Theory Series: Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) was developed by Marsha Linehan in the 1970s. Her intention was to structure a therapeutic method specifically for those with borderline personality disorder (BPD). It is a pragmatic and psychoeducational approach to managing strong, difficult, and negative emotions, such as anger and suicidal urges. With roots in cognitive behavioral therapy (CBT) clients of DBT are also taught that the world is challenging, and constantly changing, and that for human beings to manage it, we must learn how to cope with the reality of things. These foundational ideas are heavily influenced by ancient Eastern philosophies, such as Buddhism. In fact, mindfulness is taught regularly in DBT, to educate clients that the negative and harmful thoughts that they are experiencing do not define them. In essence, “your thoughts are not who they are, they are simply thoughts”. For example, angry thoughts do not necessarily make you an angry person. This idea of opposing forces - that two things can be true at the same time - is the definition of ‘dialectical’ in DBT.
At its core, DBT is designed to help clients cope with their negative thoughts, feelings, and most importantly, their behaviors. Although it was designed specifically with BPD in mind, this approach has been shown to be effective for numerous other populations who struggle with issues like self-harm, anxiety, depression, and substance abuse, among others. Non-judgment, acceptance, and coping are a few of the guiding principles of DBT, making it especially useful in for these challenging issues. While there are countless variations of DBT, the basic structure is as follows with individual work and group psychoeducation sessions working together while keeping the core ideas omnipresent throughout.
Individual Therapy:
Identify, address, minimize, and eliminate any suicidal behaviors or non-suicidal self-harming (NSSI).
Identify, address, minimize, and eliminate any barriers to consistent attendance for therapy. …after all, therapy only works if you go!
Achieve goals of healing (depression, suicidality, anger, etc.) and/or improve quality of life (employment, relationships, social life, etc.)
Learn new, helpful coping strategies to achieve your goals and better manage your life
Group Psychoeducation:
Approach life with increased awareness and focus on the present - mindfulness
Understand that thoughts, actions, and identity are separate and that one does not need to act on their impulses (especially the negative ones) - distress tolerance
Improve personal and social boundaries to avoid overextension and resentment - interpersonal effectiveness
Improve understanding of personal emotions and increase control over them - emotion regulation
Packing numerous concepts and goals into one therapeutic approach makes DBT both impactful and time consuming. Critics call the 6–12-month timeframe for DBT completion too long. Additionally, it necessitates more effort and patience from clients, requiring them to be consistent about attending and practicing its skills. With the length and combination of individual and group work, also comes a price tag. Because DBT is still considered somewhat niche, it can be difficult to find practitioners and group sessions. Those that are out there are often pricey, especially considered in aggregate over the course of a year. Lastly, since it was originally developed for BPD, many of its ancillary benefits have not been convincingly researched. On the other hand, DBT has been shown to be effective with personality disorders known for some harmful and difficult symptoms, such as suicidality, aggression, and substance abuse. The benefits of DBT are laid out in a pragmatic, and realistic approach that is easy to comprehend, even for skeptics of the therapeutic process.
This practicality and focus on reality acceptance is something that draws me to DBT. Interestingly, I have had considerable insight into this approach as it is commonly taught at the inpatient hospital where I work. I have seen first-hand the positive effects it can have on our patients. From what I have seen, people are often receptive to the core messages of DBT if they can wrap their mind around it conceptually and push past the occasionally boring lectures. As a fan of mediation, I also find it encouraging that DBT champions this practice as part of a healthy lifestyle. Overall, this is a cognitive approach to healing some of the most serious mental health issues, with strength in its practicality. My hunch is that it might work best with intellectual clients.
For more on DBT, I recommend reading Building a Life Worth Living by DBT’s founder, Marsha Linehan. The title of the book doubles as an explanation of the author as well as a mantra for clients of DBT. Linehan details her personal experience as a suicidal young adult, highlighting personal insights that served as inspiration for her groundbreaking therapeutic approach. Happy reading!
