Dialectical Behavior Therapy (DBT) is a form of Cognitive Behavioral Therapy (CBT) developed specifically for chronically suicidal individuals who have borderline personality disorder (BPD). It’s now considered to be the gold standard treatment for this particular group, though it has also been used to treat other disorders including post-traumatic stress disorder (PTSD), substance use disorders, eating disorders, and depression.
The term dialectical refers to a synthesis of opposites. In DBT, therapists focus on two seemingly opposite strategies: acceptance and working toward change. DBT therapists at once stress that they accept their clients as they are and acknowledge that change needs to take place in order for them to become functional in day-to-day life. For example, clients are taught both to tolerate distress rather than try to change it, and to identify and work on emotions that they want to change.
DBT is designed to deal with patients who have complex and severe disorders that are difficult to treat. BPD is a serious mental illness that has integrated into the individual’s personality, making it particularly difficult to root out. It’s characterized by issues regulating emotions and thoughts, unstable relationships, and impulsive and/or reckless behavior. BPD is found in 5.9 percent of adults in the US and in 20 percent of people admitted to psychiatric hospitals. Symptoms never entirely disappear for people with this illness, but they can be managed through extensive therapy and behavioral training. Those afflicted often have to return to therapy during stressful periods of their lives for further support.
Numerous studies, outlined by the Linehan Institute, have supported the effectiveness of DBT for these individuals.
How It Works
DBT typically consists of four components, but it can be personalized for each individual client to increase effectiveness. The four standard components are:
- DBT skills training group: This is group therapy that is run like a class by a therapist who teaches behavioral skills and assigns practice homework. These classes typically meet once per week for 24 weeks in 2.5-hour sessions and are often repeated.
- DBT individual therapy: Each client also meets individually with a therapist to work on the specific challenges in each person’s life. This goes on alongside the training group for as long as said training lasts.
- DBT phone coaching: Clients are encouraged to call their individual therapists in between sessions when they need in-the-moment coaching to get through difficult situations when they arise.
- DBT therapist consultation team: In order to best serve these high-risk clients, therapists meet in groups on a weekly basis to keep each other motivated and compare notes on clients they all assume responsibility for. These meetings are essential to prevent burnout or vicarious trauma, and 90 percent of DBT teams meet weekly for these reasons.
Skills taught during training and individual therapy include mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation. Mindfulness refers to the practice of being fully aware and present in the moment, which can be achieved through grounding techniques and meditation. Interpersonal effectiveness involves learning how to get needs met – how to effectively ask for what is needed and set boundaries by saying “no” in a way that minimizes conflict and keeps relationships healthy.
The progression of DBT works by targeting the most disruptive behaviors engaged in by each client in a sequence. First, life-threatening behaviors are addressed. Suicidal ideation, self-harm and self-injury, and excessively reckless behavior, such as intense drug or alcohol binges, must be rooted out first for the safety of the client. A whopping 60-70 percent of individuals with BPD attempt suicide.
Next, behaviors that directly interfere with treatment must be taken care of. Impulsive behaviors can cause these clients to often be late to or cancel appointments, or fail to do homework. Clients can also be generally noncompliant or uncooperative, resisting change or being skeptical of the effectiveness and/or necessity of the therapy.
Once these are dealt with to a reasonable degree, quality of life issues are addressed. These often include relationship issues and behaviors that interfere with them, financial stability and employment, home environment, and anything else that interferes with the client getting basic needs met. Finally, once the client is fully stable, the therapist can effectively begin teaching the skills necessary to replace maladaptive behaviors with healthy ones, allowing the client to reach goals and achieve life satisfaction.
Once clients are in a place where they are not a danger to themselves or others, therapists can implement the typical behavior enhancement techniques:
- Motivational enhancement: Therapists create individualized treatment plans designed to address maladaptive behaviors that affect quality of life. This includes the use of behavior tracking sheets to identify the most disruptive behaviors that need to be addressed first.
- Capability enhancement: This refers to the strengthening of existing skills. All people possess some capability with mindfulness and emotion regulation, but people who grew up in chaotic or abusive environments may have lower skill levels in these areas. Once these skills are enhanced, the client can feel more confident and in control.
- Generalization: Clients are taught that the skills they learned to deal with one type of situation can also be used in many different types of situations. Mindfulness in a therapy setting, for example, could be used to identify troubling emotions in family settings or at work.
- Environmental structuring: This involves making sure all treatment programs the client is involved in reinforce positive behaviors and the use of learned skills.
All of these techniques and strategies are designed to make up for the pitfalls of standard CBT, which often does not work for individuals with BPD or other severe mental illnesses. These individuals are likely to feel invalidated by therapy that focuses purely on changing thoughts and behaviors, feeling as though the therapist is not accepting of them as they are. The severity of the illness and the present dangers of self-injury and behaviors that disrupt the therapeutic process also make it difficult to spend any time learning new skills without the specific structure of DBT.
The combination of these methods are responsible for the high effectiveness and retention rates of DBT. In one study, dropout rates were cut in half for clients in a DBT program compared to those who didn’t have skills management training.
Stages of DBT
In addition to targeting behaviors, DBT is often described in stages based on the severity of the client’s distress. It’s common for people to wait to enter therapy until their situations are completely unbearable. When it comes to people with BPD, “rock bottom” often comes when they attempt suicide.
- Stage 1: The client is actively suicidal and miserable. Self-destructive behaviors and self-harm are very likely. Clients describe themselves as feeling out of control and report extreme emotional pain and distress.
- Stage 2: Behavior is under control, but emotional pain and distress are severe. Emotional experience is often inhibited as past trauma and invalidation have yet to be addressed and continue to cause suffering. PTSD symptoms, if any, still run rampant.
- Stage 3: With behavior improving and suffering alleviated, the client is ready to begin learning helpful behavioral skills. Goals are set and therapy work is primarily focused on achieving life balance and satisfaction.
- Stage 4: Additional goals are addressed, often including spiritual fulfillment. Any feeling of incompleteness in life is addressed until the client feels in possession of all the skills necessary to lead a satisfying life.
By defining stages of treatment by the client’s experience, mental health professionals are able to tailor the progression of treatment to each individual rather than trying to force a client into a treatment plan that might not work for that person. This increases the likelihood of a good outcome in clients with complex mental illnesses like BPD and PTSD.
Skills Needed to Administer DBT
DBT is a specialized form of therapy that requires additional training for any mental health professional who wants to use it. Therapists need to be able to adequately validate their clients, be prepared to provide extra support outside of office hours, and be particularly apt at spotting signs of distress and key emotions in clients.
The mental health professional needs to be familiar with the biosocial theory of BPD. This theory states that people with BPD are born with a temperament that includes emotional vulnerability – defined as being particularly reactive to minor emotional stimuli, a tendency to have stronger emotional reactions than most, and difficulty returning to a “normal” emotional state. Research suggests that this may be due to biological genetic abnormalities that may be responsible for 60 percent of the risk of developing the disorder.
Children with this temperament need to be taught how to effectively cope with their emotions. Without careful parenting, such children are more apt to develop BPD and other problems, including reckless behaviors designed to get attention or becoming fearful of their own emotions. Knowing this, the DBT therapist must be able to handle frequent emotional outbursts and validate clients’ feelings no matter how strong they may be or how minor the stimuli is. Dismissing the emotions of these clients or directing them to change the emotions without first acknowledging their validity can result in anger or withdrawal from the afflicted individual.
Without proper emotional regulation skills, DBT clients often have trouble recognizing or accurately identifying their emotions. The therapist therefore needs to be able to recognize these emotions for them by watching out for facial expressions and body language that indicate emotional disturbance. Clients can then be stopped and directed to acknowledge that an emotion is occurring and assisted in pinning down what the emotion is and why it came up. The frequent use of this technique helps clients to learn how to do this on their own.
Lastly, DBT therapists must be able to help clients apply these skills when emotions become overwhelming. They need to be able to tailor their approach to each individual and identify which particular skills are best for each client in a number of different situations. A background in mindfulness is helpful for teaching grounding techniques, meditation, and emotional acceptance to help clients learn to calm themselves, so they may approach difficult situations in a healthy manner rather than reverting to old, destructive habits.
Limitations and Alternatives
Although DBT has been found to be generally effective for most clients, there are always limitations to any type of therapy. In some instances, DBT may not be the best option, even for clients who seem to fit the bill for it.
One of the biggest limitations of this type of therapy is that it is particularly demanding. Going to both individual and group therapy sessions each week can be an unreasonable expectation for those suffering from mental illness. The poorest fifth of the population have a 24 percent likelihood of developing a mental illness, and these individuals are likely financially unable to take time off work to attend therapy. Even if the person has insurance that covers DBT, copayments can be a substantial burden on a person’s budget, and it may be difficult to schedule this many weekly appointments around work. Transportation costs are also a concern.
If the individual can pay for it, people with BPD often find it difficult to keep appointments due to problems with impulse control and because of how draining emotional volatility and extreme mood swings can be. On top of this, clients are expected to do regular homework and reach out to their individual therapists on the phone when the need arises.
This means that the person must be highly motivated to engage in and complete therapy. It may not work well for those who were pushed into therapy by family or for those who are experiencing comorbid disorders like depression. Interestingly, studies have failed to demonstrate that DBT reduces depression, even though it reduces suicidal ideation and incidents of self-harm.
Due in part to the myth that personality disorders can’t be treated, only 42.4 percent of those with BPD are in treatment for it, according to the National Institute of Mental Health. Even if DBT doesn’t work, there are plenty of other options that individuals can try. Alternatives to DBT for those with BPD include:
- Mentalization-Based Therapy: This type of therapy is commonly used for people with BPD, as it helps them to identify and understand the thoughts and emotions of others.
- Transference-Focused Therapy: This therapy depends on developing a deep relationship between therapist and client, allowing clients to explore their emotions and issues through said relationship in a safe environment.
- Schema-Focused Therapy: This program combines elements of CBT with other types of therapy that are focused on changing the way clients view themselves. This is meant to improve self-image, therefore reducing self-destructive behaviors and improving relationships.
- Systems Training for Emotional Predictability and Problem-Solving (STEPPS): This 20-week program integrates family members, friends, significant others, and/or caregivers into group therapy, allowing the individual to actively repair and improve relationships while also helping loved ones to better understand and handle the person’s mental illness.
- Medication: Drug therapy can’t cure BPD, but it can be used to treat symptoms like depression, anxiety, and minor psychosis and disorganized thoughts that can be associated with the disorder.
There are plenty of other options for individuals with BPD, PTSD, eating disorders, and substance abuse disorders as well. Whether or not a person will respond to a particular type of therapy depends on many factors, including temperament, environment, and co-occurring disorders. Primary care doctors and psychiatrists can guide an individual to the kind of therapy that is most likely to be effective.