Dialectical Behavior Therapy (DBT) is a form of cognitive-behavioral therapy that involves powerful strategies for change balanced with acceptance and compassion. It is a comprehensive treatment program designed to address the needs of clients with severe and complex emotion dysregulation problems. Emotion dysregulation is at the core of a variety of disorders that result in extreme, impulsive, or highly dysfunctional behaviors, and DBT utilizes strategies that directly and thoroughly address these emotion challenges.
What is emotion dysregulation?
Emotion dysregulation is characterized by emotion episodes that are frequent, intense, and long-lasting because the person is highly emotionally sensitive and also has considerable difficulty tolerating and controlling their emotions and their emotion-driven behaviors. Many emotions often get dysregulated across a wide range of situations, often leading to impulsive behaviors and relationship problems. Individuals who struggle with dysregulation often feel ashamed to experience basic emotions like sadness or anger, even when they are normal reactions to events. Because they invalidate and suppress their emotions, they alternate between extremes of experiencing and blocking emotions. Many suffer so intensely that they try to end their own lives.
DBT is especially effective for people with the following problems:
Painful emotions that are experienced as intolerable
Quickly shifting between different emotions and moods
Feeling controlled by your emotions
Intense self-hatred and shame
Prone to irritability and anger
DBT also addresses other difficulties:
Intense fears of abandonment and sensitivity to criticism
A profound sense of emptiness or emotional numbness
Self-defeating behaviors that are impulsive or destructive
What Are the Main Strategies that Make DBT Effective?
DBT utilizes scientifically-established strategies for improving emotion regulation, and the approach is called “dialectical” because it seeks to balance therapy strategies that appear opposite. Specifically, it includes many strategies aimed to change the individual's behaviors, thoughts, emotions, relationships, and life problems, while at the same time the therapist validates that the person and their struggles make complete sense, helping the person to fully accept themself and their emotions. The change strategies are cognitive-behavioral therapy (CBT) strategies, including problem-solving, skills training, developing more effective thinking, behavioral activation, and exposure therapy. The primary acceptance skill is mindfulness, which involves learning to focus your attention, and learning to see things for what they are, including your thoughts, emotions, and other people, without getting caught up in assumptions, interpretations, or judgments. Mindfulness is used as a way to decrease suffering by developing the ability to better tolerate emotional pain and accept yourself, your past, and your current life.
DBT is called “behavior therapy” because it is based on the belief that the most effective way for clients to make substantial changes in their emotion regulation is to immediately stop serious out-of-control behaviors such as suicidal and self-injurious behaviors, alcohol and drug abuse, angry behaviors, and overuse of psychiatric hospitalizations and emergency services. The initial goals of treatment are primarily to help the client achieve stability and behavioral control, and to acquire the necessary capabilities to achieve these goals, especially distress tolerance. Immediately, there is a focus on increasing behaviors that are effective for having a life worth living, especially interpersonal relationships and regular meaningful productive activities, including paid employment or volunteer work.
Components of Standard DBT
DBT individual therapy
Focused on enhancing client motivation and helping clients to apply the skills to specific challenges and events in their lives. Standard DBT individual therapy occurs once a week for as long as the client is in therapy and runs concurrently with skills groups.
DBT skills training group
Focused on enhancing clients' capabilities by teaching them behavioral skills. The group is run like a class where the group leader teaches the skills and assigns homework for clients to practice using the skills in their everyday lives. Groups meet on a weekly basis and it takes about 25 weeks to get through the full skills curriculum, which is often repeated to create a 1-year program. Briefer schedules that teach only a subset of the skills have also been developed for particular populations and settings.
The skills taught in DBT are:
Mindfulness - staying present in the moment without judgment
Distress Tolerance - getting through the tough times without making things worse
Emotion Regulation - learning to understand and manage your emotions
Interpersonal Effectiveness - asserting your needs, communicating effectively and maintaining relationships
DBT phone coaching
Focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most.
DBT therapist consultation team
Intended to support DBT providers in their work with people with severe, complex, difficult-to-treat disorders. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. Teams typically meet weekly and are composed of individual therapists and group leaders who share responsibility for each client's care.
Prioritization of Treatment Targets
When there are multiple problems in a particular week, DBT addresses them in the following order of priority:
Life-threatening behaviors - First and foremost, behaviors that could lead to the client's death are targeted, including all forms of suicidal and non-suicidal self-injury, suicidal ideation, suicide communications, and other behaviors engaged in for the purpose of causing bodily harm.
Therapy-interfering behaviors - This includes any behavior that interferes with the client receiving effective treatment. These behaviors can be on the part of the client and/or the therapist, such as coming late to sessions, canceling appointments, and being non-collaborative in working towards treatment goals.
Quality of life behaviors - This category includes any other type of behavior that interferes with clients having a reasonable quality of life, such as mental disorders, relationship problems, and financial or housing crises.
Skills acquisition - This refers to the need for clients to learn new skillful behaviors to replace ineffective behaviors and help them achieve their goals.
Within a session, presenting problems are addressed in the above order. For example, if the client is expressing a wish to commit suicide and reports recurrent binge eating, the therapist will target the suicidal behaviors first. The underlying assumption is that DBT will be ineffective if the client is dead or refuses to attend treatment sessions.
Stages of Treatment
DBT is divided into four stages of treatment. Stages are defined by the severity of the client's behaviors, and therapists work with their clients to reach the goals of each stage in their progress toward having a life that they experience as worth living.
In Stage 1, the client is miserable and their behavior is out of control: they may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When clients first start DBT treatment, they often describe their experience of their mental illness as "being in hell." The goal of Stage 1 is for the client to move from being out of control to achieving behavioral control.
In Stage 2, they're living a life of quiet desperation: their behavior is under control but they continue to suffer, often due to past trauma and invalidation. Their emotional experience is inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.
In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that the client leads a life of ordinary happiness and unhappiness.
For some people, a Stage 4 is needed: finding a deeper meaning through a spiritual existence. Linehan has posited a fourth stage specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.
How effective is DBT?
Research has shown DBT to be effective in reducing suicidal behavior, non-suicidal self-injury, psychiatric hospitalization, treatment dropout, substance use, anger, and depression and improving functioning. For a review of the research on DBT, click here.
In this video, DBT Developer and Behavioral Tech founder Dr. Marsha Linehan describes the amazing changes she's seen in people who have received DBT.
Why not Pursue Standard Cognitive Behavioral Therapy?
Dr. Linehan developed DBT based on her failed attempts to treat patients with severe dysregulation, including chronic self-injury and suicidality. When she and her research team applied standard CBT, they encountered numerous problems with its use. Three were particularly troublesome:
Clients receiving CBT found the unrelenting focus on change inherent to CBT to be invalidating. Clients responded by withdrawing from treatment, becoming angry, or vacillating between the two. This resulted in a high drop-out rate. If clients do not attend treatment, they cannot benefit from treatment.
Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. For example, the research team noticed through its review of taped sessions that therapists would "back off" pushing for change of behavior when the client's response was one of anger, emotional withdrawal, shame, or threats of self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they did not want to discuss to one they did want to discuss.
The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients (suicide attempts, self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, and more) and have session time devoted to helping the client learn and apply the skills.
In response to these problems with standard CBT, Linehan made significant modifications to standard CBT, including adding acceptance and validation strategies to the change-based strategies of CBT, adding skills training as a separate component that occurs concurrent with individual therapy, and adding the DBT therapist consultation team.
Guidelines for Choosing a DBT Therapist
The nonprofit organization Treatment and Research Advancements for Borderline personality Disorder (TARA) provides guidelines for choosing a DBT therapist. The mission of TARA is to foster education, research, and advocacy relevant for Borderline Personality Disorder (BPD) and other personality disorders. It targets mental health professionals, consumers of mental health services, families and/or the community at large in order to reduce stigma and increase awareness of personality disorders and their treatments.
How to Know if a Therapist Does DBT?
These are the questions you should ask:
Have you completed a 10 day intensive DBT training ?
Are you a member of a DBT consultation team ?
Have you been supervised by an expert DBT therapist?
Are you familiar with the main sets of DBT strategies (CBT, validation, dialectics)
Do you teach skills, practice behavior analysis, review diary cards?
Do you do phone coaching?
How many clients have you treated using DBT?
The answer to these questions should be yes. You have a right to check on the therapist’s credentials; to know if the therapist is licensed in his/her state; to know the extent and nature of the therapist’s education and training; the extent of the therapist’s experience in treating clients with similar problems; the therapist’s arrangements for coverage or emergency contacts.
Why is it Important to See a Trained DBT Therapist?
DBT may be the most hopeful and helpful of any new therapy available for people with BPD. Many people with BPD have problems trusting others, have “failed in treatment” or have been dropped by former therapists. When DBT is not done as designed, the results may not be the same, causing the person with BPD to lose hope and trust and then be reluctant to ever try DBT again. If DBT is not practiced according to the research model that produces effective change but is practiced “my way” by a therapist without adequate training, it probably won’t produce the same kind of results as the research programs. Outcomes from this kind of DBT will not justify additional DBT training or new DBT programs in the community. Currently, Dr. Linehan is working on a way to certify therapists who practice DBT so that people can determine if a therapist is truly qualified to practice DBT.