Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a cognitive-behavioral treatment program originally developed by Marsha Linehan as a treatment for highly suicidal women with borderline personality disorder (BPD) and other difficult-to-treat mental disorders. DBT draws its principles from behavioral science (e.g., reinforcement, classical conditioning), Zen mindfulness practices (e.g., quieting the mind and focusing attention), and dialectical philosophy (e.g., finding the synthesis between two differing or opposing positions). The essence of DBT as a treatment is helping the client find the synthesis of and middle path between acceptance and change. This emphasis came out of the finding that focusing solely on behavioral change or on acceptance and validation of the client’s pain led to poor outcomes. Clients in DBT require a balance of acceptance and validation of their painful experiences while also working to change the behaviors and environmental factors contributing to the pain.

Functions and Modes of Dialectical Behavior Therapy

DBT is a comprehensive treatment approach designed to serve five functions. First, DBT therapists help clients correct behavioral skills deficits by enhancing their capabilities. Second, motivational enhancement is generally accomplished by removing factors that detract from therapy success and increasing reinforcement of effective behaviors. A third function of DBT is to assure generalization of skillful behaviors to client’s lives outside of therapy. Fourth, therapists and clients work to structure the client’s environment and intervene in the world outside of therapy in ways that maximize therapy gains. Finally, to avoid therapist burnout and increase the chances of therapy being successful, DBT serves the function of enhancing therapist capabilities and motivation.

DBT uses individual therapy, telephone consultation, therapist consultation teams, and group skills training to serve these functions. The individual DBT therapist takes primary responsibility for a client’s treatment plan, progress toward therapy goals, integration of therapy modes, and management of life-threatening behaviors and crises. Individual therapy dyads engage in brief phone consultations to help the client engage in effective behavior outside of therapy sessions. DBT therapists meet as a consultation team to help one another engage in more effective treatment and to reduce burnout.

The fourth mode of DBT is skills training, which teaches clients four sets of skills. The core set of skills includes the mindfulness skills of observing, describing, fully participating, being nonjudgmental, focusing on one thing in the moment, and focusing on being effective. Interpersonal effectiveness skills include obtaining objectives, maintaining or improving relationships, and increasing self-respect in interactions. Emotion regulation skills include methods to increase positive emotions and to decrease ineffective emotional responses. Finally, distress tolerance skills include methods to help clients accept life’s unchangeable and unwanted characteristics and survive crises.

Dialectical Behavior Therapy Targets

DBT provides a hierarchy of treatment targets to help organize therapists’ work with clients who have chaotic lives and multiple problems. Life-threatening behaviors including suicide attempts and intentional self-injury, and urges to engage in these behaviors are the highest targets. Once these objectives are obtained, the focus turns to the elimination of client and therapist behaviors that interfere with the effectiveness of therapy. The next target is behaviors that interfere with quality of life (e.g., criminal behaviors, interpersonal dysfunction, high-risk sexual behavior, or homelessness). Finally, DBT individual therapists help clients acquire skills.

Overall, the goals of DBT are to help clients replace suicidal behaviors with more effective behaviors and to help clients build lives they regard as worth living.

References:

  1. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
  2. Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
  3. Salsman, N. L., & Linehan, M. M. (2006). Dialectical-behavior therapy for borderline personality disorder. Primary Psychiatry, 13, 51-58.

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