Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment that was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD). It is now recognized as the gold standard psychological treatment for this population. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance use disorder, depression, post-traumatic stress disorder (PTSD) and eating disorders.
The term "dialectical" means a synthesis or integration of opposites. The primary dialectic within DBT is between the seemingly opposite strategies of acceptance and change. For example, DBT therapists accept clients as they are while also acknowledging that they need to change in order to reach their goals. In addition, all of the skills and strategies taught in DBT are balanced in terms of acceptance and change. For example, the four skills modules include two sets of acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness).
DBT includes four sets of behavioral skills.
- Mindfulness - the practice of being fully aware and present in this one moment
- Distress Tolerance - how to tolerate pain in difficult situations, not change it
- Interpersonal Effectiveness - how to ask for what you want and say no while maintaining self-respect and relationships with others
- Emotion Regulation - how to change emotions that you want to change
There is increasing evidence that DBT skills training alone is a promising intervention for a wide variety of both clinical and nonclinical populations and across settings.
DBT is divided into four stages of treatment. The stages are defined by the severity of the client's behaviors, and therapists work with their clients to reach the goals of each stage in their progress toward having a life that they experience as worth living. Research has shown DBT to be effective in reducing suicidal behavior, non-suicidal self-injury, psychiatric hospitalization, treatment dropout, substance use, anger and depression and improving social and global functioning.
The four components of DBT include:
- Skills training group is focused on enhancing clients' capabilities by teaching them behavioral skills. The group is run like a class in which the group leader teaches the skills and assigns homework for clients to practice using the skills in their everyday lives. Groups meet on a weekly basis for approximately 2.5 hours and it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a one-year program. Shorter schedules that teach only a subset of the skills are also available.
- Individual therapy is focused on enhancing client motivation and helping clients to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for as long as the client is in therapy and runs concurrently with skills groups.
- Phone coaching is focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most.
- Therapist consultation team is intended to be therapy for the therapists and to support DBT providers in their work with people who often have severe, complex, difficult-to-treat disorders. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. Teams typically meet weekly and are composed of individual therapists and group leaders who share responsibility for each client's care.
Stages of DBT
Stage 1 - The client is miserable and their behavior is out of control
He or she may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When clients first start DBT treatment, they often describe their experience of their mental illness as "being in hell." The goal of Stage 1 is for the client to move from being out of control to achieving behavioral control.
Stage 2 - The client is living a life of quiet desperation
Their behavior is under control but they continue to suffer, often due to past trauma and invalidation. Their emotional experience is inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.
Stage 3 - The challenge is learning to live
Here we define life goals, build self-respect and work to find peace and happiness. The goal is that the client leads a life of ordinary happiness and unhappiness.
Optional Stage 4 - Finding a deeper meaning through a spiritual existence
Linehan has posited a Stage 4 specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.