilities and capabilities create a life worth living. As seen in these adjunctive treatments, clients are able to achieve many life goals including reducing posttraumatic stress responses or increasing employment, self-sufficiency, and financial independence.