Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) was originally developed as a cognitive-behavioral approach to treatment for individuals who (1) meet the criteria for a diagnosis of borderline personality disorder (BPD) and (2) exhibit suicidal behavior (Linehan et al. 1991). DBT can be utilized on an individual basis or as a group skills training (Linehan 1993b, pp. 8–11). Research has shown that DBT is highly effective in the treatment of suicidal behavior among adults with BPD features (Linehan et al. 1993). These findings have been extended to adolescents, which has resulted in the development of Dialectical Behavior Therapy for Adolescents (DBT-A; Miller 1999). To aid in the delivery of DBT for adolescents, a DBT-A Skills Manual was recently published (Rathus and Miller 2015). In addition to borderline personality disorder, DBT has been used to treat a range of other mental health concerns such as substance use disorders (Linehan et al. 2002), eating disorders (Chen et al. 2008), and depression among older adults (Lynch et al. 2003).
Principles of DBT
Dialectical Behavior Therapy (DBT) uses a cognitive-behavioral approach that involves assessment and data collection on client progress, a strong therapeutic alliance between the client and clinician, and the use of treatment strategies that address both maladaptive cognitions and problematic behaviors (Linehan 1993a, p. 19). Although DBT is founded within the framework of cognitive-behavioral therapy (CBT), there are characteristics which distinguish it from other cognitive-behavioral approaches. As the term “dialectical” suggests, DBT operates under the assumption that two opposite notions can coexist simultaneously. For example, one of the most important DBT dialectics is that between change and acceptance. This dialectic posits that “change can only occur in the context of acceptance of what is; however, ‘acceptance of what is’ is itself change” (Linehan 1993a, pp. 98–99). DBT also relies heavily on the combined use of validation and problem-solving skills. Validation involves seeing the value in one’s current emotional-behavioral state while also acknowledging that individual’s capacity for change (Linehan 1993a, p. 99). Problem-solving entails understanding the current problematic behaviors, generating behavioral alternatives (i.e., developing the treatment plan), proposing the treatment plan to the client, gaining the client’s commitment to that plan, and beginning the treatment (Linehan 1993a, pp. 99–100). Finally, because DBT involves working with clients who are often viewed as difficult to treat, clinician consultation with or supervision by colleagues is an essential component (Linehan 1993a, pp. 104–105).
Goals for Treatment
DBT includes three primary treatment goals that are addressed in hierarchical order according to importance. The first treatment goal involves the reduction of self-injurious or life-threatening (i.e., suicidal) behaviors that may pose an imminent risk to the client’s safety and well-being. The second treatment goal involves the reduction of therapy-inhibiting behaviors, which impede the client’s ability to maximize the benefits of therapy. Such behaviors include inattentiveness during therapy, noncompliance with DBT rules, conflict with other clients, or pushing the clinician’s personal limits (Linehan 1993a, pp. 132–135). The third treatment goal involves the reduction of behaviors that create client distress through skills training and problem-solving. The third goal of treatment is primarily concerned with improving the client’s quality of life (Linehan et al. 1991).
DBT Behavioral Skills
Dialectical Behavior Therapy (DBT) involves four skills training modules, each of which addresses strategies to use when encountering specific problematic thoughts and behaviors. The four areas are as follows: “(1) core mindfulness skills, (2) interpersonal effectiveness skills, (3) emotion regulation skills, and (4) distress tolerance skills” (Linehan 1993b, p. 11). Although the order in which modules are taught may vary, mindfulness skills are typically taught first in treatment, as an understanding of mindfulness is essential when learning skills in subsequent modules (Linehan 1993b, p. 12). The mindfulness skills module involves balancing logic or reason with emotion or intuition (Linehan 1993b, p. 63). The interpersonal effectiveness skills module involves communicating with others in ways that preserve one’s self-respect, maintain important relationships, or assist in obtaining something desirable (Linehan 1993b, p. 70). The emotion regulation skills module involves reducing or changing one’s responses to painful emotions, while accepting that painful emotions are often justified (Linehan 1993b, pp. 12, 84). Finally, the distress tolerance skills module involves enduring painful experiences without trying to change one’s circumstances (Linehan 1993b, p. 96).
The first component of DBT is individual therapy, in which the client meets with a clinician to achieve treatment goals. During individual therapy, the clinician should always address any type of self-injurious or life-threatening behaviors at the beginning of each session. After appropriately dealing with self-injurious or life-threatening behaviors, the clinician can address any therapy-interfering behaviors (i.e., behaviors that inhibit progress or could result in termination). Once therapy-interfering behaviors have been discussed, the clinician can target behaviors that affect the client’s quality of life (Linehan 1993a, pp. 102–103). This can be done in a variety of ways. For example, a therapist can ask the client to keep track of behaviors and skill use throughout the week using a diary card (Linehan 1993a, pp. 184–185). Another example is called a “Behavioral Chain Analysis,” which allows the client to understand factors that lead up to problematic behaviors so he or she may intervene before those behaviors occur.
The second component of DBT is skills training, which typically takes place in a group setting with multiple clients and group leaders present. Skills training begins with review of homework from the previous session. During this portion, clients discuss the use of behavioral skills in their daily lives. Once homework review is complete, group leaders can focus on the presentation of new skills material (Linehan 1993a, p. 103). While skills training is most effective in combination with the other three DBT components, there is some evidence that it is one of the most important in terms of client progress (Linehan et al. 2015).
The third component of DBT is phone coaching, in which the client can make phone calls to the clinician between sessions and receive guidance on how to apply skills in his or her daily life (Linehan 1993a, p. 104). For example, phone calls are often made when the client is experiencing thoughts about self-harm or suicide. In this case, the clinician focuses heavily on reducing the crisis and increasing the use of behavioral skills (Linehan 1993a, pp. 188–189).
The fourth component of DBT is a consultation team meeting for the clinician. Consultation is somewhat like therapy for the clinician, as DBT involves working with clients who are often viewed as difficult to treat. During a consultation team meeting, the clinician discusses his or her experiences delivering DBT with clients. The primary goal of consultation is to ensure that the clinician is practicing DBT effectively and that burnout is avoided (Linehan 1993a, pp. 104–105).
Dialectical Behavior Therapy (DBT) is an evidence-based treatment that was developed for clients with borderline personality disorder (BPD) and suicidal behavior. At its core, DBT involves the use of validation and problem-solving skills to reduce the client’s psychological distress. More specifically, DBT relies on training clients in the skill areas of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. While the focus of DBT is primarily on those with BPD and suicidal behavior, there is emerging evidence that DBT is effective in the treatment of a range of psychological issues such as substance use, eating disorders, and elderly depression.
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