Dialectical Behavior Therapy

Older woman looking into flower box from windowDialectical behavior therapy (DBT), a comprehensive cognitive behavioral treatment, aims to treat individuals who see little or no improvement with other models of therapy. This treatment focuses on problem solving and acceptance-based strategies within a framework of dialectical methods. The term dialectical refers to the processes that synthesize opposite concepts such as change and acceptance.

Certified practitioners of DBT offer acceptance and support to people in therapy, many of whom have conditions described as "difficult to treat," as they work to develop techniques in order to achieve goals, greater overall mental and emotional well-being, and lasting positive change.

What Is Dialectical Behavior Therapy?

Originally designed as a treatment for people experiencing chronic suicidal thoughts as a symptom of borderline personality, DBT is currently used to treat people who experience an array of chronic or severe mental health issues, including self-harm, eating and food issuesaddiction, and posttraumatic stress, as well as borderline personality. 

DBT, which can be used in a variety of mental health settings, incorporates the following five components:

  1. Capability enhancement: DBT provides opportunities for the development of existing skills. In treatment, four basic skill sets are taught: Emotion regulation, mindfulness, interpersonal effectiveness, and distress tolerance.
  2. Generalization: DBT therapists use various techniques to encourage the transfer of learned skills across all settings. People in therapy may learn to apply what they have learned at home, at school, at work, and in the community. For example, a therapist might ask the person in treatment to talk with a partner about a conflict while using emotion regulation skills before and after the discussion.
  3. Motivational enhancement: DBT implements individualized behavioral treatment plans in order to facilitate the reduction of problematic behaviors that might negatively affect quality of life. For example, therapists might utilize self-monitoring tracking sheets so individual sessions can be adapted to address the most severe issues first.
  4. Capability and motivational enhancement of therapists: Because DBT is often provided to people who experience chronic, severe, and intense mental health issues, therapists receive a great deal of supervision and support to prevent things like vicarious traumatization or burnout. For example, treatment-team meetings are held frequently to give therapists a space to provide and receive support, training, and clinical guidance.
  5. Structuring of the environment: A goal of therapy is often to ensure positive, adaptive behaviors are reinforced across all environmental settings. For example, if an individual participates in multiple treatment programs within one agency, the therapist might make sure each program was set up to reinforce all the positive skills and behaviors learned.

The standard form of DBT consists of individual therapy, skills training group, phone coaching, and a therapist consultation team. Those in standard DBT attend therapy and a skills training group weekly. The groups are designed to help those in treatment develop behavioral skills through group work and homework assignments. These assignments provide individuals with the opportunity to practice learned skills in day-to-day life. Phone coaching is also an important component of DBT, as it allows people in treatment to reach their therapist for support when a challenging situation presents itself between sessions. 

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Due to the complexity and severity of the issues faced by many individuals participating in DBT, a consultation team is considered essential for DBT providers. The team, made up of group leaders and individual therapists, can offer support, motivation, and therapy to the therapists working with difficult issues. 

Development and History

DBT was developed by Marsha Linehan in the 1970s through her work with two mental health populations: people experiencing chronic thoughts of suicide and people diagnosed with borderline personality disorder. Linehan, intrigued by the building reputation of cognitive behavioral therapy (CBT), decided to utilize standard CBT in her practice. After conducting research relative to the effectiveness of CBT in her chosen populations, Linehan and her colleagues experienced difficulties. They discovered three major problems with the application of standard CBT:

  1. Participants experienced the change-focused interventions as invalidating. These feelings of invalidation often resulted in withdrawal from therapy, aggression toward therapists, or a fluctuation of both extremes.
  2. Participants and therapists recreated a pattern of reinforcement in which good work was stalled and avoidance and redirection was encouraged. When therapists pushed for change, participants reacted in anger. When therapists allowed a subject change, participants reacted with warmth and positive feedback. This loop seemed to trick both therapist and participant into thinking they were on the right track, when in retrospect, they were not.
  3. Due to the intensity of crisis-related situations, therapists spent a good deal of time addressing safety concerns, such as suicidal thoughts or gestures, hostility and threats toward the therapist, or self-injurious behavior. Often, little time was left to teach coping skills or address behavioral functioning.

After analyzing these problems, Linehan devised several adaptations to CBT that directly addressed the needs of the population. Acceptance-based techniques were included to ensure participants felt supported and validated before they were asked to focus on change. In addition, dialectics were incorporated to allow therapists and participants in treatment to focus on the synthesis of polar opposites, such as acceptance and change, in order to avoid becoming trapped in patterns of extreme position-taking.

These and other adaptations were added to the practice of CBT, and in 1993, Linehan published the first official treatment manual, Cognitive Behavioral Treatment of Borderline Personality Disorder. Since then, the practice of DBT has grown in popularity. Over the last several decades, a great deal of research has supported the efficacy of DBT, and this form of therapy is now practiced in dozens of countries around the world. It is also listed in SAMHSA's Registry of Evidence-Based Programs and Practices.

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DBT Theory

Three major theoretical frameworks—a behavioral science biosocial model of the development of chronic mental health issues, the mindfulness practice of Zen Buddhism, and the philosophy of dialectics—combine to form the basis for DBT.

The biosocial theory attempts to explain how issues related to borderline personality develop. The theory posits that some people are born with a predisposition toward emotional vulnerability. Environments that lack solid structure and stability can intensify a person's negative emotional responses and influence patterns of interaction that become destructive. These patterns can harm relationships and functioning across all settings and often result in suicidal behavior and/or a diagnosis of borderline personality.

DBT draws mindfulness techniques from Zen Buddhism in order to use here-and-now presence of mind to help people in therapy objectively and calmly assess situations. Mindfulness training allows people to take stock of their current experience, evaluate the facts, and focus on one thing at a time.

Dialectics are used to support both the therapist and person in treatment in pulling from both extremes of any issue. Therapists use dialectics to help people accept the parts of themselves they do not like and to provide motivation and encouragement to address the change of those parts. Synthesizing polar opposites can reduce tension and help keep therapy moving forward.

Stages and Goals in DBT

This form of therapy is designed to systematically and comprehensively treat issues in order of severity. Because DBT was initially intended for people with suicidal tendencies and extreme emotional issues, treatment happens in stages so all concerns are eventually addressed. DBT involves the following four stages:

Findings from multiple studies reflect the efficacy of DBT, especially for the treatment of borderline personality issues, posttraumatic stress, self-harm, and suicidality.

  • Stage 1: The focus of this stage is stabilization. People in therapy may be dealing with things like suicidal thoughts, self-harm, or addiction. They often report feeling like they are at an all-time low point in their lives. Therapy is centered on safety and crisis intervention. The goal of this stage is to help people achieve some control over problematic behaviors.
  • Stage 2: In this stage, behaviors are more stable, but mental health issues may still be prevalent. Emotional pain is typically brought to the surface, and traumatic experiences are safely explored. The goal of this stage is for people in treatment to fully experience their emotional pain instead of silencing or burying it.
  • Stage 3: This stage focuses on enhancing the quality of life through maintenance of progress and reasonable goal-setting. The goal of this stage is the promotion of happiness and stability.
  • Stage 4: During this stage, therapists support people in advancing their lives to the next level. In therapy, people may improve upon learned skills or work toward spiritual fulfillment. The goal of this stage is to help people achieve and maintain an ongoing capacity for happiness and success.

How Effective Is DBT?

Findings from multiple studies reflect the efficacy of DBT, especially for the treatment of borderline personality issues, posttraumatic stress, self-harm, and suicidality.

  • A controlled trial conducted in an inpatient setting by Bohus et al. (2004) found people in therapy who received three months of DBT improved at a greater rate than those who received treatment as usual.
  • According to the SAMHSA National Registry of Evidence-based Programs and Practices, multiple controlled trials and independent studies found that one year of DBT decreased the instances of self-harming behaviors at a greater rate than alternative treatments. One such study reported that the participants who received DBT had only .55 incidents of self-injurious behavior over one month, compared to 9.33 incidents among those who received treatment as usual.
  • A study conducted by Linehan et al. (2006) suggests DBT may be effective in reducing suicide attempts. This study reported those who received DBT were half as likely to attempt suicide, had less psychiatric hospitalizations, and were less likely to drop out of treatment compared to those who received psychotherapy from professionals considered to be experts in the treatment of suicide and self-harm.

Certification Requirements for DBT

Some mental health practitioners offering DBT are not certified by the Linehan Board of Certification. The DBT-LBC program is the only developer-approved treatment program in the United States. Other programs may not provide practitioners with the necessary training to provide DBT effectively, and treatment from a provider who is not appropriately qualified may simply be unsuccessful but may also cause harm. 

Because DBT is a type of therapy currently in high demand, many practitioners may wish to offer this therapy in their practice. It is important for all practitioners who wish to offer DBT to obtain certification through the DBT-LBC program. Linehan herself discusses the importance of this certification in a live presentation for Family Action Network.

Practitioners interested in becoming certified must apply to take an exam, which is based on Linehan's training manual and skills training manual. Those who pass the exam are then required to submit first a treatment conceptualization for a person they wish to treat with DBT and then three videotapes of consecutive treatment sessions with that same individual. If this completed Work Product adheres to DBT standards, and the practitioner has demonstrated the ability to effectively provide DBT, the practitioner can then obtain certification as an Individual Therapist in DBT. 

Criticisms and Limitations of DBT

Although a significant body of research suggests DBT is an effective treatment for several mental health issues, there are a few criticisms and limitations.

  • Much of the available research on the efficacy of DBT included small sample sizes and focused on a specific sector of the mental health population. Critics argue more research should be done to determine whether DBT works well for those with varied or complex mental health concerns.
  • DBT uses a detailed manual and requires solid training to implement. In many of the research studies where DBT was found to be effective, the providers implementing the DBT treatment were doctoral-level students or higher, and most were trained by the developer, Marsha Linehan. This does not necessarily indicate a weakness in the model itself but underscores the intensive amount of training required to deliver the services as designed. Therefore, expanding the availability of comprehensive training could be useful for community mental health organizations.
  • Many of the DBT research trials lasted up to a year and some included a post-treatment follow-up interview. However, it was not determined whether therapeutic gains lasted beyond the post-treatment follow up interviews. Due to the chronic nature of the conditions treated, the field would likely benefit from more research measuring treatment gains long after the administration of DBT.

References:

  1. Blennerhassett, R. C., & O'Raghallaigh, J. W. (2005, March). Dialectical behaviour therapy in the treatment of borderline personality disorder. The British Journal of Psychiatry186(4), 278-280. doi:10.1192/bjp.186.4.278.
  2. Chapman, A. L. (2006, September). Dialectical Behavior Therapy Current Indications and Unique Elements. Psychiatry MMC,3(9), 62-68. Retrieved from National Center for Biotechnology Information (PMC2963469).
  3. Dimeff, L., & Linehan, M. (2001). Dialectical Behavior Therapy in a Nutshell. The California Psychologist, 10-13. Retrieved from http://www.dbtselfhelp.com/dbtinanutshell.pdf
  4. Intervention Summary - Dialectical Behavior Therapy. (2006, October). Retrieved from http://legacy.nreppadmin.net/ViewIntervention.aspx?id=36 
  5. Linehan, M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., & Korslund, K. E. (2006, July 1). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. JAMA Psychiatry63(7), 757-766. doi:10.1001/archpsyc.63.7.757.
  6. What is DBT?. (n.d.). In The Linehan Institute. Retrieved from http://behavioraltech.org/resources/whatisdbt.cfm
  7. Why Get Certified? (2014). Retrieved from http://www.dbt-lbc.org/index.php?page=101138

 

Last updated: 11-22-2016

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