What is Dialectical Behavior Therapy?
Dialectical Behavior Therapy (often abbreviated DBT) is a specific type of psychotherapy based on the principles of Cognitive Behavioral Therapy, originally developed to treat individuals who were suicidal or had very serious psychopathology. Over time, DBT has become the frontline treatment for borderline personality disorder, which is one of the most severe forms of psychopathology, and people with this diagnosis are notoriously difficult patients. DBT has also been refined to be used in a number of other treatment contexts and for a number of other issues.
Development of DBT
It is important when discussing DBT to recognize the technique’s founder and developer, Dr. Marsha M. Linehan. Dr. Linehan embraced a number of different modes of thought when developing DBT.
- Roots of DBT: Unlike some forms of therapy, DBT has roots that come from psychological principles, philosophy, and hard science.
- Nothing stays the same: DBT assumes that reality is constantly evolving, and the only consistent factor in the universe is change.
- Connections: DBT makes the assumption that total opposite viewpoints can be integrated and come together to represent reality. This is an extremely important assumption of DBT as will be explained below.
- Dialectic: The term dialectic is meant to describe the philosophy of synthesizing opposite points of view or opposite states of mind. Thus, the major focus of DBT is to bring together totally opposing beliefs, behaviors, or styles of interacting in such a way that makes these opposites functional.
The development of DBT occurred as a response to the difficulties therapists encountered when working with individuals who were actively suicidal. These very distressed individuals were at the point of killing themselves because they had come to the conclusion that they did not have the ability to deal with whatever problem made their lives stressful and intolerable. Therapists attempting to treat these people would try and get them to change their beliefs, and these individuals would either become very resistant, drop out of therapy, or become aggressive.
When therapists tried the opposite approach, trying to get these people to accept their feelings as opposed to trying to change them, these clients accused the therapist of being insensitive and not understanding their feelings. Again, clients would become distant, drop out of therapy, or even become aggressive toward the therapist. Therapists working with these individuals believed that they were in a no-win situation.
DBT was developed in an attempt to deal with this type of no-win situation by bringing together these two opposite viewpoints together, such that individuals could change their behaviors and at the same time still perceive reality as harsh and unfair.
Goals of DBT
The overall aims DBT attempts to fulfill during treatment can be described by three different objectives:
- Being oriented toward the client:
DBT attempts to identify the client’s personal issues as well as their own strengths. Then, by using a tailored approach to bring the individual’s strengths into play, it assists the client in addressing their issues.
- The use of cognitive-behavioral principles:
DBT’s methodology is to work with the individual to identify certain core beliefs they have about themselves, others in the world, and the nature of things that are irrational and dysfunctional. Once these are identified, the therapist helps the client adjust to these beliefs so they are more realistic and rational.
- Therapeutic alliance:
The therapeutic alliance refers to a well-researched aspect of therapy that describes the working bond between the therapist and client. When the client and therapist respect each other, are motivated to work together, and are in agreement as to what it is they need to work on, the outcome of therapy is often significantly more positive than when this alliance or bond is not as strong.
Specific Goals and Techniques
In DBT, the therapeutic alliance is considered to be the main mechanism of change, and the therapeutic alliance is fostered by the client’s support system outside the therapeutic environment. This means that therapists also recruit aspects of the client’s family, friends, and other supports to assist the client in making needed changes.
The therapist concentrates on improving several basic areas:
- Motivation: Therapists trained in DBT are constantly working on ways to motivate clients, develop motivation, and get clients’ support systems involved in helping to motivate them.
- New skills: DBT therapy works on teaching clients new skills and ways of interacting in the world.
- The client’s capacity to change: While working with a client, the therapist also needs to maintain perspective regarding the client’s capacity or desire to change. Working with the client often involves working at the client’s level to change, or developing motivation or new skills to broaden the client’s capacity for change.
- Keeping it real: Therapists make sure that the therapy sessions are arranged in such a manner that clients can practice new skills in therapy sessions but apply them in the real world.
- Acceptance: Therapists also structure the treatment to account for the acceptance of certain factors or issues that cannot be changed.
- Continual improvement: Therapists actively practicing DBT are expected to evolve as well. They are expected to continue to improve their own motivation, training skills, and confidence by staying involved in continuing DBT education.
A Comprehensive Approach
Often, individuals entering therapy will choose between becoming involved in individual or group therapy sessions. In many instances, individuals participate in both. DBT typically requires that a comprehensive approach be implemented using all aspects of therapy.
- Individual therapy: Clients in DBT typically attend individual therapy sessions once a week. During the sessions, the bulk of the work is tackled. Of course, the “work” depends on the client and the client’s motivation. Individual therapy sessions are often devoted to identifying irrational thinking patterns, challenging these thinking patterns, developing new thinking patterns, developing new skills, and understanding that there are certain aspects of reality that cannot be changed. Individual therapy sessions continue as long as needed.
- Group therapy: DBT also utilizes group therapy sessions where individuals with similar diagnoses or problems meet with a group therapist who teaches skills or supplies information in the form of lectures or discussions. These group therapy sessions are very structured and often meet once a week for 20-24 weeks. Individuals in treatment are expected to attend every group session, and the cycle repeats itself so individuals who have missed some of the sessions can attend them.
- Accessibility: Traditionally, DBT also uses phone coaching to provide clients with immediate support if they encounter emergency situations and need emergency supervision or advice. Clients are often given a phone number where they could talk to their therapist or another therapist and receive support on the spot. Not all DBT therapists offer this option.
- Therapist training: Therapists also have ongoing training and consultation teams who keep them updated on new techniques and research, and help to instill motivation and confidence in therapists. Therapists are required to continually maintain communication with these consultation teams in order to remain updated and current with new research findings and techniques. For example, improved techniques on mindfulness, cognitive-behavioral skills for emotional regulation, and psychotropic medications are areas that are constantly upgraded.
Training for DBT Therapists
Even though there is quite a bit of literature on DBT, the practice requires very specific training as well as long-term supervision from a certified DBT therapist before therapists can employ these techniques. Only licensed therapists, such as counselors, psychologists, and social workers, are qualified to receive specific training in DBT, and not every one of them will be qualified to deliver the technique. DBT cannot be learned from reading a few articles or books, but requires actual hands-on supervision from a qualified DBT therapist who is trained in the technique.
Who Would Not Be an Appropriate Client for DBT?
DBT was initially developed to be used in the treatment of very serious forms of psychopathology. Because it is intense and requires quite a bit of participation, some individuals may not be appropriate for DBT. For example, individuals are expected to attend weekly group and individual therapy sessions, and this will typically require approximately 2.5 hours of therapy per week. Therapy sessions are typically one hour, and group sessions are typically 90 minutes in length.
Aside from the commitment issue, DBT can be applied to a number of different situations, and there is research to indicate that it is effective for various problems, including for individuals who are not normally considered to be good therapy candidates, such as individuals with bipolar disorder. In these cases, DBT is often used to develop motivation for the person to comply with medical treatment (e.g., individuals with bipolar disorder requiring regular use of medications). Individuals who are actively psychotic or who have significant cognitive limitations will have difficulty benefiting from DBT due to its reliance on cognitive-behavioral principles.
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