Dialectical behavior therapy (DBT) is a therapy designed to help people suffering from mood disorders as well as those who need to change patterns of behavior that are not helpful, such as self-harm, suicidal ideation, and substance abuse. This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions. DBT assumes that people are doing their best but lack the skills needed to succeed, or are influenced by positive or negative reinforcement that interferes with their ability to function appropriately.
- What skills
- How skills
- Distress tolerance
- Emotion regulation
- Story of emotion
- Build mastery
- Opposite action
- Problem solving
- Letting go of emotional suffering
- Interpersonal effectiveness
- Diary cards
- Chain analysis
DBT is a modified form of cognitive behavioral therapy (CBT), that was developed in late 1980s by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT is now used in a variety of psychological treatments including treatment for traumatic brain injuries (TBI), eating disorders, and mood disorders. Research indicates that DBT might have some effect on patients who present varied symptoms and behaviors associated with spectrum mood disorders, including self-injury. Recent work also suggests its effectiveness with sexual abuse survivors and chemical dependency.
DBT combines standard cognitive behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.
Linehan observed "burn-out" in therapists after coping with "non-motivated" patients who repudiated cooperation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments, and, therefore, required a climate of loving-kindness and somewhat unconditional acceptance (not Rogers' positive humanist approach, but Hanh's metaphysically neutral one), in which to develop a successful therapeutic alliance. Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction.
DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the client's feelings at any given time, while, nonetheless, informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives.
Linehan and others combined a commitment to the core conditions of acceptance and change through the principle of dialectics (in which thesis + antithesis → synthesis) and assembled an array of skills for emotional self-regulation drawn from Western psychological traditions, such as cognitive behavioral therapy and an interpersonal variant, "assertiveness training", and Eastern meditative traditions, such as Buddhist mindfulness meditation. One of her contributions was to alter the adversarial nature of the therapist-client relationship in favor of an alliance based on intersubjective tough love.
All DBT can be said to involve 4 components:
No one component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.
Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one's emotions and senses fully, yet with perspective.
Many current approaches to mental health treatment focus on changing distressing events and circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.
Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Since this is a non-judgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.
Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:
Story of emotionThis skill is used to understand what kind of emotion one is feeling.
- Prompting event
- Interpretation of the event
- Body sensations
- Body language
- Action urge
- Emotion name, based on previous items on list
PLEASEThis skill concerns ineffective health habits can make one more vulnerable to emotion mind. This skill is used to maintain a healthy body, so one is more likely to have healthy emotions.
Build masteryTry to do one thing a day to help build competence and control.
Opposite actionThis skill is used when you have an unjustified emotion, one that doesn't belong in the situation at hand. You use it by doing the opposite of your urges in the moment. It is a tool to bring you out of an unwanted or unjustified emotion by replacing it with the emotion that is opposite.
Problem solvingThis is used to solve a problem when your emotion is justified. It is used in combination with other skills.
Letting go of emotional sufferingObserve and experience your emotion, accept it, then let it go.
Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.
Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing their own situation.
The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person's goals in a specific situation will be met, while at the same time not damaging either the relationship or the person's self-respect.
This list does not include the "problem solving" module, the purpose of which is to practice being one's own therapist.
Specially formatted cards for tracking therapy interfering behaviors that distract or hinder a patient's progress. Diary cards can be filled out daily, 2-3 times a day, or once per week.
Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining. A growing body of research supports the use of behavior chain analysis with multiple populations.
The milieu, or the culture of the group involved, plays a key role in the effectiveness of DBT.