DBT: Dialectal Behavioral Therapy

What is Dialectical Behavior Therapy (DBT)?

Dialectical Behavior Therapy (DBT) is a treatment that was originally designed specifically for individuals with self-harm behaviors, such as self-cutting, suicidal thoughts, urges to suicide, and suicide attempts. People with these behaviors sometimes meet criteria for a condition called borderline personality disorder (BPD). Individuals diagnosed with BPD also tend to struggle with other problems — depression, bipolar disorder, post-traumatic stress disorder (PTSD), anxiety, eating disorders, or alcohol and drug problems.

In our experience, the symptoms people experience exist for a good reason.  Their previous experience has led to their developing a manner of coping that helped them survive difficult circumstances.  Typically, people who benefit most from DBT are people who are highly sensitive by nature.  They feel their own emotions and their environment deeply and intensely.  Additionally, highly sensitive people often experience invalidation from their environment.  Other people, who are not as sensitive, may not understand or accept a more sensitive person's experience, and thus try to convince them that they are wrong or bad for feeling as they do.  When this happens often enough, it can cause a highly sensitive person to question and mistrust their own reality, their thoughts and feelings, in a way that creates distress.  This leads to a vicious cycle of feeling misunderstood, wrong, bad, and miserable.  This, in turn, leads to coping behaviors that tend to make the problems worse.  

DBT is a modification of cognitive behavioral therapy (CBT) developed by Dr. Marsha Linehan, who first tried applying standard CBT to people who engaged in self-injury, made suicide attempts, and struggled with out-of-control emotions. When CBT did not work as well as she thought it would, Dr. Linehan and her research team added other types of techniques until they developed a treatment that worked better.
DBT has been researched in clinical trials, and is now considered an “empirically supported” treatment. While the research on DBT was conducted initially with women who were diagnosed with BPD, DBT is now being used for individuals who struggle with:

  • self-mutilation such as cutting, burning, piercing for the experience of the piercing
  • disordered eating
  • weight and body image issues
  • serial problematic relationships
  • over-spending; financial disorders
  • chronic relapse with substances (after a period of sobriety)
  • isolation and chronic feelings of emptiness
  • emotional and behavioral distress related to issues of chronic pain
  • repeated or continued depression and/or anxiety

Standard DBT consists of three forms of therapy applied concurrently: individual therapy, skills group, and phone coaching. In individual therapy, clients receive once weekly individual sessions. Clients also must attend a weekly skills group for at least one year. In these skills groups, clients learn and practice four sets of important skills – Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Clients are also asked to call their individual therapists for skills coaching prior to hurting themselves. The therapist then walks them through alternatives to self-harm or suicidal behaviors.

The individual therapist is “in charge” of the treatment with standard DBT. It is the individual therapist’s job to coordinate the treatment with other professionals involved in the client’s therapy. The client’s job it so collaborate with the therapist, who keeps track of how the treatment is going, how things are going with everyone involved in the treatment, and whether or not the treatment is helping the client reach his or her goals. In some situations, DBT clients may also be on medications for problems like major depression bipolar disorder, are transient (short-term) psychotic episode.

How is DBT different from regular Cognitive Behavioral Therapy?

DBT is a modification of standard cognitive behavioral treatment. As briefly stated above, Marsha Linehan and her team of therapists used standard CBT techniques, such as skills training, homework assignments, symptom rating scales, and behavioral analysis in addressing clients’ problems. While these worked for some people, others were put off by the constant focus on change.

Clients felt the degree of their suffering was being underestimated, and that their therapists were overestimating how helpful they were being to their clients. As a result, clients dropped out of treatment, became very frustrated, shut down or all three. Linehan’s research team, which videotaped all their sessions with clients, began to notice new strategies that helped clients tolerate their pain and worked to make a “life worth living.”

As acceptance strategies were added to the change strategies, clients felt their therapists understood them much better. They stayed in treatment instead of dropping out, felt better about their relationships with their therapists, and improved faster.

The balance between acceptance and change strategies in therapy formed the fundamental “dialectic” that resulted in the treatment’s name. “Dialectic” means ‘weighing and integrating contradictory facts or ideas with a view to resolving apparent contradictions.’ In DBT, therapists and clients work hard to balance change with acceptance, two seemingly contradictory forces or strategies.

Likewise, in life outside therapy, people struggle to have balanced actions, feelings, and thoughts. We work to integrate both passionate feelings and logical thoughts. We put effort into meeting our own needs and wants while meeting the needs and wants of others who are important to us. We struggle to have the right mix of work and play.

In DBT, there are treatment strategies that are specifically dialectical; these strategies help both the therapist and the client get “unstuck” from extreme positions or from emphasizing too much change or too much acceptance. These strategies keep the therapy in balance, moving back and forth between acceptance and change in a way that helps the client reach his or her ultimate goals as quickly as possible.

Excerpted from http://behavioraltech.org/downloads/dbtFaq_Cons.pdf