Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is an effective, evidence-based treatment option for a number of mental health issues. It was developed by Marsha Linehan, Professor Emeritus of Psychology at the University of Washington. Originally, Linehan created DBT to treat highly suicidal patients. DBT used problem-solving to help people make major life changes. However, Linehan found the emphasis on encouraging change made patients feel rejected and invalidated. Therefore, Linehan changed her approach dramatically and began using an acceptance-based technique instead, focusing on providing acceptance and warmth. This technique, too, did not prove effective. Though it made patients feel validated, it was not helping them solve their problems.

It soon became quite clear that a simple approach would not work for this patient population. A more complex and dialectical method of treatment was required. Patients needed to feel accepted for who they were but also encouraged to change. So acceptance and change had to be balanced and integrated. One difficulty was that suicidal patients often had many problems and focusing on any one of them meant temporarily not paying attention to other distressing problems. So Linehan reasoned DBT must include distress tolerance techniques (e.g., mindfulness) that teach her patients how to tolerate distress without resorting to destructive actions.

Stages of DBT

To organize the treatment, Linehan created a treatment hierarchy consisting of four stages. Some, particularly highly suicidal individuals, start with the first stage, while others might start at later stages.

In Stage 1, the goal is to stabilize the patient and help him/her have more behavioral control. In order of priority, treatment targets in this stage are:

1. Life-threatening behaviors (e.g., suicidal behaviors, non-suicidal self-injury).
2. Behaviors that interfere with therapy (e.g., coming late or canceling sessions, not cooperating).
3. Behaviors that interfere with having a decent quality of life (e.g., substance abuse, severe financial problems).
4. Dysfunctional behaviors (these will be replaced with skillful behaviors).

Patients who feel less out of control and are less likely to act in destructive ways move to Stage 2. Despite having more control, they are still suffering tremendously, perhaps due to past trauma or present invalidating environment. Therefore, the goal of the treatment now is to address potential trauma symptoms and help reduce experiential avoidance, so one can experience a wider range of emotions in a more healthy way.

During Stage 3, the focus is on learning to lead a normal life—one of ordinary joys and sorrows. The therapist helps the patient set life goals and learn to cope with ordinary problems in living (e.g., mild depression, lack of intimate relationships) effectively.

For some people, a fourth stage is needed: finding a deeper meaning. In this stage, the goal of treatment is to help individuals move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and a sense of fulfillment.

Concluding thoughts on Dialectical Behavior Therapy

DBT is a scientifically validated treatment, particularly useful for people with severe mental health issues. DBT includes multiple components—it teaches skills in emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness. And it is offered in several modes of delivery (e.g., individual and group therapy, between-session coaching). DBT has been used for the treatment of many conditions (e.g., substance use disorders, eating disorders, depression, post-traumatic stress disorder) and is the gold standard for the treatment of individuals with suicidal tendencies and borderline personality disorder.