Dialectical Behavior Therapy
What is DBT?
Dialectical behavioral therapy (DBT) is a branch of psychotherapy that is rooted in the principles of cognitive-behavioral therapy (CBT) with several modifications and additions. The treatment style was developed originally to aid those with borderline personality disorders (BPD) but has found success treating conditions that are related to or independent from BPD including:
- Depressive disorders.
- Bipolar disorder.
- Posttraumatic stress disorder.
- Anxiety disorders.
- Eating disorders.
- Substance use disorders.
Like CBT, DBT is a type of treatment that is studied and researched to demonstrate its efficacy in these types of situations. It is shown to be more effective than other types of treatment or no treatment at all.
History and Development
DBT was created in the late 1980s and early 1990s by Dr. Marsha Linehan. While working with clients that engaged in self-injury and had suicidal thoughts, she found the standard CBT principles to be limiting, as they maintained a constant emphasis on changing these behaviors. Because of this, she developed DBT to add validation/acceptance and dialectics (explained below) into the CBT frame.
The validation is added to balance the desire for change with acceptance on behalf of the therapist and client. Validation is not used to permit or encourage unwanted behaviors, only to offer an understanding of why the client would act in these ways.
The addition of dialectics expands on the notion of validation. Dialectics is the idea that:
- Everything is connected.
- Change is constant.
- Opposing forces can be brought together to find balance. This is illustrated in the view that acceptance and taking action to change are unified opposites.
Video: What Is Dialectical Behavior Therapy?
The following video will provide a short but comprehensive overview of DBT - what it means, its goals, and what to expect.
Credit: UC San Francisco (UCSF)
Views and Beliefs
DBT shares many views and beliefs with CBT, noting that unwanted thoughts and behaviors are learned and reinforced. DBT believes that the interaction between two factors increases the chances of persistent mental health issues:
- Emotional vulnerability.
- Invalidating environments.
Someone that is emotionally vulnerable will feel like their life is turbulent and extreme, and they will be quick to respond with strong emotional reactions. This vulnerability can be caused by traumatic events or from the individual’s natural disposition (i.e., genetics).
An invalidating environment is where someone is consistently made felt as though that their feelings are wrong or “bad.” A lack of kindness, respect, and acceptance can produce an invalidating environment.
DBT includes a level of optimism that is not found usually in CBT. DBT conveys that:
- People are doing the best they can in their current situation.
- They want situations to improve.
- People are capable of learning new behaviors to change their lives.
- The problems are not always the person’s fault, but it is their duty to resolve it.
Goals of DBT
DBT includes 4 main goals of treatment for the client that are divided into stages.
The Four Main Goals of Treatment
Stage 1: Transitioning from out of control to in control.
This stage is focused on reducing reckless and dangerous behaviors (e.g., self-harming) while building skills that include increasing attention, improving relationships, understanding emotions, and managing distress.
Stage 2: Transitioning from emotional unavailability to emotional engagement.
People will shut down emotions that are too overwhelming to manage. The goal in stage 2 is to fully and accurately experience feelings without relying on avoidance or escape.
Stage 3: Building an ordinary life and solving ordinary problems.
During this stage, the client will focus on problems that are more common and expected. Rather than targeting extreme symptoms like chronic suicidality, the treatment will focus on the relationship conflicts, problems at work, life goals, and more mild mental health symptoms that most people experience.
Stage 4: Transitioning from feeling incomplete to feeling complete/connected.
The previous stages were focused on reducing the unwanted symptoms, but the goal of the final stage is to allow the client to move towards happiness in the future. DBT believes that finding a sense of connection to the world facilitates this goal.
Methods of Change
In DBT, the therapist controls all aspects of treatment planning and movement. The therapist will establish and organize the components listed below. Beyond that, the therapist will direct other care including medication management, substance use treatment, case management, and vocational rehabilitation when needed.
To successfully accomplish the goals of treatment, DBT uses a specialized treatment approach. The approach is comprised of 4 parts with three involving the client and one focusing on the therapist. They are:
- DBT group therapy. A major focus of DBT is the use of a skills group where a client will meet with a group of other people that exhibit similar self-destructive symptoms. The skills group will appear like a schoolroom where the therapist will teach a particular topic or skill during the session and assign follow-up homework for the client to practice between sessions. These weekly groups generally last for 2.5 hours over 24 weeks. At times, the groups are broken into four six-week sessions that focus on one skill only.
- DBT individual therapy. This individual treatment will address past and present client issues as they occur. In some cases, the individual therapist will be the group therapist, but it could be a different therapist depending on the treatment center. Individual therapy sessions will last for about an hour and occur weekly.
- DBT phone coaching. The therapists will make themselves available to the client to assist with issues as they present during time away from treatment. Like with other treatment styles, it will not be the job of the therapist to instruct the client on what to do. Rather, the therapist will guide the client through options and available resources to improve decision-making.
- DBT therapist consultation. DBT is an intense course of treatment for the client. The same intensity is present for the therapist as well. To ensure the best treatment is being prescribed and followed through, therapists attend consultation in group or individual settings. These act as a support system to the therapist to discuss their clients, their progress, and the therapists’ reactions. When the therapist is well supported, he can better care for the client. Other theoretical orientations recommend supervision, but DBT is one of a few that demand this focus on the therapist.
As mentioned, DBT is focused on creating an effective environment for the client to learn and practice skills. The primary skills addressed in DBT are:
- Mindfulness. This is the act of being completely aware and engaged in one’s current setting. People with mental health or substance use issues often spend increased time distracting themselves, thinking about the past, or worrying about the future. Mindfulness is the practice of being fully immersed in the here and now, with kindness and curiosity towards one’s current experience.
- Distress tolerance. When people experience distress, there is an urge to reduce or change it immediately. Using a substance during periods of stress is an example of an unhealthy way to manage distress. Distress tolerance teaches how to accept and tolerate distress rather than escape from it.
- Interpersonal effectiveness. When communication and conflict resolution skills are lacking, problems increase. DBT teaches people to learn how to have happier, more fulfilling relationships through effective interactions with others.
- Emotional regulation. This is another example of dialectics. Distress tolerance moves towards acceptance while emotional regulation works to identify unwanted feelings and find ways to change them.
These skills are so effective that other styles of therapy have borrowed them and currently use them in a number of settings. People that are interested in DBT but cannot commit to the full treatment plan (including group and individual sessions) can still benefit from these skills.
DBT has been shown to help clients invest and remain engaged in sessions.
Even though DBT is relatively young in the world of psychology, it has become the standard treatment for borderline personality disorder (BPD). Over the years, its efficacy has spread to include treatment of many self-destructive behaviors like self-injury and substance abuse.
The treatment works to improve the client’s well-being even when he does not meet the criteria for a mental health diagnosis. DBT has been shown to help clients invest and remain engaged in sessions.
Another positive about DBT is that all of the support for the style is backed by scientific evidence. It does not base its accomplishments on anecdotal information collected over the years. Many of the findings related to DBT are available here.
Finding a DBT Therapist
Depending on your location, finding a therapist trained in DBT should not be difficult. Because of its reputation for success, even therapists that were trained before DBT existed have attended trainings on the subject. The institute named for the creator of DBT offers a DBT therapist directory to locate a therapist that completed their training.
- Dialectical Behavior Therapy Frequently Asked Questions. (n.d.). Retrieved November 5, 2015, from http://behavioraltech.org/downloads/dbtFaq_Cons.pdf
- What is DBT? (n.d.). Retrieved November 5, 2015, from http://behavioraltech.org/resources/whatisdbt.cfm
- Solof, B. (2013). The therapist's guide to addiction medicine: A handbook for addiction counselors and therapists. Las Vegas, NV: Central Recovery Press.