What is Dialectical Behavior Therapy (DBT)

Jaiyant Cavale, Clinical Psychologist

Jaiyant Cavale, Clinical Psychologist

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Dialectical behavior therapy is an established form of psychotherapy that helps people who experience emotional disturbances. It is different from cognitive behavior therapy which is more aligned with helping you understand how your thoughts affect your emotions and behaviors.

Dialectical behavior therapy, on the other hand, unifies contradictory ideas and situations in people’s lives. More specifically, it helps people to accept their lives’ realities and the limitations of behavior. However, it also equips them to change these unhelpful behaviors. 

It was developed by Marsha Linehan, a psychological researcher, in 1993. It has since been used to treat personality disorders and interpersonal difficulties. It is an evidence-based treatment for various mood disorders and suicidal ideation. Other applications include substance abuse, self-harm, inability to tolerate distress, etc. 

In this article, we will take a closer look at DBT and how it will help you overcome your past trauma and different kinds of emotional disturbances.

Development and History 

Marsha Linehan, who has admitted to being previously diagnosed with Borderline Personality Disorder, felt the need to devise a therapeutic model that centers the client. In the 1970s and 80s, borderline personality disorder had a lot of stigma. 

  • Back then, people diagnosed with borderline personality disorder did not receive the care they deserved. 
  • Even clinicians often gave up on them instead of helping them. 
  • Marsha Linehan decided to explore forms of therapy that would validate the clients’ feelings instead of treating them like adversaries during the psychotherapeutic process. 
  • The therapist works as an ally and validates the client’s feelings while simultaneously pointing out maladaptive behaviors and emotions. 
  • This creates a sort of balance in the therapeutic process and helps the client change their behaviors, especially when it is chronic. 

The ultimate goal of dialectical behavior therapy is to help the client find a life worth living. Marshall Linehan was deeply influenced by mindfulness, the meditative practice of being aware of one’s reality and consciousness. 

It has roots in Buddhist contemplative practices and has since been proven effective by psychological research. However, Marsha Linehan studied both borderline personality disorder and different therapeutic approaches to treat it and finally came up with dialectical behavior therapy as a treatment approach.

Stages in DBT

DBT is a complex therapeutic approach that requires rigorous training and expertise. Administering DBT to clients requires a multi-pronged approach, and often involves the following four stages:

DBT pre-assessment

DBT does not work for everyone. It is specifically meant for people with personality disorders such as borderline personality disorder. It has also been known to help:

  • People with suicidal ideation
  • Posttraumatic stress disorder
  • Substance use disorders
  • Eating disorders
  • Self-harm behaviors. 

Consequently, your clinician or therapist needs to devise a diagnostic formulation and decide that DBT is the right approach for your issues. The clinician may ask you several questions to understand how your problem evolved and also help you understand how DBT works. Once you choose DBT as the preferred form of therapy, they will request you to commit to the treatment and its duration.

DBT can last for months to years, and it is difficult to predict how many sessions you may require. The pre-assessment stage also involves administering several psychological tests that will help the clinician gain better insight into your problems. 

Individual therapy

Individual DBT therapy sessions last between 40 to 60 minutes. Your therapist may decide to have weekly sessions or a more intensive approach. There are specific goals for individual DBT sessions. These include 

  • Reducing self-harming behaviors
  • Eliminating suicidal thoughts
  • Avoiding counterproductive behaviors
  • Address interpersonal issues 
  • Replace unhelpful patterns of behaviors with new skills. 

You may also be asked to write a thought diary to understand how your thoughts and emotions influence your behaviors. You’ll need to bring this diary each time you meet your therapist. Then, your therapist will identify core dysfunctional beliefs and help you challenge your dysfunctional thought patterns.

Skills training in groups

Group skills training helps clients to learn new skills and apply them in various aspects of their lives. It includes structured group activities and psychoeducational sessions. 

Group sessions complement individual therapy and cannot be opted for independently. Usually, group therapy sessions are conducted every week and may last between two and 2 1/2 hours. 

The four essential skills that you learn during group skills training are:

  • Mindfulness
  • Emotion regulation
  • Distress tolerance 
  • Interpersonal effectiveness. 

It is important to note that group skills training may only be available in some geographical locations. In such situations, your therapist may improvise and offer individual sessions instead. 

Telephone crisis coaching

Most therapeutic approaches, such as cognitive behavior therapy, psychodynamic therapy, and others, do not encourage inter-session contact. Telephonic contact with the therapist is discouraged, and clients are urged to share their problems only during the session. 

On the other hand, DBT makes intersession contact mandatory during treatment. This is done to ensure that clients apply the skills they learn during group and individual sessions. In addition, this also helps the therapist to help the client prevent self-harm and suicidal behaviors. This approach is known to reduce unnecessary hospitalizations. 

Usually, telephonic coaching calls last between 10 and 20 minutes. As and when the client begins to improve during the treatment, the expectation is that the telephone calls will also reduce.

Goals in DBT

To summarize, DBT has four important goals. Those are:

Behavioral control 

Most people who seek DBT often suffer from behavioral dysregulation. They are prone to impulsive behaviors such as substance abuse, high-risk sexual behaviors, impulsivity, reckless behaviors such as overspending, etc. In addition, they may also engage in self-harming behaviors such as cutting, experiencing anger outbursts, acting out, and other self-destructive behaviors. Thus, the first goal is to achieve behavioral control.

Emotional stability and cognitive clarity 

Many personality disorders are characterized by emotional disturbance and faulty cognitive processes. Many self-harming behaviors stem from these dysfunctional thought patterns and emotional dysregulation. Past trauma is one of the reasons why these emotional and mental issues persist for almost all their adult lives. The most crucial goal of DBT is to address these past traumatic incidents and find healing through validation. 

Interpersonal relationships

People who suffer from BPD and other personality disorders suffer from chaotic relationships with their loved ones. They may fear being abandoned and act out in desperate ways that often confuse their loved ones. One of the most important goals of DBT is to reduce interpersonal conflicts and find meaningful and mutually beneficial relationships. 

Resolving identity disturbances 

At the core of every BPD-diagnosed individual is a shifty sense of self-identity. Lack of purpose, chronic emptiness, boredom, and a shifty sense of identity are all hallmarks of borderline personality disorder. DBT helps clients find meaning in their lives and establish a stable sense of identity that persists. In other words, a fundamental goal of DBT is to help the client resolve their identity disturbances. 

Skills in DBT

DBT is an evidence based psychotherapeutic practice that equips clients with a number of essential skills. The four most important skills that DBT teaches its clients are:

Mindfulness

Mindfulness has its roots in the Buddhist conception of contemplation. The idea is to be fully aware of what is happening and focus on the present. At the same time, one should not worry and dwell on the past or the future. Therapists teach their clients to observe their thoughts and not fight them because thoughts are automatic and cannot be stopped. However, with the help of mindfulness, one can learn not to react to triggering thoughts. Clients practicing mindfulness will learn to be less emotionally reactive to their thoughts. They will learn to let go of thoughts that are not very helpful.

Distress tolerance

Distress tolerance is often minimal among people with borderline personality disorder. They tend to react immediately and impulsively and may display a disproportionate amount of anger. Distress tolerance technique helps clients to understand and manage their emotions, and stressful and difficult situations. It also teaches them not to engage in harmful behaviors or react to negative stimuli as they used to before.

Interpersonal effectiveness

As discussed previously, people with borderline personality disorder have a lot of interpersonal difficulties. They often struggle to maintain good relationships with their parents, lovers, friends, and colleagues. They also find it challenging to set boundaries and maintain respect for themselves and others. Interpersonal effectiveness teaches clients to draw boundaries and to communicate what they want in an assertive manner. This module helps clients learn what being assertive is and how it differs from being aggressive.

Emotional regulation

The most crucial aspect of dialectical behavior therapy is emotion regulation. Studies show that people with borderline personality disorder find it challenging to evaluate their cognitive processes, also known as cognitive reappraisal. On the other hand, they tend to suppress their emotions which is not a very useful strategy. Suppressing emotions often leads to bottling them up, Which eventually is vented out in a volcanic manner. As a result, learning how to regulate emotions is one of the most critical aspects of DBT skills training.

How effective is DBT?

It is one of the most effective treatment approaches to help people with personality disorders like borderline personality disorder. It is a long-term approach and often takes many years. As a result, many people cannot afford dialectical behavior therapy. 

However, it is known to reduce suicidal behaviors and improve people’s quality of life with borderline personality disorder. In addition, it also helps people with substance abuse disorders, anger management issues, and other forms of psychological and emotional distress. 

In short, DBT is a highly effective and evidence-based treatment approach that is used all over the world. 

Certification requirement in DBT 

To be certified as a DBT professional is a voluntary process. The Linehan board of certification awards people with predetermined standards of knowledge, skills, and competencies. Those who meet the criteria and complete the board assessment process will be given a certificate, which permits them to use the designation “DBT-Linehan Board of Certification, Certified DBT Clinician™.” 

Of course, many people practice DBT-influenced therapeutic modules that Marsha Linehan or her foundation does not officially recognize. Although not technically illegal, one cannot voice these individuals’ expertise or professionalism. 

It is also important to note that many therapists may not be able to offer group therapy sessions and telephonic support. Both of these are essential to DBT. In other words, many offer therapeutic modalities that resemble DBT but are not officially endorsed by Marsha Linehan or her foundation. 

Criticisms and Limitations of DBT 

It is important to note that DBT was initially developed only to treat borderline personality disorder. However, many individuals have started using it for other mental health conditions, and it has not been adequately studied. In addition, DBT requires a certain level of expertise which many therapists may not be able to acquire. As a result, there are some genuine criticisms. 

They may also be unable to offer telephonic support, group sessions, and peer support. All these are essential aspects of DBT. Without this, one cannot claim to be offering DBT. Moreover, getting certified as an official DBT practitioner is quite tricky, and international therapists may not be able to do so unless they visit the US. 

Although its efficacy in treating borderline personality disorder has been studied, it is not clear how effective it is in treating other chronic mental health conditions.

FAQs

What is DBT used to treat?

DBT is primarily used to treat borderline personality disorder. However, a lot of clinicians have begun to use it to treat substance abuse disorder, other personality disorders, post-traumatic stress disorder, and even depression. 

Can I do DBT by myself?

DBT needs to be administered by a trained clinical psychologist or therapist. It is not a self-help method, as it requires individual sessions with a trained therapist alongside group therapy, telephonic consultations, and training in different kinds of skills.

When is DBT not appropriate? 

DBT is not appropriate if you are not suffering from personality disorders such as borderline personality disorder, or even PTSD. Its efficacy is not studied in other mental health conditions. DBT may also not be appropriate if your therapist is not trained in it adequately.

Support links

  1. DBT-Linehan Board Certification – This website has clear guidelines regarding acquiring the official DBT certification. 
  1. DBT Worksheets – This is a great resource for downloading DBT handouts and worksheets. 
  1. DBT for Borderline Personality Disorder – Understand the link between borderline personality disorder and DBT, and how DBT can help alleviate the symptoms of BPD. 
  1. What is Borderline Personality Disorder? – Demystify the complex and enigmatic condition of borderline personality disorder, for which DBT is one of the few evidence-based treatment modalities. 
  1. DBT Therapists’ Guide – A vast resource of handouts, cheatsheets, information sources, etc. regarding DBT. 

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Jaiyant Cavale, Clinical Psychologist

Jaiyant Cavale, Clinical Psychologist

Jaiyant Cavale is an RCI-registered clinical psychologist who works with various populations. He has over ten years of experience working in different professional settings, ranging from multi-specialty clinics to private practice. He uses an eclectic therapeutic approach to treat acute and chronic mental health conditions.

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