Therapy is a structured intervention that is performed by a professional trained in psychological principles designed to help a person or people change their way of thinking, their behavior, or their way of adjusting to situations that occur in their life. There are literally hundreds of different types of psychotherapy, and most of these different models of therapy have their origins within five major paradigms (schools of thought).
Two of the major paradigms in psychology are the cognitive paradigm and the behavioral paradigm. The cognitive paradigm is focused on the relationship between an individual’s thoughts, belief systems, attitudes, etc., and their behavior, whereas the behavioral paradigm is simply interested in the environmental factors that drive behavior and the results of performing a particular behavior. Therapies based on these two paradigms focus on their basic approaches to understanding what drives behavior. A very popular paradigm of psychotherapy, the cognitive-behavioral paradigm, combines the principles of cognitive psychology and behaviorism to create an approach to therapy that has been successful in numerous contexts. Derivatives of Cognitive Behavioral Therapy (CBT) are the most popular and studied therapies used today.
Dialectic Behavior Therapy (DBT) is a type of Cognitive Behavioral Therapy that was developed to address individuals with severe problems that were often difficult to treat using other forms of CBT. DBT is a very complex type of CBT that requires specific training in both general psychotherapy techniques and theory and in the DBT approach. Only individuals who have advanced training in psychotherapy (most often, licensed psychologists) and specialized training in DBT (which is typically performed by a national DBT organization) can apply the principles of DBT.
General Foundations of DBT
The developer and founder of DBT is Dr. Marsha M. Linehan. Dr. Linehan made three major assumptions when organizing the principles of her approach to psychotherapy:
- Multiple foundations: The approach had its basis in the foundations of philosophy and science.
- Change is inevitable: The approach assumes that truth and reality constantly evolve.
- Integration: Everything is connected with everything else. The one major constant in the universe is that change is inevitable and that even what appear to be totally opposing points of view can be integrated.
Dr. Linehan chose the term Dialectic Behavior Therapy to describe the approach that is designed to synthesize opposite states or points of view. DBT was originally conceptualized as a method to approach clients who were actively suicidal or who have a severe personality disorder known as borderline personality disorder. Those with borderline personality disorder often have numerous issues with their identity and are compelled to be accepted and loved by others, while at the same time engaging in aspects of self-harm and even in suicidal behaviors. Clients who are actively suicidal often wish to end their lives because they believe they are inadequate in dealing with issues that they view as making their existence unmanageable. Cognitive-behavioral approaches attempt to address an individual’s irrational belief system and then change their behavior.
Therapists who attempted to get these types of clients to change their beliefs and then their behavior (not to engage in self-harm) were faced with the problem of clients totally cutting themselves off from therapy or just dropping out of therapy. Therapists who attempted to help clients accept their feelings were accused of being insensitive, and clients often became detached or left therapy. DBT was developed in an effort to unite these opposites; learning to accept the harsh realities of the world and at the same time changing one’s attitudes and behavior.
Components Utilized in DBT
Traditionally, the approach to DBT is to be as comprehensive as possible and to implement multiple resources in order to develop an effective approach to assisting a client in therapy. In DBT, the following aspects are often utilized:
- Individual therapy sessions: The clients will most often attend individual therapy once per week. Individual therapy sessions address the major issues and treatment approaches. During individual sessions, the therapist and client work together to understand how the client’s thoughts, beliefs, and expectations contribute to their issues and to help them develop new approaches, skills, and an understanding and approach to acting in the world that is both functional and successful for them. People involved in DBT remain in individual therapy throughout the entire treatment process.
- Group therapy sessions: In many different CBT paradigms, clients either attend individual sessions or group sessions. DBT is one of the CBT paradigms where both individual and group therapy sessions are typically utilized. Group therapy sessions are most often a combination of psychoeducational discussions and lectures and formal practice of techniques. These sessions are often very structured and will typically meet once a week over a 20-week (or more) time period. These sessions are designed to present clients with specific skills and to practice them in order to address their issues. Clients are expected to attend all the group sessions, and the course typically repeats itself after the entire sequence of classes or practice sessions has run its course to allow individuals to make up any sessions they have missed (although missing sessions is strongly discouraged).
- Making assistance accessible: In the real world, clients in therapy may run into situations that require immediate assistance. In traditional DBT, clients are given access to a phone coach whom they can contact in a situation where they need to consult with someone. This is often a DBT therapist or a trained phone coach; it might even be the client’s personal therapist, or it could be some other DBT therapist who is available. The use of this resource is designed to help individuals work through issues that may be difficult for them and may not have been addressed in therapy; however, the abuse of this resource is discouraged. When an individual is believed to be relying too much on phone coaching and not enough on addressing their problems through the techniques they learned during individual and group therapy sessions, this becomes a topic of individual therapy.
- Keeping therapists updated: DBT therapists are expected to continue ongoing training and required to attend periodic training updates, group meetings, and consultation meetings. They are expected to keep up with the research literature regarding DBT therapy and other aspects of mental health treatment.
The above description includes the full complement of services available in traditional DBT interventions. In some cases, the personal coaching option may not be available, depending on the type of issues the client is attempting to resolve, and the feasibility of having such a service available will vary from treatment provider to treatment provider. Group sessions could conceivably include ongoing groups such as 12-Step-type groups for individuals primarily being treated for substance abuse.
The approach used in DBT allows for the use of three empirically validated components to assist in the treatment of clients in therapy:
- Orientation toward the individual: All forms of therapy have specific generalized principles that they follow; however, these principles cannot always be applied in the same way with everyone. DBT attempts to approach the individual by helping them use their strengths to change and to develop their weaknesses in addressing whatever problems they face.
- Thinking and behaving: Because DBT is a cognitive-behavioral form of therapy, it utilizes both the individual’s cognitions and actions in the recognition of their problems and in the development of solutions to them. This means understanding how and why a person believes the way they do and how that affects their actions.
- Using the therapeutic alliance to achieve change: The therapeutic alliance refers to the working bond that occurs between the therapist and the client in therapy. This bond represents both an understanding and respect for the client as a person and the therapist as someone with certain expertise who can help the client. Research has identified the therapeutic alliance as one of the major mechanisms that contributes to successful outcomes in psychotherapy.
DBT considers the therapeutic alliance to be the fostering mechanism of change for the client, but also recognizes that the client’s support system outside of therapy is extremely important in helping the client to address their issues. DBT therapists often attempt to get family members, friends, working associates, peers in group therapy sessions, etc., involved in the client’s treatment. General treatment goals consist of:
- Developing new skills: A core component of both individual and group therapy sessions is to help clients to develop new strengths and skills so they can successfully interact in the world.
- Increasing motivation: DBT attempts to keep the client’s motivation high through the use of therapeutic techniques and with the involvement of family members and peers.
- Accepting what cannot be changed: Despite all of the potential therapeutic techniques available in DBT and the constant training and updating of the therapist’s skills, there are always facts about life that are beyond our control. Often, clients are distressed about things they cannot change. Helping clients accept certain aspects of the world and adjusting to them is an important part of DBT.
- Understanding where the client is regarding change: Therapists in DBT are trained to understand and recognize the client’s capacity for change and motivation to change. Therapists are trained to work at the client’s level while helping them to develop their motivation and capacity for change.
- Functionality: Therapists ensure that the new skills learned in therapy can be applied in the real world by the client.
Like all forms of Cognitive Behavioral Therapy, DBT has numerous approaches and techniques that the therapist can use depending on the particular client, the client’s issues, and the capacity of the client to utilize them. There are literally volumes of books discussing particular techniques that can be used in specific situations. Some of the more general techniques and approaches used in DBT include:
- Incorporating the concept of mindfulness: Although the notion of mindfulness is often presented as a new concept, it is a very old and established concept in many forms of CBT. The concept of mindfulness refers to the ability to give one’s undivided attention to what is happening in the moment in a nonjudgmental manner and experiencing the moment as it occurs. It is a skill that requires far more practice than one may believe, but it allows an individual to objectively review and interpret the events around them. For individuals with distressing problems, it is often important for them to suspend their expectations and biases in order to understand others.
- Tolerating stress/distress: This technique is related to the mindfulness approach. Recall that DBT was developed to address issues that were often conflicting. Individuals frequently come to therapy attempting to change stressful or distressing circumstances (e.g., loss of a loved one, a traumatic experience, etc.). In some cases, such change is impossible. DBT endeavors to assist clients to accept such inevitabilities in a nonjudgmental and non-evaluative fashion. This allows them to accept more positive approaches and take more positive actions to address issues they can control. For example, one cannot control past events, such as the loss of a loved one, but one can learn to manage the stress associated with this loss. The use of stress management techniques is common in many forms of Cognitive Behavioral Therapy, and DBT is no exception.
- Emotional regulation: Many clients who are originally referred for DBT experience very extreme and intense emotional states (e.g., actively suicidal clients or clients with borderline personality disorder). DBT has developed numerous approaches to understanding and regulating one’s emotions. This often involves a structured approach that includes being able to identify emotions, reducing one’s vulnerability to reactive behaviors that may occur as a result of emotional states, increasing mindfulness, identifying obstacles to changing emotions, learning to take opposite actions, and/or applying stress management for stress/distress tolerance.
Is DBT Effective?
There have been numerous research studies investigating the utility of using the techniques of DBT for many different psychological issues. The full scope of issues that can be addressed using therapies like DBT that incorporate mindfulness approaches is far beyond the capacity of this article. Some of the research findings have shown that DBT is effective in treating issues related to:
- Borderline personality disorder
- Depression and suicidality
- Binge eating disorder
- Anxiety disorders
- Sexual abuse and PTSD
- Substance abuse
Although there is empirical evidence to suggest that DBT has numerous uses, this should not be taken to mean that DBT is a panacea. In order to receive the full benefit of DBT, individuals are initially expected to participate in nearly 2.5 hours of therapy per week or more, as individual therapy sessions are typically one hour in length and group sessions are 90 minutes or more. Some individuals may not need this type of time commitment and may benefit from more traditional Cognitive Behavioral Therapy (individual sessions at one hour per week).
DBT would not be the treatment of choice for certain types of mental health disorders, such as bipolar disorder or schizophrenia, which are most often addressed primarily with medication. Some of the functional issues that occur with individuals diagnosed with these conditions might be addressed by DBT, but the core symptoms of these conditions themselves would most often not be treated with psychotherapy alone.
Individuals with significant cognitive limitations might not be appropriate for DBT. In addition, being involved in any form of psychotherapy requires a commitment from the person to actually practice the principles learned in therapy. Even though cognitive-behavioral therapies like DBT attempt to work on an individual’s motivation, some individuals may not be motivated to actually do the work in therapy. Psychotherapy is not a magical process, though some individuals are under the impression that simply being in therapy will result in positive benefits or that just being in therapy will “cure” them. Psychotherapy requires an individual to invest time and energy to change.
DBT focuses on developing motivation in individuals and helping them realize change; however, some individuals with severe forms of psychopathology may not have the resources to invest the type of time and energy required to receive the full benefits of DBT. Even though the research findings indicate that DBT is generally effective for the treatment of numerous types of issues, research findings report overall group effects. Even in these studies, there are individuals who demonstrate different or varying levels of progress. Thus, while therapies like DBT are often the preferred form of treatment for many types of psychological issues, simply being involved in them does not guarantee success.