What is Dialectical Behavior Therapy?

Marsha Linehan struggled with mental illness for a long time. She sought treatment for schizophrenia at an inpatient facility during her early years. Her experience forged the path to creating one of the most brilliant psychologists and authors in the field. She wished to help people who had struggled with the same issues she had as an adolescent. In the late 1980’s, she developed one of the most popular specific therapies for treating Borderline Personality Disorder and self-harm behavior called Dialectical Behavioral Therapy (DBT).

DBT originates from Cognitive Behavior Therapy (CBT). CBT focuses on the beliefs, or cognitions, and actions of a client. While DBT incorporates some of the same tenets as CBT, DBT adds the practice of mindfulness which is something CBT fails to integrate into treatment. DBT also places more emphasis on learning new skills and less emphasis on cognitive methods (O’Connell & Dowling, 2014). The main goal of Dialectical Behavior Therapy is to “help clients build a life worth living.”

DBT aims to modulate emotions. This therapy can be used with individuals experiencing emotional dysregulation, suicidality, or Borderline Personality Disorder. How does emotional dysregulation occur? Individuals who grew up in an invalidating environment may often suffer from emotional dysregulation. An invalidating environment can often look like disconnection between parent and child. For example, a parent responds in a very non-predictive manner to a child’s needs. This leads to the child incorrectly labeling his or her emotions. According to Hadjiosif (2013), these individuals struggle with validation later in life because the environments they were exposed to as children inhibited their ability to make sense of their emotions.

Unlike traditional types of process-oriented therapy, Dialectical Behavior Therapy is a here-and-now type treatment. Many components make this therapy effective for helping clients navigate Borderline Personality Disorder and other forms of emotional dysregulation. It might be hard to imagine how behavioral science and mindfulness meld together to create a very successful therapy. Its success stems from part of its name: Dialectics. Dialectics balance two different points of views while trying to find a common truth. Dr. Linehan based DBT on acceptance and change. The client must accept their problem while simultaneously wanting to change it.

DBT teaches numerous skills to help clients regulate their own emotions or disengage from self-harm behavior. These skills are typically learned in a weekly group format over six months to one year (Koerner, 2013). The four main tenets of DBT include mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation.

The most important skill in DBT is the art of mindfulness. Mindfulness is one of the reasons DBT has worked so well for people struggling with emotional dysregulation. Through mindfulness, clients validate the emotional pain they are experiencing and the difficulty of change. Therapists utilizing DBT as a form of therapy help the client recognize when they feel “out of control” and validate these feelings. Clients are also taught to utilize their inner strengths and capabilities to better help their emotional pain. Mindfulness provides a non-judgmental stance for individuals struggling with emotions.

Secondly, DBT incorporates distress tolerance skills. These skills essentially teach people to tolerate uncomfortable feelings. Distress tolerance skills help clients survive future crises by identifying problem behaviors. Individuals will not have a therapist accessible at all times, so these skills are very helpful to learn how to handle difficult emotions when they arise. These skills include self-soothing, accepting the moment, and weighing the pros and cons of each situation (Van Dijk, 2012). Self-soothing activities can be as simple as relaxing muscles or saying a prayer.

The third core principle of DBT is interpersonal effectiveness. People who struggle with emotional dysregulation often have a difficult time when it comes to interpersonal situations. Dr. Linehan offers multiple helpful acronyms (DEARMAN, for example) for people to follow when they encounter a difficult situation with somebody. These tough encounters can range from having a simple conversation to asking somebody for something.

Lastly, emotional regulation is a significant part of Dialectical Behavior Therapy. Clients who engage in Dialectical Behavior Therapy may struggle with suicidality or Borderline Personality Disorder. These issues will most likely create powerful emotions. Emotional regulation tools help to identify intense feelings and understand why he or she may be feeling this way. One skill in particular is to reduce painful emotions and increase positive emotions. This can be accomplished through self-validation, knowledge of primary and secondary emotions, and acting opposite of one’s urges. Validating one’s self is a difficult yet possible goal of clients going through Dialectical Behavior Therapy. They can validate themselves through accurate reflection of what they are experiencing and radical genuineness (Carson-Wong et al., 2016). The therapist can also assist clients in terms of validating the client’s biological dysfunction and the present context of what the client is experiencing.

Dialectical Behavior Therapy has been extremely successful in helping treat emotional dysregulation disorders, such as Borderline Personality Disorder, and self-harm behaviors. So, what makes DBT so successful compared to other forms of therapy? DBT is based on a behavioral science. Its roots lay in CBT, and clients are able to see the antecedents and consequences of their actions through a behavioral chain analysis. This can be a supportive tool for those struggling with their emotions. Secondly, DBT focuses on a dialectical philosophy: acceptance and change. The balance of acceptance and change allows people to understand what they are experiencing, and it also makes them want to change for the better. DBT uses mindfulness exercises and distress tolerance skills to meet these goals.

DBT is a fairly new therapy when compared to other types of treatment that have existed far before Dr. Linehan’s lifetime. Its focus on acceptance and genuineness sets it apart from different therapies as well as the different relationship between therapist and client. In DBT, the therapist is not seen as all-knowing, but instead works together with the client to understand his or her experience. According to Valentine et al. (2015), the popularity of DBT skills training may be due to its universality across different settings. Its use as a group-based therapy is valuable in communities where one-on-one therapy interventions are not possible. The combination of Linehan’s skills training modules, acceptance, and genuineness in Dialectical Behavior Therapy allow for it to be widely popular and successful in treating emotional dysregulation disorders.

References

Carson-Wong, A., Hughes, C. D., & Rizvi, S. L. (2016). The effect of therapist use of validation strategies on change in client emotion in individual dbt treatment sessions. Personality Disorders: Theory, Research, And Treatment, doi:10.1037/per0000229

Hadjiosif, M. (2013). From strategy to process: Validation in Dialectical Behaviour Therapy. Counselling Psychology Review, 28(1), 72-80.

Koerner, K. (2013). What must you know and do to get good outcomes with DBT?. Behavior Therapy, 44(4), 568-579. doi:10.1016/j.beth.2013.03.005

Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford Press.

O’Connell, B., & Dowling, M. (2014). Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder. Journal Of Psychiatric And Mental Health Nursing, 21(6), 518-525. doi:10.1111/jpm.12116

Swales, M., Heard, H. L., & Williams, M. G. (2000). Linehan’s Dialectical Behaviour Therapy (DBT) for borderline personality disorder: Overview and adaptation. Journal Of Mental Health, 9(1), 7-23. doi:10.1080/09638230016921

Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2015). The use of dialectical behavior therapy skills training as stand‐alone treatment: A systematic review of the treatment outcome literature. Journal Of Clinical Psychology, 71(1), 1-20. doi:10.1002/jclp.22114

Van, D. S. (2012). DBT Made Simple: A Step-by-Step Guide to Dialectical Behavior Therapy. Oakland, CA: New Harbinger Publications.

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