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DBT Therapy

Psychotherapy refers to a structured process where a professionally trained individual helps one or more people alter their behavior, attitudes, or ability to adjust to situations, or helps the individual with other important areas of life. The professional is trained in psychological principles, and has formal documentation of both their training in these principles and their ability to implement them in a therapeutic environment.

Psychotherapy differs from other types of interventions in this manner. For instance, social support groups, like 12-Step groups, are typically not run by professionally trained therapists. Getting advice from a friend is not a form of psychotherapy unless the friend is a professionally trained and licensed therapist. Practicing yoga or running as a form of intervention for some emotional or physical issue is not a form of psychotherapy. Even though all of these alternative interventions may be experienced as being therapeutic in the sense that they help an individual adjust, change, or relieve stress, they are not formal forms of psychotherapy.

Psychotherapy differs from other types of interventions in this manner. For instance, social support groups, like 12-Step groups, are typically not run by professionally trained therapists. Getting advice from a friend is not a form of psychotherapy unless the friend is a professionally trained and licensed therapist. Practicing yoga or running as a form of intervention for some emotional or physical issue is not a form of psychotherapy. Even though all of these alternative interventions may be experienced as being therapeutic in the sense that they help an individual adjust, change, or relieve stress, they are not formal forms of psychotherapy.

There are literally hundreds of different forms of psychotherapy, many that are very similar to one another, and many that are quite different from one another.

Most historians consider Sigmund Freud to be the father of modern psychotherapeutic interventions. All of these different types of psychotherapy can be traced back to one of five major schools of thought that drove clinical psychological theories.

One of the most common forms of psychotherapy is Cognitive Behavioral Therapy (CBT), which combined two of these schools of thought: the cognitive school of psychology and the behavioral school of psychology. CBT is not one particular type of therapy; rather, it represents numerous different types of psychotherapies that all function under the basic assumption that helping a person to change their beliefs, attitudes, and thoughts in conjunction with having them work on changing their behavior is an effective form of psychotherapeutic intervention.

Dialectical Behavior Therapy (DBT) is one of many different types of CBT that was originally developed to address clients with a very specific condition, but it has been expanded over time to be utilized in numerous instances.

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A Very Brief History of DBT

In order to understand some of the basic principles of Dialectical Behavior Therapy, it is necessary to provide a very brief explanation of how and why DBT was developed. Many individuals who enter psychotherapy do so for common everyday problems, such as issues with mild depression, anxiety, relationship issues, etc. While treating these individuals can be challenging, these clients often do not have very complicated or severe emotional issues that significantly complicate treatment. Some other individuals with very severe emotional or psychological problems enter treatment with both the innate fear of changing and the fear of not changing or bettering their condition.

Individuals who are actively suicidal are often very challenging for therapists to work with. These individuals are suicidal because they do not wish to face the perceived harshness of reality, and at the same time, they are very resistant to changing how they view reality. Therapists who used cognitive-behavioral techniques to help them to accept aspects of reality that they cannot change were often viewed as being uncaring and cold, and suicidal clients would either drop out of therapy or become very aggressive (verbally and sometimes even physically) with the therapists. Likewise, therapist who suggested that they should change the way they view the world were also accused of being uncaring and insensitive. Dialectical Behavior Therapy was developed as an approach to help therapists treat actively suicidal individuals by allowing these individuals to incorporate both points of view: that the world is indeed sometimes harsh and unfair, and that they can change certain aspects of their behavior.

As the DBT technique evolved, it became the standard form of treatment for borderline personality disorder, a severe personality disorder that was often considered very difficult to treat. At one time, borderline personality disorder was considered to be nearly untreatable, and the prognosis for these individuals was considered to be poor at best. Individuals with borderline personality disorder display the same type of severe emotional presentation as individuals who are severely suicidal, and DBT was easily adjusted to address issues that occur with these individuals. Over time, DBT developed further to address numerous other issues.

Basic Principles of Dialectical Behavior Therapy

DBT is a very specialized form of Cognitive Behavioral Therapy that requires specialized training. Individuals who are interested in becoming DBT therapists must first obtain an advanced degree in psychology, social work, or counseling, and obtain licensure in their state to practice psychotherapy. After obtaining at least a master’s degree (or in the process of obtaining a master’s degree or higher), individuals can also be trained specifically in DBT.

Psychologist Dr. Marsha M. Linehan is the founder of Dialectical Behavior Therapy. She combined principles from both philosophy and science in the development of DBT. The formulation of DBT involves the notion that change is an inevitable facet of life, and everything can be integrated, even opposing viewpoints. The term dialectical in DBT is used as a description of an approach that synthesizes opposite emotional states or opposite views.

DBT still retains the major assumptions and processes used in all cognitive-behavioral therapies, which involves identifying irrational beliefs or thoughts, helping the client restructure these, and helping the client change their behavior by using a holistic approach to assisting clients. In addition to working with clients from multiple perspectives, DBT is also very focused on training and maintaining the competence of DBT therapists. This means that DBT includes:

  • Individual therapy sessions as the core: DBT uses individual therapy sessions, most often weekly sessions, to increase the client’s motivation, to help them change their thoughts and attitudes, to guide them in changing behaviors, and to develop new skills and coping techniques. Individual therapy sessions are the core components of treatment for DBT and continue for the duration of treatment.
  • Group sessions for psychoeducation and practice: DBT classically requires that clients attend weekly individual sessions and also complete a course of group sessions. Group sessions are very structured with a formal agenda, primarily psychoeducational in nature, and last for many weeks. Individuals learn specific aspects regarding the issue they are being treated for (e.g., principles of substance abuse), learn specific skills, and practice these skills in group sessions. Group sessions are typically time-limited, and individuals are required to complete the entire course of sessions. If they miss a session, they can always go back and attend it when the sequence repeats, although this is not preferable.
  • Phone coaching availability: Classically, DBT clients also had access to on-the-spot consultations via the phone with their therapist or with a trained phone coach. The use of this technique is limited to emergency situations where the person needs immediate assistance, such as when an individual may be about to relapse regarding their substance abuse issue, may be extremely suicidal, etc.
  • Consultation teams to keep therapists current: DBT also provides ongoing training and consultation for therapists. Therapists are able to meet regularly, discuss cases, get input from each other, and learn about the latest techniques in therapy and other forms of treatment, such as learning about the newest medication for depression, a new antipsychotic medication, etc. These consultation teams are a requirement for therapists who belong to DBT organizations, and they meet on an ongoing basis. This keeps therapists updated on the latest research.

Because DBT is an evolving technique, it incorporates other principles from other forms of therapy, such as Motivational Interviewing and even psychodynamic therapy. The approach DBT uses addresses specific areas of intervention that include:

  • Emotional regulation techniques: Clients in DBT learn to understand how emotions can trigger dysfunctional behaviors, and how to change attitudes and beliefs that can trigger certain emotional states. Clients are also given skills to deal with stress management, depression, anxiety, or other negative emotional states.
  • Cognitive restructuring: A standard technique used in CBT is cognitive restructuring. Therapists help clients to recognize irrational or dysfunctional thoughts, beliefs, or attitudes, and then work together with the client to challenge them. Once these belief systems are recognized as being irrational or dysfunctional, the therapist and client work together to restructure them to be in line with reality.
  • Increasing tolerance for stress: Because stress is a fact of life, individuals need to learn and practice stress management techniques. This goes hand in hand with the emotional regulation techniques that are taught in DBT.
  • The use of mindfulness: Mindfulness is a concept that is borrowed from Buddhist thought, and it refers to the notion of maintaining an awareness of one’s inner states, intense, attitudes, etc. Mindfulness also emphasizes living in the moment and concerning oneself with performing well in the current situation as opposed to worrying or trying to predict the future.
  • Effectiveness as a person: DBT also devotes significant energy into developing effective communication skills and relationships with others.

Overall Approach

Dialectical Behavior Therapy is tailored to fit the needs of each individual, but there is an general overall approach.

  • Repetitive use of Concerta by an individual who does not have a prescription for the drug
  • Assessment: Initial sessions are devoted to understanding the client, their specific issues, and then prioritizing the individual’s issues in order to develop a plan of treatment.
  • Addressing serious issues: The more pressing or serious issues (e.g., suicidality) are addressed first.
  • Ensuring that therapy is effective: Potential behaviors that would interfere with the progress of therapy, such as the client missing individual or group sessions, not doing homework, engaging in drug abuse, etc., are addressed next.
  • Helping to increase the quality of life: The problems that affect the person’s quality of life, such as relationship issues, depression, substance abuse, etc., are addressed next.
  • Working on specific issues: Specific interventions to develop new skills and replacing behavior/habits that are dysfunctional are addressed after the above issues have been addressed relatively well by the therapy. Specific issues include:
  1. The development of new skills
  2. Increasing the client’s motivation
  3. Understanding the client’s attitude toward change
  4. Helping the client accept things that cannot be changed
  5. Making sure that therapy provides functional skills

Effectiveness of DBT

Psychotherapy is an intervention that is not designed to “cure” an individual of many of the issues they bring with them to the therapy. For example, individuals who use psychotherapy to address depressive behaviors will still experience normal issues with sadness and depression from time to time. Individuals who initiate psychotherapy for issues with anxiety will still have normal experiences of anxiety. Psychotherapy is designed to help individuals treat the dysfunctional nature of their problems, develop coping skills, understand and accept the notion that they cannot change everything, and develop skills to help them change issues that they can effectively change or address.

There are no overall statistics compiled by national organizations regarding the overall success of any type of psychotherapy. Instead, different research studies using different groups of participants often report similar trends in the effectiveness of a therapy like DBT, but may have different rates of success depending on what is being treated and how the variables in the study are defined.

DBT is generally found to be effective in treating numerous psychological conditions. With this in mind, various research studies have demonstrated the effectiveness of DBT interventions for treating:

DBT also has numerous other applications.

According to many clinical sources, such as the book Dialectical Behavior Therapy and Clinical Practice: Applications across Disorders and Settings, DBT can be used to assist in the treatment of co-occurring disorders; however, it is often not the only form of treatment used for these conditions. This is because individuals who have co-occurring disorders are often treated according to an integrated treatment plan that uses multidisciplinary teams of treatment professionals from different backgrounds, such as psychiatrists, addiction medicine physicians, other physicians, and therapists. Thus, in some cases where individuals are receiving formalized treatment for a dual diagnosis or co-occurring disorders, DBT is part of the integrated treatment program, but it is not the only component, or it may not be the main component of the program, depending on the stage of addiction that is being treated.

DBT Is Effective, but Not a Panacea

Even though there is a large body of empirical evidence that indicates that DBT can be effective in the treatment of numerous issues, DBT should not be considered to be a “cure all.” DBT, like any intervention, does have limitations.

  • Classical DBT delivery involves a considerable investment on the part of the client. For example, an individual who attends at least one weekly individual therapy session, one weekly group session, and any other adjunctive therapies is spending quite a bit of time in therapy. Sometimes, individuals with serious issues may need to initially attend two or more weekly sessions of individual therapy. Individual sessions typically last one hour, and group sessions can last significantly longer, 90 minutes to 2.5 hours in some cases. This can incur a significant financial and time commitment that some individuals cannot maintain.
  • A person who is actively psychotic, such as an individual with schizophrenia, bipolar disorder, or even a personality disorder with psychosis, would not initially benefit from DBT. Instead, these individuals would need their psychosis to be treated via medically assisted techniques, such as medications, before considering any form of psychotherapy.
  • Certain types of mental health disorders, such as bipolar disorder and schizophrenia, are not amenable to psychotherapy alone. These disorders are most often treated with medications, and therapy is often used to help individuals adjust, develop social skills, and stick with treatment.
  • Individuals with significant cognitive issues may struggle with DBT. Cognitive Behavioral Therapy like DBT involves significant use of insight, reasoning, and the ability to learn and remember information. A person who has a significant cognitive compromise as a result of a head injury, stroke, or developmental condition would probably better be treated in a formal program of behavioral therapy.
  • Even though CBT techniques like DBT often include motivation-building aspects to their treatment, some individuals may have the wrong impression that therapy works similar to medically assisted treatments. Often, these individuals think that simply just going to therapy sessions and attending group sessions is enough to bring about change. While some change may occur, DBT is an action-oriented therapy that requires the individual to become involved and proactive, and then apply the principles learned in therapy sessions. Individuals with very low levels of motivation may not be able to get the full benefits of DBT.