Dialectical Behavioral Therapy (DBT)

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Dialectical Behavioral Therapy (DBT)

THC Editorial Team February 12, 2021
Pelham Bay, ca. 1875, Henry Farrer, Public domain, Met museum
Pelham Bay, ca. 1875, Henry Farrer, The Metropolitan Museum of Art

Contents

What Is Dialectical Behavioral Therapy?

Dialectical behavior therapy (DBT) is a comprehensive, evidence-based form of therapy that blends the most effective interventions within behavioral psychotherapy while incorporating notions of acceptance and validation. Based in dialectical philosophy, DBT posits that reality comprises opposing polar forces that generate tension. For instance, clients may experience tension because they feel like they need to change in order to reduce their problems but would rather accept their issues without changing. This dialogue between the opposing forces—needing change and being resistant to change—is ultimately what helps clients change their ways.

We are all complex beings with individual quirks and qualities that make us who we are. However, we also all have (re)actions, beliefs, and behaviors that may benefit from being challenged, and change may, in turn, improve our quality of life. Overall, DBT offers individuals ways to handle stress, develop and maintain healthy relationships, regulate emotions, and live in the present moment.

What Is the History of Dialectical Behavioral Therapy?

Founded by American psychologist Marsha Linehan in the 1980s, DBT was initially used to treat borderline personality disorder, a particularly challenging condition whereby people experience intense and uncontrollable negative emotions.1 Linehan assessed her patients and determined that their problems with emotions were caused by deficits in efficient emotional-processing skills and that their abilities to deal with emotions were heightened when they learned skills related to mindfulness, interpersonal assertiveness, emotion regulation, and distress tolerance. To help people with borderline personality disorder, Linehan worked with patients to implement radical acceptance and mindfulness and to transform all-or-nothing mentalities into more balanced perspectives.1

Since then, researchers have studied DBT and have established it as an effective form of therapy for several disorders and conditions, such as borderline personality disorder, bipolar disorder, and emotional dysregulation.1,2,3

How Does Dialectical Behavioral Therapy Work?

DBT therapists teach particular skills during individual sessions or group sessions and assign homework to help patients cultivate stronger senses of their personal identity, identify and explore their maladaptive thoughts and assumptions, and engage collaboratively with therapists and other patients.3

Stages of Therapy

Initially, therapists focus on identifying and minimizing patients’ most life-threatening or self-destructive behaviors, such as self-harm or thoughts of harming others. They try to stabilize the patient’s mental health before building skills through traditional talk therapy techniques. Then, therapists help patients learn or develop new skills to improve their relationships, self-esteem, self-acceptance, confidence in their abilities, long-term joy, and overall quality of life.

Learned Skills

The main skills taught in DBT sessions are mindfulness, distress tolerance, interpersonal assertiveness, and emotion regulation. These are outlined below:4,5,6

  • Clinicians teach their patients mindfulness—how to be nonjudgmentally self-aware and present in any given moment. Patients are taught to avoid associating their thoughts with positive or negative value judgments and to approach their thoughts neutrally. Mindfulness skills allow individuals to slow down, observe their sensations, and apply healthy coping mechanisms to reduce emotional duress.
  • Often, bad situations worsen when people act impulsively on intense negative emotions. Clinicians teach distress tolerance skills to help patients handle crises during heightened emotional states when they are vulnerable to their thoughts. Patients are taught to distract themselves, do what they can to improve the moment, practice self-care, and rationally observe the pros and cons of allowing the negative experience or thought to persist. This skill allows patients to learn to cope in dire situations and to positively affect their outlooks on life and obstacles. It also incorporates radical self-acceptance.
  • Clinicians teach interpersonal assertiveness—how and when to say “no” and how patients can express their own needs while maintaining healthy relationships and boundaries. Communication is key, and this skill helps patients figure out how to reduce conflict, be more straightforward, deal with difficult individuals, and have more self-respect.
  • Clinicians teach emotion regulation—how to realize, acknowledge, and label emotions correctly. Patients are taught how to make decisions that will increase the frequency of positive experiences or situations, create long-term goals, and focus on ways for the emotions to not drastically change. For example, the acronym GIVE teaches patients to be gentle by not attacking or judging others, show interest by being a good listener, validate and acknowledge others’ feelings, and try to keep an easy attitude.

What to Expect in Therapy Sessions

The weekly individual therapy sessions are administered by either licensed psychologists or DBT-Linehan board-certified clinicians and last about an hour. The clinicians help patients apply learned DBT skills and strategies into daily life while finding solutions for any obstacles in the way of improvement.

In the weekly group therapy sessions, patients are taught new skills and ways to approach life. The group sessions aren’t meant to be a support or process group; rather, it is more like a classroom setting without the pressure of tests. The therapy portion of DBT occurs during individual sessions, not group ones. Lasting about 1.5 to 2.5 hours, group sessions provide a place to practice mindfulness skills, such as mindful eating, coloring, or meditation. Clients also discuss insights realized while they completed the assigned work for the week to make small, tangible changes. They then spend time learning about the main modules: mindfulness, distress tolerance, interpersonal skills, and emotion regulation.

Purpose of Sessions

DBT strongly emphasizes acceptance and change. In this framework, most situations are neutral and lack good/bad or right/wrong value judgments. Life is considered fluid, and DBT advocates dynamic approaches for addressing each situation. Ultimately, patients are taught to pursue a long-term, higher quality of life by accepting who they are—as they are—and by changing any maladaptive behaviors they can control. DBT is based on the idea that people will live fuller, more enjoyable, and more enriching lives when they accept their current reality while also acknowledging and changing any of their personal shortcomings or negative behaviors.5

How Effective Is Dialectical Behavioral Therapy?

People of all ages, genders, sexual orientations, and ethnicities can benefit from this evidence-based form of therapy.

Research has demonstrated the following findings regarding DBT’s effectiveness in the treatment of borderline personality disorder, depression, anxiety, and substance use disorders:

  • It decreases suicide attempts and depression and increases anger control among people who have borderline personality disorder.7
  • It significantly improves depressive symptoms among treatment-resistant individuals with major depressive disorder.8
  • It reduces the frequency of deliberate self-harm and improves emotion regulation in adults who self-harm or meet the criteria for borderline personality disorder.9
  • It improves the effects of antidepressant medications in older adults with depression.10
  • It improves depression and emotion dysregulation and decreases suicide attempts among adolescents who exhibit suicidal and self-injurious behavior.11
  • It reduces emotional dysregulation among people with depression and anxiety.12
  • It improves mood and decreases substance-use frequency among women who have substance-use dependence and borderline personality disorder.2,13
  • It significantly improves depression, anxiety, interpersonal functioning, social adjustment, and self-mutilation among people who have borderline personality disorder.3,4,7

Some of these findings are elaborated on below.

Researchers at St. Patrick’s University Hospital in Ireland explored DBT’s impact on patients who self-harm. A sample of 103 patients aged 18–60 years who either deliberately self-harmed or were diagnosed with borderline personality disorder were randomly enrolled into a DBT-informed skills group or a control group. Their frequency of self-harm, anxiety, depression, and emotion regulation were assessed at baseline and post-intervention. The researchers found significant reductions in the frequency of deliberate self-harm, which were maintained at the 3-month follow-up.9

A group of researchers investigated the efficacy of DBT for patients with bulimia nervosa. A sample of 31 women who, on average, binged/purged at least once a week were randomly assigned to DBT or a control group. The results revealed that DBT and the learned emotion regulation skills were associated with a significant decrease in the rate of binge/purge behaviors.14

Neacsiu, Rizvi, and Linehan evaluated the efficacy of DBT and whether the skills learned in sessions mediated or changed the treatment outcomes, such as suicide attempts, non-suicidal self-injury, anger, and depression. The study involved a sample of 108 women who were diagnosed with borderline personality disorder. The researchers found evidence that an increase in DBT skills decreased the likelihood of suicide attempts. This study suggested that enhancing and increasing behavioral skills through DBT was a mechanism for change in suicidal behavior, depression, and anger control.12

DBT may help improve the following mental health disorders:2,3,8,9,14,15,16

  • major depression
  • bulimia nervosa
  • borderline personality disorder
  • binge-eating disorder
  • bipolar disorder
  • posttraumatic stress disorder
  • substance use disorder
  • attention-deficit/hyperactivity disorder

References

  1. Chapman, A. L. (2006). Dialectical behavior therapy: Current indications and unique elements. Psychiatry, 3(9), 62–68.
  2. Axelrod, S. R., Perepletchikova, F., Holtzman, K., & Sinha, R. (2011). Emotion regulation and substance use frequency in women with substance dependence and borderline personality disorder receiving dialectical behavior therapy. American Journal of Drug and Alcohol Abuse, 37(1), 37–42.
    https://doi.org/10.3109/00952990.2010.535582
  3. Bohus, M. (2008). Effectiveness of dialectical behavioral therapy for borderline personality disorder under inpatient conditions: A controlled trial and follow-up data. European Psychiatry, 23.
    https://doi.org/10.1016/j.eurpsy.2008.01.237
  4. Stepp, S. D., Epler, A. J., Jahng, S., & Trull, T. J. (2008). The effect of dialectical behavior therapy skills use on borderline personality disorder features. Journal of Personality Disorders, 22(6), 549–563.
    https://doi.org/10.1521/pedi.2008.22.6.549
  5. Choudhary, S., & Thapa, K. (2012). Dialectical behavior therapy for managing interpersonal relationships. Psychological Studies, 57, 46–54.
    https://doi.org/10.1007/s12646-011-0132-8
  6. Behavioral Tech. (n.d.). DBT training and certification. Retrieved January 17, 2021, from
    https://behavioraltech.org/resources/faqs/training-faqs/
  7. Fleischhaker, C., Böhme, R., Sixt, B., Brück, C., Schneider, C., & Schulz, E. (2011). Dialectical behavioral therapy for adolescents (DBT-A): A clinical trial for patients with suicidal and self-injurious behavior and borderline symptoms with a one-year follow-up. Child and Adolescent Psychiatry and Mental Health, 5, Article 3.
    https://doi.org/10.1186/1753-2000-5-3
  8. Harley, R., Sprich, S., Safren, S., Jacobo, M., & Fava, M. (2008). Adaptation of dialectical behavior therapy skills training group for treatment-resistant depression. Journal of Nervous and Mental Disease, 196(2), 136–143.
    https://doi.org/10.1097/NMD.0b013e318162aa3f
  9. Gibson, J., Booth, R., Davenport, J., Keogh, K., & Owens, T. (2014). Dialectical behaviour therapy-informed skills training for deliberate self-harm: A controlled trial with 3-month follow-up data. Behaviour Research and Therapy, 60, 8–14.
    https://doi.org/10.1016/j.brat.2014.06.007
  10. Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003). Dialectical behavior therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric Psychiatry, 11(1), 33–45.
    https://doi.org/10.1097/00019442-200301000-00006
  11. MacPherson, H. A., Cheavens, J. S., & Fristad, M. A. (2013). Dialectical behavior therapy for adolescents: Theory, treatment adaptations, and empirical outcomes. Clinical Child and Family Psychology Review, 16(1), 59–80.
    https://doi.org/10.1007/s10567-012-0126-7
  12. Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59, 40–51.
    https://doi.org/10.1016/j.brat.2014.05.005
  13. Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832–839.
    https://doi.org/10.1016/j.brat.2010.05.017
  14. Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158(4), 632–634.
    https://doi.org/10.1176/appi.ajp.158.4.632
  15. Zargar, F., Haghshenas, N., Rajabi, F., & Tarrahi, M. J. (2019). Effectiveness of dialectical behavioral therapy on executive function, emotional control and severity of symptoms in patients with bipolar I disorder. Advanced Biomedical Research, 8, 59.
    https://doi.org/10.4103/abr.abr_42_19
  16. Görg, N., Böhnke, J. R., Priebe, K., Rausch, S., Wekenmann, S., Ludäscher, P., Bohus, M., & Kleindienst, N. (2019). Changes in trauma-related emotions following treatment with dialectical behavior therapy for posttraumatic stress disorder after childhood abuse. Journal of Traumatic Stress, 32(5), 764–773.
    https://doi.org/10.1002/jts.22440

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