What is Dialectical Behaviour Therapy?

Dialectical Behaviour Therapy was developed for clients with Borderline Personality Disorder (BPD), who felt invalidated when practitioners of the then-predominant Cognitive Behaviour Therapy (CBT) challenged their thoughts. This article examines its underpinnings, treatment functions and stages, and treatment modalities.

Related articles: Dialectics, DBT and the Therapeutic Process, Integrating DBT Group Training Skills to Other Approaches, Case Study: DBT and Bulimia Nervosa.

Introduction

Dialectical Behaviour Therapy, or DBT, was developed in 1991 by U.S. psychologist Marsha Linehan for use specifically with clients diagnosed with borderline personality disorder (BPD), who cope with distressing emotions and situations by using self-destructive behaviours such as suicide and self-harm, eating disorders, and substance abuse. Linehan’s assessment of the therapies available to BPD clients at the time was that traditional treatments were “woefully inadequate” (1993, p 3).

DBT has nearly three decades of research behind it and is considered the “gold standard” for the treatment of BPD (Grohol, 2018). Investigations have shown that DBT is effective at reducing the harmful behaviours that go with BPD diagnosis. As an example, a randomised controlled study (RCT) within a routine Australian public mental health service was conducted in which adult patients with BPD were provided with outpatient DBT for six months. Patient outcomes were compared to those obtained from patients in a wait list group receiving treatment as usual. After six months, the DBT group showed significantly greater reductions in suicidal and non-suicidal self-injury, emergency department visits, psychiatric admissions, and bed days. On self-report measures, the DBT patients demonstrated significantly improved depression, anxiety and general symptom severity scores compared to the treatment-as-usual group. Average treatment costs were significantly lower for those patients in DBT than those receiving treatment as usual (Pasieczny & Connor, 2011).

Increasing numbers of investigations since that 2011 study have found similar results – that is, that DBT is superior to “treatment as usual” and to other therapies used to treat BPD. Thus, researchers and clinicians began to ask if it could be used to help with other disorders. By the turn of the millennium, a burgeoning number of studies saw it successfully adapted for use with domestic violence, in forensic settings, for substance abuse, and in the treatment of elderly individuals with depression (Miller & Rathus, 2000; MacPherson, Cheavens, & Fristad, 2013). The myriad randomised trials conducted in the two decades since then have seen DBT’s star shine even more brightly as researchers, clinicians, and consumers alike are captivated by its sound research backing with a multimodal, principle-based treatment conceptualising emotional dysregulation as the core of myriad emotional difficulties. Its compassion-engendering stance, based on Linehan’s biosocial theory, has endeared it to all parties (Miller, 2015).

Speaking foundationally: The theoretical underpinnings of DBT

When Dr Linehan began working with her borderline clients, she was using the then-dominant modality of cognitive behavioural therapy (CBT), which challenges clients to re-evaluate irrational, unhelpful cognitions and replace them with kinder, more realistic ones. Her clients, however, typically felt invalidated by having their thoughts challenged. She further realised that many of the clients with the BPD diagnosis seemed to have a high degree of emotional vulnerability, and would react intensely to stressors, taking longer than normal to return to baseline levels of calmness. Emotional dysregulation was constant, threatening their lives, the therapy, and certainly their relationships. Thus, a new therapy was needed for this population, one which would: (1) be highly supportive; (2) show acceptance of the client while still suggesting that change might improve the client’s quality of life; and (3) help clients to live more in the present moment, not over-reacting to every stimulus. The therapy, most importantly, needed to keep clients engaged in therapy while teaching them how to regulate their emotions. Thus DBT – an incorporation of behavioural science, dialectical philosophy, and Zen practice – was born (Miller, Rathus, & Linehan, 2017; MacPherson, Cheavens, & Fristad, 2013).

What do you mean, “dialectical”?

Both dialectical philosophy and biosocial theory underlie DBT. Dialectics can be said to be the mind’s way of understanding things by comprehending their polar opposites. We perceive most core concepts in this way; for instance, we know light because we have experienced darkness, happiness because we have experienced sorrow, and fidelity because we have experienced betrayal. Dialectics is based on the notion that we fully comprehend things when we perceive not only the pair of polar opposites, but also, the integration of the two at a higher level. Not only concepts, but all of existence relies on the fact that the world is constructed and perceived around seeming opposites (Elliott, 2010).

In more technical language, then, we can state that dialectics posits a worldview characterised by wholeness, interrelatedness, and process. It does not assert that a single, objective truth exists. Rather, it sees the simultaneous existence of opposing forces, each of which has its own piece of truth. The objective of therapy is to reconcile the two poles, recognising the validity in each and seeking a synthesis (MacPherson et al, 2013). Clients accordingly are urged to come into relationship with the opposites, embracing the “both and”.

“Opposites” as two sides of the same coin

The problem is that the word “opposite” implies something antagonistic and irreconcilable. Yet Eastern mystic traditions and even modern physics have been showing us that what often seem like totally opposite ideas are in fact, two sides of the same coin, each representing a side of the truth. The same holds true for views of our self and others. Thus, applied to the world views commonly experienced by BPD clients (and as researchers and clinicians have seen, many with other disorders as well), we can look at seemingly opposite perspectives which people could hold about themselves or the world which lead to a similar, poor outcome:

• Both people who feel ultra-dependent on others and also those who must be independent at all times often fail to get useful help when it would come in handy

• Both folks who feel blameworthy most of the time and also those who fail to accept appropriate blame tend to have blame thrown at them

• Both people who feel unworthy of having their needs met and also those who feel excessively entitled tend to cause people to avoid meeting their needs (Elliott, 2010).

The integrated middle ground leading to healing

The list of extreme, opposite views of self and others is endless, but sadly, most examples from it produce the same rigid stances, tumultuous feelings, damage to relationships and health, and unrealistic expectations that burden the client. Enter DBT: Linehan’s therapy for helping clients to find an integrated middle ground that puts them on the road to healing (related reading: Why Mental Health is Not the Opposite of Mental Illness). That is: the client learns how to hold a point of tension with notions such as, “I need to learn to help myself” and “It is ok to ask for help sometimes” and with propositions such as, “My therapist fully accepts me” and “She is suggesting some behaviours that I might want to change”.

Dialectics in therapeutic dialogue and in relationship refers to change by persuasion, making use of oppositions found in the therapeutic relationship, and continually probing to see what has been left out of understanding, thus opening the door to a reduction in polarised thoughts and behaviours.

The DBT therapist also uses communication strategies to help clients see how opposing desires or views can exist within a single person, causing conflict. Thus, a client could proclaim, “I want to die” and also “I want to live”. It is in the recognition and acceptance of this dialectical tension that both therapist and client can move past a treatment standstill and embrace change. Of course, the central dialectic in DBT is the inherent tension between acceptance and change (MacPherson et al, 2013).

Biosocial theory

Biosocial theory, meanwhile, arises from recognition of the deficits in understanding, skills, and techniques in earlier (mostly CBT) work with BPD clients. The theory suggests that BPD is primarily a problem with emotion regulation: that is, the ability to monitor, evaluate, and modulate one’s affective state (i.e., when and how emotions occur, and how one experiences and expresses those emotions) in order to accomplish one’s goal. Specifically, Linehan observed that the emotional, behavioural, interpersonal, and cognitive self-dysregulation of borderline individuals was developed and maintained through the interaction between a biological tendency toward emotion dysregulation and an invalidating environment. An early biological vulnerability – expressed as impulsivity in childhood – has also been identified as a precursor to the development of BPD (Crowell, Beauchaine, & Linehan, 2009).

Invalidating environments prioritise self-control and self-reliance

Characteristics of emotional vulnerability typically include high sensitivity to emotional stimuli, emotional intensity, and as we noted above, slow return to emotional baseline. An invalidating environment negates, punishes, and/or responds erratically (usually, inappropriately) to the child’s experiences, punishes emotional displays, unevenly reinforces emotional escalation, and oversimplifies problem-solving (MacPherson et al, 2013). The invalidating experiences could be, for example, those of not accepting the child’s personal communications as an accurate indication of her true feelings, or implying that – even if the communications were a true reflection of her feelings – having such feelings would not be valid for the circumstances. Invalidating environments, found Linehan, tend to place a premium on self-control and self-reliance. Caregivers in such environments tend to believe that any difficulties in achieving those qualities show characterological deficits and that inability to perform to the expected standard is therefore due to the child being either lazy or unmotivated (Tartakovsky, 2020).

Poles of emotional inhibition and spectacular display of emotion persist with intermittent reinforcement

Being told that one’s reactions are not an accurate indication of one’s feelings – and that, even if they were, they would be inappropriate for the situation – means that the person cannot learn to label feelings, or to trust them as valid reactions to events. Similarly, such an individual will have greater difficulty coping with stressful situations, because her reactions (perceptions of problems) are not acknowledged. Believing that she cannot cope, she is thus led to look externally, to others, for indications of how she should feel and for help with solving problems. By definition, an invalidating environment will be even less capable than a normal one of allowing her to make demands on others. The heightened perception of need for help combined with the diminished possibility of receiving it set up a situation of pinging back and forth between two poles: emotional inhibition, on the one hand, in order to gain acceptance and spectacular displays of emotion – in order to have feelings acknowledged – on the other. The poor-quality environment, relationally speaking, will not know how to handle such extreme oscillation, resulting in intermittent reinforcement: the response that, according to behaviourism, will most surely result in the behaviour persisting.

Swinging between poles results in emotional dysregulation

The consequence of persistent (partially reinforced) swinging back and forth between emotional inhibition and emotional overreaction sets up a failure to control and regulate emotions. BPD clients are characterised by a lack of skill with emotional modulation. The resultant emotional dysregulation combines with the person’s emotional vulnerability and the invalidating environment to produce the typical symptoms of BPD. The childhood sexual abuse experienced by most BPD clients is perhaps the most common and also most extreme form of invalidation (Mental Health Academy, 2013).

We have been talking about how borderline personality disorder comes to be set up in order to show how Linehan’s development of DBT was a specific response to perceived deficits in then-available therapy for those clients with diagnosed BPD. The symptoms of BPD sufferers are similar to those of other disorders, with whom DBT has also come to be used. The similarity can be boiled down, at its base, to what empirical research has established: namely, that emotion dysregulation has a central role, not only in BPD, but also across broad areas of psychopathology (Nolen-Hoeksema, 2012). We turn now to the framework of functions, stages, and modalities that a DBT program would typically include.

Treatment functions and stages

The theoretical underpinnings of DBT (as noted above) inform its treatment functions and stages.

The functions

There are held to be five functions of DBT:

1. Motivating the client to make a commitment to change.
   
2. Teaching the client to become more capable of taking care of him/herself by learning new skills.
   
3. Assuring generalisation of skills learned to the natural environment beyond the treatment setting.
   
4. Structuring the environment so that it reinforces adaptive rather than dysfunctional behaviours, ensuring that unsafe behaviours are not inadvertently reinforced, and that practitioners observe their own behavioural limits in their own practice settings.
   
5. Enhancing therapist competence and motivation to maintain effective treatment (Harvey & Rathbone, 2013; MacPherson et al, 2013).

There is a (primary) DBT program modality for each of the above functions, although DBT practitioners acknowledge that each function tends to be addressed through several modalities. The functions come to be manifest over the stages of a typical DBT program which, for adults, has been six months to one year long (Choate, 2012; Miller et al, 2017).

The stages

Linehan was clear in setting up early DBT programs that, because there was such a high incidence of attempted and completed suicides, along with non-suicidal self-injury (NSSI) among her BPD clients, there would be a hierarchy of treatment targets for each stage of the programs.

• Pre-treatment stage: Here the therapist orients the client to treatment and obtains commitment to the therapist-client relationship, and to work on the goals. The therapist must also obtain commitment from family members for their roles in the treatment.
• Stage 1: At the first stage of treatment, the hierarchy of skills is most clearly seen. The therapist assists the client in obtaining basic capabilities by fostering skills which reduce: (1) life-threatening behaviours, such as those of suicide and self-injury (highest priority!); (2) therapy-interfering behaviours , such as non-compliance or missing appointments; and (3) quality-of-life-interfering behaviours, such as comorbid psychiatric disorders. At this stage, the therapist is also involved in helping the client to increase behavioural skills.
• Stage 2: Post-traumatic stress is decreased here, replaced by a more normative emotional experience.
• Stage 3: By working on enhancing respect for self and others, this stage is characterised by attempts to achieve ordinary happiness and unhappiness, and an ever-increasing capacity for resolving problems.
• Stage 4: At this final stage, the therapist helps to client to attain the capacity for freedom and ongoing contentment through the resolution of an earlier sense of incompleteness. Many studies examining DBT have focused on Stage 1, but it should be noted that the flexibility of the DBT stages allows therapists to apply DBT principles in their work with clients having various degrees of dysfunction (MacPherson et al, 2013).

The treatment modalities

We should note at this point that DBT can be implemented in a comprehensive way, with all of the modalities that Linehan developed for her BPD clients. As DBT has gained recognition for its efficacy, however, many practitioners have moved to adopt some of the components even though they are unable to do all of them, thus achieving a “DBT-informed” approach. DBT has four modalities. Here is a brief overview of them.

Individual therapy

A client’s individual therapist is the primary therapist and the main work of therapy is carried out in weekly, individual sessions which are (approximately) one-hour-long. BPD clients, the original client population, typically presented multiple problems, posing challenges for their therapist in deciding what to focus on and when: hence the delineation of the above pre-treatment and therapeutic stages. As noted, each stage has clear goals and is structured in terms of hierarchies of targets. The goal behaviours of each stage are brought under control before moving on to the next phase. Every session has a goal of helping the client to think more dialectically; it is here that individual out-of-session work is reviewed and discussion occurs of self-injurious behaviours and obstacles to acting skilfully (Harvey & Rathbone, 2013; Miller et al, 2017).

Skills training

Skills training sessions, often conducted in groups, are not group psychotherapy sessions. Rather, they allow DBT therapists to teach skills that can help people deal with life situations more effectively. Ideally, these skills are conducted by a different therapist than the “primary therapist” with whom the client is having individual sessions. For adults, the skills taught are comprised of four modules or clusters of skills which were recognised as being particularly relevant to BPD clients, but have also come to be seen as very helpful to others with disorders of emotion regulation: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance.

• Mindfulness skills. Derived from certain techniques of Buddhist and other Eastern spiritual practices, mindfulness skills are psychological and behavioural versions of meditation practices which do not involve any religious allegiance to apply them. Essentially they are techniques to enable the practitioner (the client) to become more aware of the contents of experience, and to develop the ability to stay with that experience in the present moment (Pederson, 2017; Choate, 2012).
• Interpersonal effectiveness skills. The response patterns taught in skills training focus on effective ways of achieving one’s objectives with other people; they are similar to many assertiveness and interpersonal problem-solving classes. These include acquiring effective strategies for coping with conflict, asking to have one’s needs met, and saying no (Choate, 2012).
• Emotional regulation. BPD-diagnosed clients, those who are suicidal, and clients with other disorders of emotional dysregulation tend to be emotionally intense and unstable. Mood can range from depressed or anxious to angry or intensely frustrated, so an important aspect of the healing is to learn to regulate their emotions in order to change from distressing emotional states (Linehan, 1993; Harvey & Rathbone, 2013).
• Distress tolerance techniques. In teaching participants how to deal with crises in a more effective way, without having to resort to self-harm or other problematic behaviours, distress tolerance skills have the objective of showing people how to bear pain and distress skilfully. These skills show clients how to accept both themselves and the situation without judgment or evaluation, even though the client might not approve of a given situation (Linehan, 1993; Grohol 2019; Behavioral Tech, 2019).

A fifth skills module added to DBT-A: Walking the middle path. As DBT practitioners began to work with adolescents, they realised the need to add a fifth skills module, in order to give the teens and families the opportunity to apply the behavioural and validation skills (to self and other) that had been taught in other skills modules; they also needed help with dialectical synthesis of opposing viewpoints (Harvey & Rathbone, 2013).

Telephone contact/crisis coaching

One of the more contentious issues related to being a DBT therapist is the requirement to provide telephone contact or crisis coaching, including out-of-hours contact. The therapist, while needing to agree to provide the contact, may nevertheless set limits on it, and in any case the purposes of such contact are clearly defined. It is not for the purpose of doing psychotherapy. Rather, the client may telephone her individual therapist in the following situations:

1. When she needs help dealing with a crisis situation
2. When she is trying to use DBT skills but wants some advice on how to do it
3. When she has good news to report
4. When she wants to repair her relationship with the therapist, and does not want to wait until the next session in order to do it.

In order to avoid reinforcing self-harm, calls are not acceptable after the client has injured herself and – after ensuring her immediate safety – calls are not allowed for a further 24 hours (Miller et al, 2017).

Therapist consultation groups

An essential aspect of the therapy is that therapists, who usually work in teams rather than independently, receive DBT from each other. Working with people who have suicidal ideas and are self-harming can be very stressful (related reading: Identifying and Managing Therapist Burnout), so the members of the group undertake to keep each other in DBT mode: being dialectical with one another and avoiding pejorative descriptions of either client or therapist behaviour. The weekly sessions are a form of group supervision, in which therapists express feelings and concerns about the therapy they are giving, and solicit advice and different ideas for treatment. Members strive to respect one another’s limits and to treat one another as well as they treat their clients (Miller et al, 2017; Choate, 2012).

Summary

In this article we have elaborated on the theoretical underpinnings of dialectical behaviour treatment, noting the central role of dialectics and the foundation of biosocial theory. We have outlined the treatment functions, stages, and modalities that are in play when DBT is used with adults.

DBT training & DBT courses

Following is a curated list of Mental Health Academy DBT training and DBT courses. Click the links to learn more about each course, and enrol (enrolment is available for MHA members only – if you’re not a member, click here to learn more about membership):

• Dialectical Behaviour Therapy (learn more). This DBT course provides an introduction to Dialectical Behaviour Therapy (DBT), with a specific focus on its applications with clients with Borderline Personality Disorder.
• Dialectical Behaviour Therapy for At-risk and Suicidal Adolescents (learn more). In this DBT course, those who work with adolescents and would like to work in a DBT-informed way are shown the theoretical assumptions, principles, and skills/techniques with which they must work if they are to implement successful DBT-A (dialectical behaviour therapy for adolescents) with their clients.
• Dialectical Behaviour Therapy for At-risk and Suicidal Adolescents: Specific Considerations (learn more). In this DBT course, we look into treatment differences between five common presentations for DBT-A therapy, including the theoretical dialectics, case conceptualisation, goal setting, and ongoing assessment tools and change strategies.
• Dialectical Behaviour Therapy for Eating Disorders (learn more). In this DBT course, focusing on DBT adapted for eating-disordered client populations, attendees briefly review standard DBT, examine the DSM-5 definitions of binge-eating disorder and bulimia nervosa, and proceed through detailed sessions showing how to use DBT skills for those with BED and BN. The DBT course framework is based on a 20-session program which has demonstrated efficacy at reducing binge-eating and compensatory behaviours such as purging.
• Dialectical Behaviour Therapy: Case Studies (learn more). In this DBT course, case studies are presented of Sandy, a 39-year-old woman with bulimia nervosa and Aidan, a 20-year-old man who experienced sexual abuse as a child. Both clients go through a DBT program adapted for their needs: eating disorders in Sandy’s case and complex PTSD in Aidan’s. The contents of each program are outlined and highlighting vignettes detailed as the two clients undergo demanding but life-changing therapy programs.

For more courses, visit https://www.mentalhealthacademy.com.au/catalogue

Key takeaways

• Dialectical behaviour therapy, or DBT, has increasingly demonstrated its efficacy, especially for clients diagnosed with borderline personality disorder or other conditions involving emotional dysregulation.
  
• It has five functions, including gaining client commitment to the therapy, teaching them skills, and helping to restructure their environment for success.
  
• There are four treatment stages, plus a pre-treatment stage.
  
• There are four modalities, including individual therapy, skills training, telephone contact, and therapist consultation groups.

References

• Choate, L. (2012). Counseling adolescents who engage in non-suicidal self-injury: A dialectical behavior therapy approach. Journal of Mental Health Counseling, 34 (1), 56-70.
• Crowell, S.E., Beauchaine, T.P., & Linehan, M.M. (2009). A biosocial developmental model of borderline personality disorder: Elaborating and extending Linehan’s theory. Psychological Bulletin, 135, 495-510.
• Elliott, C. (2010). What does dialectical mean? Psych Central. Retrieved on 5 November, 2103, from: https://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy
• Grohol, J. (2018). Another treatment for Borderline Personality Disorder. PsychCentral. Retrieved on 16 May, 2020, from: https://psychcentral.com/disorders/borderline-personality-disorder/treatment
• Harvey, P., & Rathbone, B. (2013). Dialectical behaviour therapy for at-risk adolescents: A practitioner’s guide to treating challenging behaviour problems. Oakland, CA: New Harbinger Publication, Inc.
• Linehan, M. (1993). Skills training manual for treating Borderline Personality Disorder. United States: Guilford Publications.
• 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, 59-80. DOI 10.1007/s10567-012-0126-7
• Mental Health Academy. (2013). Dialectical Behaviour Therapy (course). Mental Health Academy. Retrieved on 23 April, 2020.
• Miller, A.L. (2015). Introduction to a special issue dialectical behavior therapy: Evolution and adaptions in the 21st century. American Journal of Psychotherapy, Vol. 69 (2), 91-95.
• Miller, A.L., & Rathus, J.H. (2000). Dialectical behavior therapy: Adaptations and new applications. Cognitive & Behavioral Practice, 7, 420-425.
• Pasieczny, N. & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial. Behaviour Research and Therapy, 2011, Jan; 49(1) 4-10. Doi: 10.1016/j.brat.2010.09.006. Epub2010 Oct 1.
• Tartakovsky, M. (2020). Living with borderline personality disorder. Psych Central. Retrieved on 16 May, 2020, from: https://psychcentral.com/disorders/borderline-personality-disorder/living-with