Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment developed by Marsha Linehan, PhD, ABPP. It emphasizes individual therapy and group skills training classes to help people learn and use new skills and strategies to develop a life that they experience as worth living. DBT includes skills for mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.
DBT was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD). It is now recognized as the gold standard psychological treatment for this population. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.
COMPONENTS OF TRADITIONAL DBT
1) Enhance Capabilities with DBT Skills Training
DBT skills training focuses on enhancing people’s capabilities by teaching behavioral skills. Skills training is frequently taught in groups; the group is run like a class where the group leaders teach the skills and assign homework. The homework helps individuals practice using the skills in their everyday lives. There are four modules in skills training:
- Mindfulness: the practice of being fully aware and present in this one moment
- Distress Tolerance: how to tolerate pain in difficult situations, not change it
- Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others
- Emotion Regulation: how to change emotions that you want to change
2) Enhance Motivation with Individual Therapy
DBT individual therapy is focused on enhancing motivation and helping people to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for as long as a person is in therapy, and it runs concurrently with DBT skills training.
3) Ensure Generalization with Coaching
DBT uses telephone coaching and other in vivo coaching to provide in-the-moment support. The goal is to coach individuals to use their DBT skills to effectively cope with difficult situations that arise in their everyday lives. Coaching means that it is optional for someone to call their individual therapist between sessions to receive coaching during the times when they need help the most.
4) Structure the Environment with Case Management
Case management strategies help people manage their own life, such as their physical and social environments. The therapist applies the same dialectical, validation, and problem-solving strategies in order to teach individuals to be their own case manager. This lets the therapist consult-to-the-client about what to do, and the therapist will only intervene on someone’s behalf when absolutely necessary.
5) Support Therapists with the DBT Consultation Team
The DBT consultation team is focused on the clinicians and supports who provide DBT, including individual therapists, skills training group leaders, case managers, and others who help treat an individual. The consultation team is intended to support DBT providers in their work; it’s almost like therapy for the therapist. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. This is especially important when they are treating people with severe, complex, difficult-to-treat disorders so the team can help one another manage burnout and share their knowledge.
STAGES OF TREATMENT
DBT is divided into four stages of treatment. Stages are defined by the severity of someone’s behaviors, and therapists work within this frame to support people in achieving their specific goals. There is no set timeframe allotted to each stage; instead, an individual and their therapist will spend as much or as little time as needed, based on identified goals.
- In Stage 1, a person is often miserable and behavior is out of control: they may be suicidal, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When individuals first start DBT treatment, they often describe their experience of their mental welfare as “being in hell.” The goal of Stage 1 is for a person to move from being out-of-control to achieving behavioral control.
- In Stage 2, someone may feel they are living a life of quiet desperation: their life-threatening behavior is under control, but they continue to suffer, often due to past trauma and invalidation. Their emotional experience may be inhibited. The goal of Stage 2 is to help someone move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated if it is part of the diagnosis.
- In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that a person leads a life of ordinary happiness and unhappiness.
- In Stage 4, for some, a fourth stage is needed: finding a deeper meaning through a spiritual existence. Dr. Marsha Linehan has posited a Stage 4 specifically for those individuals for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for a person to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.
Behavioral Tech. (2018). What is Dialectical Behavior Therapy (DBT)?. [online] Available at: https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/ [Accessed 7 Jan. 2018].