dialectical behaviour therapy

dialectical behaviour therapy (DBT), in psychotherapy, a type of cognitive behaviour therapy (CBT) that emphasizes the acceptance of all feelings and behaviours while at the same time attempting to change some of those behaviours.

History

Dialectical behaviour therapy (DBT) was developed in the 1980s by the American psychologist Marsha Linehan, who viewed standard CBT as insufficient for treating chronic self-harm and suicidal behaviours, such as those stemming from borderline personality disorder (BPD). Linehan found that standard CBT often led patients to become hostile or to abandon therapeutic programs altogether, because the patients tended to experience the programs’ emphasis on life changes as invalidating. DBT is one of several forms of psychotherapy that were developed in what is known as the “third wave” of CBT programs. These treatments focused on the importance of expressing acceptance of patient experiences rather than avoiding or condemning them. DBT is unique in that it embraces the dialectics of this treatment—that is, the conflict between accepting all feelings and behaviours without judgment while still attempting to change them. In the 1980s and ’90s, DBT was shown to be clinically effective in treating BPD and parasuicidal behaviours (i.e., apparent acts of attempted suicide performed with or without the intention of causing one’s own death), and since then it has been applied successfully to many other conditions related to emotional dysregulation (i.e., the poor regulation of emotional responses).

Characteristics

DBT is based on the concept of dialectic, or the synthesis of opposing forces. This way of thinking is itself a part of the DBT program—learning to see and think in dualities rather than in black-or-white dichotomies. For example, finding a “both-and” approach to understanding one’s own behaviour and feelings helps that individual see an experience as being both biologically and socially induced as well as both acceptable and changeable. The dialectic element of DBT is often described as borrowing a mindfulness component from Zen Buddhism, and in fact mindfulness is one of the major skills patients are taught during DBT.

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In its original form, as Linehan describes it, DBT as a therapeutic program includes skills training conducted in groups, individual therapy sessions, phone contact between patients and therapists, and team meetings for therapists and consultants without patients. The skills training specifically addresses the following four abilities: mindfulness, emotional regulation, interpersonal skills, and stress tolerance. The individual therapy sessions develop these skills in the patient and introduce a mindset of acceptance while finding areas of change. The phone contacts are an attempt to help patients apply these skills not only in therapy sessions but in their daily life environments. The therapist team meeting is meant to increase motivation for the therapists and to avoid their exhaustion or burnout, with the ultimate goal of improving therapeutic outcomes for patients.

These components of DBT are applied to bring patients through four stages of treatment. Stage one helps patients out of a self-destructive phase of misery that can cause parasuicidal behaviours. Stage one can also include working to eliminate dangerous or counterproductive behaviours or conditions, such as substance abuse and homelessness. This stage of treatment is often considered the stabilizing and behavioral-control stage. Stage two attempts to replace emotional problems such as quiet desperation and numbness with calm emotional experiences. In general, this stage focuses on regulating emotions. Stage three addresses interpersonal behaviours and any difficult practical life situations with the goal of reducing disorder in daily life. Stage four attempts to replace feelings such as general emptiness with joy and a sense of well-being.

DBT has also been described in terms of its functional goals, which include giving patients new skills and abilities, improving patients’ motivation to make changes in their lives, and helping patients to apply their skills and abilities to real-life situations. DBT programs also aim to manage the types of contacts between patients and therapists and to ensure the quality of patient care through regular meetings between therapists and teams of consultants. Generally speaking, practitioners of DBT view it as a means of assisting people who engage in harmful behaviours in response to difficult emotions by teaching them coping skills that they can use to regulate their emotions in a healthy nondestructive manner.

Applications

Although DBT was originally developed for patients experiencing chronic suicidal behaviour and BPD, it has since been applied to many psychological conditions. DBT has been shown to be effective in reducing self-harming behaviours among adolescents, eating disorders, mood disorders, substance abuse, and post-traumatic stress disorder (PTSD). Current studies continue to examine how to best focus the components of DBT in the treatment of a variety of psychological conditions.

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