Dialectical Behavior Therapy (DBT) was created by Marsha Linehan, PhD as a method of treating Borderline Personality Disorder. Prior to DBT, the treatment of Borderline Personality Disorder (BPD) met with limited success. DBT, a type of Cognitive Behavioral Therapy (CBT), has been demonstrated to be an effective treatment not only for BPD, but for many other dysfunctions as well.

DBT is founded on the principle of the Hegelian Dialectic. Georg Wilhelm Friedrich Hegel’s concept of the dialectic is usually described as: thesis/antithesis/synthesis, wherein the thesis is the theory or idea in question, the antithesis is the idea’s polar opposite, and synthesis is a fusion of thesis and antithesis. DBT examines the dialectics behind maladaptive thought patterns and attempts to achieve a synthesis in order to restore balance to the psyche. For example, people with BPD often engage in splitting, in which they see a person either as all bad or all good. In this case, “all good” would be the thesis, and “all bad” would be the antithesis. A synthesis of these two ideas would be the realization that sometimes bad people can do good things, and sometimes good people can do bad things. DBT makes use of the dialectic to challenge maladaptive patterns of behavior.

Another example, and one of the major dialectics used in DBT, is the Acceptance vs. Change dialectic. In this dialectic, the patient learns to accept her flaws and imperfections, and to come to the realization that it is okay not to be “perfect,” while at the same time realizing that making changes in destructive coping patterns could lead to a happier, more productive life.

DBT grew out of Linehan’s work with BPD patients in the 1970s. She had this to say about the beginnings of the model: “People who meet the criteria for BPD almost always hate themselves,  so I figured I needed to accept them myself, and then teach them how to accept themselves. If you don’t accept yourself as you are, you can’t change. It’s a paradox, but true.”

Fundamental DBT Concepts

One of the fundamental assumptions of DBT is that patients are doing the best they can. Adler (1957) said that, “All behavior is purposeful when you understand the context.” According to the tenets of DBT, patients behave the way they do because at some point in time those behaviors yielded beneficial results. Over time, these patterns of behavior may not remain as successful, but patients become stuck in those patterns because they don’t know how to change.

Another assumption of DBT is that patients are motivated and willing to change. When a patient becomes stuck in a pattern of behavior, she may not be able to see a way out. This does not mean that she doesn’t want to change. She knows her impulsive and maladaptive patterns may be leading her to consequences she doesn’t want to experience. In short, BPD patients often have a strong motivation and commitment to change.

The third and final fundamental assumption of DBT is that radical acceptance is essential to recovery. The paradox at the heart of DBT is that before you can change, you must first accept yourself exactly the way you are. This means examining yourself non-judgmentally, without blaming, shaming or guilt. By coming to the realization that they were doing the best they knew how in a given situation, patients learn to accept that they are human, and they are entitled to make mistakes. This acceptance of self then frees them up emotionally and mentally and allows them to move forward towards change.

DBT and Emotional Regulation

A common problem in most mental dysfunctions and disorders is the tendency to become overwhelmed by powerful emotions. Such emotional flooding tends to disengage the mind’s capacity for rational thought. DBT uses mindfulness to create a space between overpowering emotions and the patient. By learning to step back from these emotions, patients come to see them as processes of the mind, and not necessarily as components of their identity. It’s not, “I’m a bad person because I’m having bad feelings.” DBT uses Mindfulness to teach patients that, “I’m a good person who occasionally has negative thoughts and feelings, and that’s okay.”

DBT: The Process

DBT is a long-term therapeutic intervention. Maladaptive behavior patterns can often be difficult to change, especially in the case of Borderline Personality Disorder. Because of this, DBT interventions routinely last two years or longer.

DBT patients have two sessions per week. One of these sessions is a skills training session (often in group format) and the other is an individual session with a DBT therapist. DBT therapists also offer coaching calls by telephone as a method of crisis management. When using such coaching calls it is important that the patient understand and agree to the limits of confidentiality regarding the sharing of clinical information by telephone.

Skills Training in DBT is comprised of four modules: distress tolerance, core mindfulness, emotional regulation, and interpersonal effectiveness.

Core mindfulness is the cornerstone of the other three modules. By learning mindfulness skills, patients learn to live in the moment. Since most anxiety and depression is rooted in thoughts and feelings about past or future events, mindfulness skills help patients overcome such anxieties by focusing on the “now” of existence. Mindfulness skills also help patients with Borderline Personality Disorder to overcome the tendency to make assumptions about situations, and to simply see what is there.

Distress tolerance works by teaching patients to find ways to distract themselves from troubling thought and feeling patterns that are self-destructive. Instead of engaging in cutting behavior, for example, a DBT student might do something nice for someone they’re angry with. Patients are taught to know their bodies, and how their bodies react to certain emotional states. By becoming familiar with the physiological changes their bodies go through as a precursor to a stressful state, patients gain more space and time in which to engage in distress tolerance skills. By examining their own beliefs and assumptions about the stressful situations, the patients also learn to create less maladaptive responses to such situations.

The emotional regulation module focuses on reducing and minimizing the intensity of overwhelming emotional cycles of response. Patients with Borderline Personality Disorder are by definition highly emotional people. In order to fit in with less emotionally-sensitive people, many people with Borderline Personality Disorder have learned to suppress stronger emotions. Over time, this suppression leads them to have difficulty in identifying cues that indicate the onset of a strong emotional cycle. In many cases, the tendency to suppress emotions can lead to the eventual inability to define subtle nuances of emotion. Most, if not all, emotions tend to become identified with one emotional state. For example, sadness, fear, and guilt may all be expressed as anger. The emotional regulation module focuses on learning to identify emotions so that their negative impact may be successfully minimized.

People with Borderline Personality Disorder often feel socially isolated simply because of their dysfunctional patterns of interaction. They literally don’t know how to behave in certain social situations. The interpersonal effectiveness module helps them to learn the skills necessary to navigate day-to-day social interactions. By learning to examine and challenge their negative assumptions about social situations, patients learn more positive resolutions to those situations. As their skills in social situations increase, their fear of abandonment diminishes.

Other Uses of DBT

Although DBT was created to treat patients with Borderline Personality Disorder, it has also been used to successfully treat many other dysfunctions. DBT has been demonstrated to be particularly effective with addiction issues and anxiety disorders. There are, however, some cases in which DBT might not be effective. Since it is a long-term treatment program, requiring two sessions per week, it is often quite expensive. People with limited financial resources might not be able to have access to such services. DBT also requires that the patient have a high motivation and commitment to change. It is an intense form of intervention, requiring a lot of hard work. If a patient is not committed to the process, DBT might not be the most effective form of therapy.

Dialectical Behavior Therapy (DBT) Resources

Dialectical Behavior Therapy

Dialectical Behavior Therapy Skills Workbook