Individuals with borderline personality disorder can be very difficult to treat. Not only are they heavy users of the mental health system, even the most compassionate and seasoned therapists often find it taxing to deal with their constant crises, volatile moods, abandonment issues, and frequent suicidal threats and behaviors. Most therapeutic approaches seemed to have limited benefit, at best. That is, until dialectical behavior therapy came along.
Dialectical behavior therapy was developed by Dr. Marsh Linehan and her colleagues at the University of Washington in the late 1970s. Linehan, with a background in behaviorism, began developing the concept when she was seeking an effective form of treatment for women who struggled with suicidal thoughts and behaviors, as well as tendencies to physically hurt themselves (common symptoms of individual with borderline personality disorder). The initial concepts evolved into what is now known as dialectical behavior therapy or DBT for short.
DBT is based on the concepts of cognitive behavioral therapy and is considered to be a form of CBT. However, it varies from CBT in that it also incorporates Eastern mindfulness practices and a dialectical perspective to treatment. Dialectical refers to integrating or balancing polar opposites in order to find the middle ground.
DBT, as a formal, comprehensive treatment program, has shown to be very effective for the treatment of borderline personality disorder, as well as several other disorders. It focuses on helping individuals regulate and manage intense emotions, develop healthy interpersonal skills, and learn to tolerate stress.
This therapeutic approach is unique in its multi-faceted approach. It utilizes individual therapy sessions, group sessions, weekly team consultations to provide support for the primary therapist, and client phone calls to the therapist (within established boundaries) between sessions if therapy clients need them.
The Role of Dialectics
Dialectics is a key principle of DBT that’s based on the idea that all things have a polar opposite. Classic examples include yin and yang, black and white, light and dark, and love and hate. Individuals with borderline personality disorder struggle with extremes in several ways. For example, they tend to engage in black-and-white (all or nothing) thinking. Their moods frequently flip from hot to cold or depressed to euphoric very abruptly. They idolize – then suddenly devalue – their relationship partners (as well as their therapists).
Individuals with BPD tend to be highly reactive. When they come into treatment, the therapist faces the challenge of validating their feelings and behavior (in the sense that they’re understandable, based on the person’s history, etc.). However, at the same time, the therapist’s goal is to help them change the very things he or she just validated. The dialectical aspect of DBT supports this delicate balancing act that occurs throughout treatment.
Dialectics allow us to truly appreciate and understand opposites. You see, it’s impossible to really understand light without also understanding it’s polar opposite, which is darkness. Likewise, we can’t fully understand or appreciate what it means to hate without also understanding what it means to love. Our minds can make sense of something and appreciate it more fully when we understand and appreciate its polar or extreme opposite.
Even though individuals with borderline personality disorder are notoriously difficult therapy clients, dialectics enable DBT therapists to work from the assumption that their clients are genuinely doing their best – no matter how bad their behavior – because it’s what they’ve learned in life – up until DBT. At the same time, the therapists also view their clients with the empowering and motivating assumption that they can learn new skills and will use them. DBT therapists understand and validate the reasons for the client’s self-destructive, unhealthy behaviors and intense negative emotions even though they don’t agree with them or regard them as acceptable or healthy.
The elegance and power of the dialectical philosophy is this: by simultaneously holding these two contradictory (or opposing) assumptions DBT clients feel genuinely validated and supported. This enables them to reconcile the internal conflict that arises when the push for change (the reason for treatment in the first place) seems to invalidate their emotional distress.
This philosophy is also valuable to therapists because it makes it easier for them to feel compassionate towards and accepting of difficult clients who might otherwise elicit strong feelings of irritation and frustration.
Four Modules of DBT
Treatment in DBT is divided into four modules, each of which is geared to help therapy clients develop essential life skills that will enable them to live a happier, more peaceful, and more fulfilling life. The four modules were designed to address the deficits typically found in individuals with borderline personality disorder. However, learning or strengthening these skills can be beneficial to individuals with a wide range of mental health issues.
The four modules of DBT are:
- Core mindfulness
- Emotion Regulation
- Distress tolerance
- Interpersonal effectiveness
Core mindfulness – The focus of this treatment module is to help clients develop mindfulness skills. Mindfulness entails learn to be mindful – to become more self-aware by being present in the moment and paying attention to (or “mindful of”) one’s thoughts, feelings, and behaviors. The origins of mindfulness can be found in Buddhism and Eastern philosophies. The practice of mindfulness is essential for making progress in the other three modules. Individuals with borderline personality disorder tend to be very impulsive and emotionally reactive; practicing mindfulness helps reduce these tendencies.
Emotion regulation – Poor emotion regulation is one of the hallmark symptoms of borderline personal disorder. However, many people who don’t have BPD also have deficits in this area. In this DBT module clients learn to identify, understand, and manage their emotions, and decrease their vulnerability to those that are painful and distressing emotions. In this module clients are taught to identify and evaluate emotional triggers, including how they interpret situations. They also look at how they act out their emotions and the consequences and impact of those behaviors.
Distress tolerance – This DBT module helps clients become more accepting and less judgmental of themselves. It also teaches them to tolerate stressful situations by distracting themselves, soothing themselves, and viewing the situation without judgment. This is essential for individuals with BPD, who have a very low stress threshold. Distress tolerance includes learning to handle and survive crises without doing things that make it worse.
Interpersonal effectiveness – The final module of DBT is to teach clients effective interpersonal skills. Individuals with borderline personality disorder are highly sensitive to perceived or real abandonment and rejection. Their volatile emotions and other maladaptive behaviors strain and often destroy their relationships, leading to more abandonment and rejection. This DBT module teaches them to set appropriate boundaries, become more assertive, handle conflict in a constructive manner, and to get their needs met from others without the use of manipulation or other unhealthy tactics.
Key Characteristics of DBT
Following are three characteristics that play a key role in dialectical behavior therapy:
Cognitive-based – Dialectical behavior therapy is rooted in cognitive behavioral therapy. Like CBT, DBT therapists work with their clients to identify irrational beliefs, negative thought patterns, and flawed assumptions that contribute to the problems in their lives and trigger negative emotions. Individuals with borderline personality disorder have a very distorted view of themselves and the world. The cognitive component of DBT helps clients begin to replace their problematic internal dialogue and irrational beliefs with self-talk that’s more objective, less judgmental, and more accepting.
In fact, several of the strategies used in DBT are common cognitive-behavioral techniques, such as exposure therapy, contingency management, learning and practicing new skills, and problem-solving.
Collaborative – DBT therapists work closely with their clients in a nonjudgmental, collaborative partnership to help them make positive changes and reach their treatment goals. Therapists encourage their clients to be open and honest with them about any troubling issues they may be experiencing in the therapeutic relationship – and vice versa. This is an opportunity for clients to practice the interpersonal skills they’re learning in treatment in a safe and supportive environment.
Therapists use this opportunity to teach and reinforce appropriate boundaries, to teach effective interpersonal skills, and to point out unhealthy behaviors that are negatively impacting the therapeutic relationship. The therapeutic relationship itself can be one of the most powerful teaching tools to help clients master the skills they’re learning in DBT. Homework assignments are used to practice and reinforce the skills that are learned.
Support-oriented – One of the goals of DBT is to ensure that clients (and therapists) feel very supported as they go through treatment. When people feel genuinely supported, it boosts their self-esteem and allows them to lower their defenses. Lowered defenses make them more teachable as well. The supportive environment enables clients to focus on their therapy goals, which in turn, enhances the treatment process. Therapists also receive much-needed support in the weekly consultation team meetings with other therapists in the DBT program.
Five Objectives of DBT
Dialectical behavior therapy is a comprehensive psychotherapeutic approach that is purposely designed to accomplish 5 specific objectives. If a program fails to meet any one of these objectives – including those that have been adjusted to work under certain circumstances or in a particular setting – then it doesn’t qualify as DBT.
The 5 objectives are as follows:
Strengthen and improve the client’s skills (e.g. emotion regulation, distress tolerance, etc.). This objective is typically achieved via the use of weekly skills group sessions.
Generalize the client’s skills to his or her daily life – the client’s world outside the therapeutic setting. This objective is typically achieved in skills training as part of individual therapy sessions. Clients are taught new skills and instructed practice them as part of homework in between sessions.
Strengthen the client’s motivation for change and decrease the frequency and occurrence of maladaptive behaviors. This is typically accomplished in individual therapy sessions. Therapists have clients fill out a weekly diary card, which is a form of self-monitory. The diary card allows therapists to track their client’s progress in terms of treatment goals (e.g. ceasing self-harm behavior). The treatment goals are prioritized, starting with the most urgent (e.g. suicidal thoughts and behaviors) to the least urgent. The diary card may also contain behaviors that negatively pertain to therapy itself, such as always being late for sessions.
Strengthen and support the therapist’s skills and motivation – This DBT objective – which is accomplished by weekly therapist consultation-team meetings – focuses on sustaining and supporting the therapist who’s the client’s primary treatment provider in the DBT program. Because borderline clients can be especially challenging and even exhausting to work with, therapists are vulnerable to burning out, questioning their abilities, and / or losing their objectivity and motivation. If any of these things occurred, it would be detrimental to the client’s progress. The weekly team meetings give the therapist an opportunity to consult the other therapists regarding the client’s treatment, but to also talk about any challenges the therapist is experiencing in the process.
Structuring the treatment environment to help ensure the client’s success – Problems in the therapy setting, including problems in how treatment is delivered, will hinder the progress clients make while they’re in treatment. This fifth objective of DBT ensures that every aspect of the treatment environment is structured in a way that fosters optimal progress in each therapy client.
What to Expect in DBT
Although there are modified versions of dialectical behavior therapy, most DBT programs are structured as follows:
- Weekly individual therapy sessions with your primary therapist
- Telephone contact with your primary therapist in between sessions
- Weekly group therapy sessions that typically last from 2 to 2 ½ hours. Group sessions focus on learning the skills listed above in the 4 modules. These sessions may be led by a different therapist than your primary therapist
Disorders, Issues, and Conditions that can benefit from DBT
Although DBT is one of the most effective types of therapy for borderline personality disorder, it is also a valuable and effective treatment for many other mental health disorders and other problems. They include:
- Suicidal thoughts and behavior
- Self-harm behavior
- Relationship problems
- Eating disorders
- Bipolar disorder
- Substance abuse and addiction
- Poor emotional regulation
- Self-destructive behavior
- Abandonment issues
- Persistent all-or-nothing thinking
- Anger issues
- Low self-esteem
- Trauma recovery
Benefits and Advantages of DBT
Some of the benefits and advantages of DBT include the following:
- It teaches practical, valuable skills that can be used to improve all areas of your life
- It is a highly structured treatment approach
- It emphasizes the importance of a supportive, nonjudgmental environment
- Therapists and clients have a collaborative therapeutic relationship
- Clients have ample opportunity to practice the skills they are learning in therapy sessions
- It’s one of the most effective treatments for borderline personality disorder
- DBT therapists (in formal DBT programs) receive weekly support from their colleagues, which enables them to provide better treatment and reduce the chance of burnout
- It’s an effective treatment approach for many different problems and disorders in addition to BPD
- Many health insurance companies recognize the effectiveness of DBT for individuals with borderline personality disorder; as a result they are willing to cover at least some of the cost for this particular treatment
Where to Find a Standard DBT Program
One of the biggest potential drawbacks of DBT is that many individual therapists, mental health clinics, and other treatment settings claim to provide “dialectical behavior therapy”. In reality, however, they are provided a substantially modified version of DBT, and not the well-researched, evidence-based DBT as designed by Linehan and associates. Many opponents of DBT use this as one of the arguments against this particular form of therapy – that too many therapists aren’t properly trained or using the treatment approach as intended by Linehan and as supported by research.
This can make it difficult for the lay person who’s looking for a standard DBT treatment program and not some version of DBT that may or may not be as effective. “Standard” is the qualifying term used by many DBT programs to indicate that they are set up and follow Lineman’s official protocols for conducting this type of therapy.
Therapists who haven’t been properly and formally trained in dialectical behavior therapy may still effectively use some of the concepts and strategies, but it won’t really be “DBT”.
Standard DBT programs are available – it just takes a bit of research to make sure that you’ve found one if you want the “real deal”, so to speak. Before committing to a treatment program, be sure to enquire about the program set up and if the program – and the therapists in it – have all been certified in DBT.
The Linehan Institute is currently developing a website that will include a list of certified DBT therapists and programs.
Dialectical behavior therapy has many strengths. However, as with all therapies, it’s not appropriate for everyone. If you’re interested in working with a qualified DBT therapist or enrolling in an official DBT treatment program, contact a DBT provider in your area to determine if this might be a good fit for you.