Dialectical Behavior Therapy Overview
Dialectical Behavior Therapy (DBT) was originally developed by Marsha Linehan for the treatment of individuals diagnosed with Borderline Personality Disorder (BPD). In recent years many new psychotherapies have been studied for the treatment of BPD; however, DBT has been the most studied and most widely practiced of all. According to Swenson (2000), some of the reasons for DBT’s popularity are strong empirical support for the treatment, integration of four domains (biological, environmental, spiritual, and behavioral) into a unique treatment approach that appeals to many people with different backgrounds, and the synthesis of acceptance and change strategies.
DBT contains four treatment modes that aim to address five functions. The four treatment modes are individual therapy, group skills training, phone coaching on an as-needed basis, and therapist consultation meetings. The five functions of treatment include increasing the client’s motivation to change, enhancing the client’s capabilities, generalizing gains to the client’s larger environment, structuring the environment to reinforce the client’s gains, and increasing therapist motivation and competence (Linehan, 1993a).
The practice of DBT relies on three overarching theories including the biosocial theory, behavioral theory, and the philosophy of dialectics.
Linehan’s (1993a) biosocial theory posits that emotion dysregulation (the core feature of BPD) stems from the interaction of a biological dysfunction in emotion regulation and an invalidating environment. The dysfunction in emotion regulation can be best described at emotional vulnerability, sensitivity, and reactivity, as well as slower return to baseline levels. Emotional vulnerability in childhood is often expressed as impulsivity, which has an important part in the development of BPD (Crowell et al., 2009). An invalidating environment is one where the child’s emotional experiences are not validated or tolerated by important figures in the child’s life. Sometimes the expression of emotions is only intermittently reinforced. This means that the child’s emotional experiences are not validated until they escalate and reach very high intensity, which in turn reinforces the child that heightened emotional expressions are necessary to communicate effectively and be heard. Moreover, in an invalidating environment effective emotion regulation skills are not taught or modeled by caretakers, so the child does not learn how to effectively manage, control, understand, or express emotional experiences. The biosocial theory is transactional in nature and believes that the two factors reinforce each other. That is, the higher emotional sensitivity a child possesses, the greater the likelihood of not getting validated from the environment, which then leads to even greater emotionality (Linehan, 1993a).
The second theoretical basis for DBT is behavior theory. According to behaviorism, the goal is to increase the frequency of adaptive (positive) behaviors and decrease the frequency of maladaptive (negative) behaviors. Treatment goals are very specific, for example decreasing the occurrence of self-injury from twice a week to zero times a week.
Behavior therapy aims to create change by understanding the behavioral factors contributing to the development and maintenance of problem behaviors, manipulating consequences of such behaviors, and creating alternative new behaviors. This theory also posits that negative behaviors are maintained due to lack of skills, problems in emotional processing, and cognitive factors. DBT therefore focuses on teaching useful emotion regulation skills, helping clients get over their fears by facing them in a gradual fashion, and identifying and changing thinking patterns that cause problematic behaviors (Linehan, 1993a).
The last theory DBT is built on is the philosophy of dialectics. In short, this theory states that reality is interconnected and interwoven, made up of opposing forces and constantly changing. In DBT dialectics are considered a general worldview and also a method of persuasion. According to this theory, opposite views often coexist in a person at the same time. Some examples are, “I want to die” and “I want to live” or “I want to be sober” and “I want to keep drinking”. These opposite views lead to tension and conflict, which are necessary to deal with and integrate in order for change to occur. The primary dialectic in DBT is, therefore, between change and acceptance. Clients learn skills to help them change their behaviors while also learning to accept themselves as they are right now. Sometimes dialecctics are also used as a way to persuade a client to move on from being stuck by accepting where they are and yet working actively to change their situation (Linehan, 1993).
Stages of DBT Treatment
DBT consists of five treatment stages, including pretreatment. In the pretreatment stages clients officially commit to therapy and set treatment goals with therapists. They also create a hierarchical list of problem behaviors that interfere with the client’s quality of life. In stage 1, the main goal is to reduce the most severe behaviors that greatly affect the client’s life. These include life threatening behaviors (suicide, self-injury), therapy-interfering behaviors (lateness, missing sessions, not completing of homework), quality of life interfering behaviors (substance use, depression, lack of skills), and increasing behavioral skills (group format).
Stage 2 attends to the quiet misery and desperation that tends to crop up after the most destructive behaviors have been addressed. Stage 3 focuses on residual problems including but not limited to boredom, emptiness, grieving, invalidation, etc. In the final stage, clients work on awareness of self, feelings of incompleteness, and spiritual fulfillment (Linehan, 1993a).
DBT Treatment Components
As mentioned above, a comprehensive DBT program includes not only individual therapy but also group skills training and phone coaching for clients. Group sessions are held weekly for 2.5 hours and include 4 modules: Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation. It typically takes 6 months to get through the modules. The first part of the session is dedicated to reviewing homework, while the second half is about learning and practicing new skills. Phone coaching is only used on an as-needed basis. Phone coaching sessions are short, not longer than 5-15 minutes. The therapist quickly assesses what problem the client is dealing with and helps the client apply an appropriate skill that can be helpful (Linehan, 1993a).
DBT is one of the most effective psychotherapies used today because of its comprehensive approach to treatment and integration of many concepts that can be useful for a wide range of clients and therapists.
Rizvi, S.L., Steffel, L.M., & Carson-Wong, A. (2013). An overview of dialectical behavior therapy for professional psychologists. Professional Psychology: Research and Practice, 44, 73-80.
Swenson, C. (2000). How can we account for DBT’s widespread popularity? Clinical Psychology: Science and Practice, 7, 87–91. doi:10.1093/ clipsy.7.1.87
Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.
Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality disorder: Elaborating and extending Linehan’s theory. Psychological Bulletin, 135, 495–510. doi: 10.1037/a0015616