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Dialectical Behavior Therapy – DBT

What is Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) is an integration of Cognitive Behavior Therapy (CBT), a Western science based psychotherapy, and a Zen Buddhist approach to mindfulness, an Eastern philosophical and mediation practice.  Together these approaches help DBT clients achieve their behavioral goals by learning how to accept and change both feelings and thoughts, and by learning how to control their attention to these internal experiences.

DBT Development

Dialectical Behavior Therapy (DBT) was developed by Dr. Marsha Linehan. She had been using traditional Cognitive Behavior Therapy (CBT) and Behavior Therapy (BT) with chronically depressed women with high levels of suicidal ideation, suicide attempts, and self-injurious behaviors, e.g., cutting.  Unfortunately, while these psychological treatments had been shown to be very effective for many depressed patients, these women were not responsive, and some in fact, became worse during the CBT treatment.

In an attempt to understand how CBT therapy was making these clients worse, she and her colleagues began conducting behavioral analyses of the sessions.  What they discovered was that these patients and therapists were reinforcing and punishing behaviors in the exact opposite direction of the therapeutic goals.  When these patients directed high levels of anger toward the therapist in response to an intervention, the therapists would frequently avoid that intervention and shift to something else.  Rather than helping the client learn to tolerate, understand, assertively communicate, or decrease her anger response, she learned that expressing anger aggressively would allow her to escape from an uncomfortable exchange with the therapist.  Likewise the therapist learned to avoid that topic.  Of course neither may have been aware in session of what was being reinforced, but nonetheless the pattern was being strengthened, leading to more anger and avoidance, and less growth.

Cognitive Behavior Therapy (CBT)

Cognitive Behavior Therapy (CBT) at the time was also ill suited for this population for a few other reasons.  Most CBT therapies, e.g., Cognitive Therapy of Aaron Beck, Rational Emotive Behavior Therapy (REBT) of Albert Ellis, posit that one of the most significant causes of our emotions is our beliefs or interpretations about a situation, ourselves, other people, or the world.  For example, it is not only that someone stepped on my foot as I waited in line at the DMV that leads to my anger, but also that I thought to myself and believed strongly that, “He must be a selfish guy to not look where he is going and should know better given that he is an adult.”   Together the trigger (having my foot stepped on) and my belief about the action and the guy who did it lead to my incredibly strong feeling of anger.  Standard Cognitive Behavior Therapy (CBT) suggests the best way to change that anger is to take responsibility for identifying one’s beliefs and then challenging the accuracy and logic of those interpretations and rehearsing something more rational.  While this technique had been shown to work for many depressed and anxious patients previously, these chronically depressed, suicidal, self-injuring women often experienced this as invalidation.  In fact, challenging their beliefs, may have made them “feel” as though their feelings about the situation were being challenged and therefore that the CBT Therapist didn’t believe the patients’ anger experience was valid.  This often led to an increase in anger or other negative emotions, like shame or guilt for feeling angry, when they shouldn’t have because it wasn’t a valid emotional response.  While the CBT Therapist was attempting to decrease the negative emotional experience, instead through invalidation the CBT technique of disputation of irrational beliefs were making these patients symptoms worse.

Standard CBT sessions are typically held once per week for approximately 45 minutes, and include setting an agenda at the beginning of the session.  Dr. Linehan, and others who have since treated patients like this, discovered that both the high number of crises presented in session and the intensity with which they were often present make it anywhere from challenging to impossible to follow and complete the therapy agenda.  These patients simply appear to present in ways and to be experiencing crises in a way that make one individual 45 minute session suboptimal as an effective treatment.

Borderline Personality Disorder (BPD)

Although Dr. Linehan was unaware at the time, the symptoms presented by these women seem to fit quite well under the diagnosis of Borderline Personality Disorder (BPD).  BPD involves at least five of nine possible symptoms.  This, of course, means that many different presentations are possible as some clients will present with very different symptoms.

BPD Symptoms include:

  • extreme fears and other feelings about abandonment
  • intense and often volatile interpersonal relationships with lovers, parents, siblings, friends, and co-workers
  • unstable and poor self-concept, impulsive and risky behaviors that could include unsafe sex, overspending, overeating
  • frequent suicidal ideation and/or urges to self-injure
  • intense and often rapidly shifting emotional states
  • chronic feelings of emptiness
  • anger management problems, often involving intense emotional experiences and self-defeating ways of expressing the anger
  • dissociative symptoms

When she began this work, no effective treatment for Borderline Personality Disorder (BPD) existed.  Therefore, her work to first conduct a thorough assessment of why standard Cognitive Behavior Therapy (CBT) was making these women suffering from BPD worse, was the beginning of the development of Dialectical Behavior Therapy (DBT).

Dialectical Behavior Therapy (DBT)

Dr. Linehan had some experience with Christian contemplative prayer and also Zen Buddhism.  And she had already been well trained as a behaviorist, i.e., the scientific and clinical approach to psychotherapy based on learning principles such as classical and operant conditioning.  The challenges to treating women with BPD were numerous and complex.  They were experiencing high levels of emotional suffering, had few healthy and stable interpersonal relationships, had difficulty inhibiting impulsive urges that were self-defeating, and were not benefitting from standard CBT Therapy.

Therefore Linehan’s new approach had to provide tools for CBT Therapists that did not invalidate the emotional suffering of clients, provided enough time and a format that could facilitate addressing a multitude of crises, provide BPD patients with tools to better communicate in interpersonal conflicts and to initiate, nurture, and maintain relationships.  And that was just for the BPD patients.  What she and her colleagues also learned during this time is that the CBT Therapists who were treating this group were also experiencing high levels of stress.  Therapy sessions with BPD patients are incredibly intense, often involve high levels of anger, high potential for suicide, and so many presenting problems- there is never a sense of completion.  These therapists were at risk for burnout.

A new CBT Therapy for BPD would need to include high levels of validation to BPD patients, a way to provide patients with a lot of tools while not triggering emotional upset, and more support for both BPD patients and the CBT Therapists providing treatment.  Dialectical Behavior Therapy (DBT) has developed to address these issues.

Dialectical Behavior Therapy (DBT) Comprehensive Program

Dialectical Behavior Therapy as a comprehensive treatment involves four components.  There is weekly individual therapy, weekly DBT Skills Group, coaching calls between the BPD client and individual CBT Therapist, and weekly Consultation Group for DBT Therapists.  Together these components allow greater support for everyone involved in the therapeutic process and a number of scientific studies have demonstrated that comprehensive DBT results in fewer days of hospitalization, self-injuries, and suicides.  It also requires a 12-month commitment from the BPD patient.  Shorter treatment is believed to be less effective.

A DBT patient therefore would see her individual therapist to learn how to better handle the current problems in her life.  And also, once enough fluency with her new DBT Skills are present, more significant symptoms, like those of Post-traumatic Stress Disorder (PTSD) may be treated with exposure therapy in individual therapy sessions.  Problems that came up during the week are often understood by conducting a chain analysis, which is a DBT term for doing a behavioral analysis of the event. The DBT client with her therapist identifies all of the links in the chain of the episode from beginning to end.  This helps both of them understand what likely predicts future episodes and how to best intervene.  For example, after conducting a number of chain analyses on anger episodes with her co-workers, it may become clear that a common pattern is a link in the chain that involves going to bed late and not getting enough sleep.  Problem solving skills are then implemented to efficiently test new ways of handling the situation moving forward while practicing self-compassion.

DBT Skills Group are conducted weekly.  These are typically led by a therapist other than the individual DBT therapist.  While this is part of the comprehensive DBT program, it is largely seen as psychoeducational.  Four modules of skills are taught to clients in a warm, supportive, and efficient manner.  DBT Group Leaders provide structure so that the content can be discussed without unnecessarily triggering and emotionally dysregulating group members.  For instance, DBT Group members are prohibited from discussing self-injury in ways that would trigger another member.  The DBT Group is begun with a mindfulness exercise, which is one of the four content modules that is taught during the 12-month program.  Similarly to CBT individual therapy homework is checked at the beginning of sessions and assigned at the end of sessions.  The four modules that are taught during DBT Group are Core Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation.

DBT Coaching Calls are another component that typically sets it apart from other Cognitive Behavioral Therapies (CBT).  Many CBT Therapists are concerned that coaching calls between sessions can lead to dependency and prevent CBT clients from developing self-efficacy skills by practicing their newly developed skills in between sessions.  However DBT believes that properly conducted DBT Coaching Calls facilitate the generalization of skills learned in session into the real world for BPD patients who may otherwise fall back on older more reliable ways of managing interpersonal conflicts and emotional suffering, strategies like self-injury or substance use.
Targets for coaching calls can include:

  • Decreasing suicidal and self-injury behaviors
  • Increasing the generalization of DBT skills into the real world setting
  • Decreasing conflict or “feelings” of distance from the individual therapist

DBT Coaching Calls need to be conducted properly though, or like standard CBT Therapy they can in fact exacerbate the symptoms of a BPD client and lead to burnout for the individual therapist.

DBT Consultation Teams meet weekly as well.  During these meetings DBT Therapists who provide both individual DBT Therapy sessions and DBT Skills Group meet to improve their own DBT Skills as therapists and group leaders. DBT Team Members share information about DBT patients and do so in a non-judgmental manner.  They work to utilize dialectical philosophy, e.g., acknowledging that there is no absolute truth.  And as such, accepting that and moving forward through synthesis can best support all of the members of the team.  This support allows the DBT Therapists to prevent themselves from burnout, hone their skills, receive technical guidance from other team members who may have a different perspective on a problem that has yet to be successfully addressed by a particular DBT Therapist.

BPD clients clearly face very serious challenges given the number of ways they suffer.  It is also clear though that comprehensive DBT, is just that comprehensive.  It provides very specific content, format, and clear parameters for how each is to be conducted.  It also provides DBT Therapists with the training and support necessary to effectively treat these courageous people diagnosed with BPD who through this process can dramatically reduce their suffering and create lives worth living.

Ben-Porath, D.D., Koons, C.R. Telephone coaching in dialectical behavior therapy: A decision-tree model for managing inter-session contact with clients. Cognitive and Behavioral Practice, Volume 12, Issue 4, Autumn 2005, Pages 448–460.