Dialectical Behavior Therapy

You may have heard that dialectical behavior therapy, or DBT, is considered the gold-standard treatment for borderline personality disorder. But what exactly is DBT? The treatment is typically classified as a type of cognitive-behavioral therapy (CBT). I like to think of it as “CBT Plus” because it utilizes the strategies of CBT, plus mindfulness, validation, and dialectical philosophy. 

How was DBT Developed?

When Marsha Linehan, PhD, was developing DBT, she set out to treat a group of women who were struggling with chronic suicidality and a host of other self-destructive behaviors. They all struggled with emotion regulation and met criteria for borderline personality disorder (BPD).

As she writes in her groundbreaking treatment manual, “Cognitive Behavioral Treatment of Borderline Personality Disorder”, she started by applying CBT to help these women change their ineffective coping strategies. She found that she didn’t get far with CBT strategies alone, because these were focused on changing behavior. Yes, that was needed, but these patients found the approach was insensitive to their internal experiences and struggles.

When Dr. Linehan instead took an approach that was consistently validating of these women’s difficulties and inner wisdom, her patients expressed that she clearly must not understand their pain, because what they needed was change!

What developed through this trial-and-error process was a treatment that artfully alternated between acceptance and change strategies. Dr. Linehan incorporated mindfulness and validation as acceptance strategies, which served as counterpoints to the change-oriented focus of CBT. She also added dialectical philosophy into the mix, which became a way to organize and understand the entire treatment, and was also taught to patients to help them find a middle path between behaviors that tended to swing back and forth between two extremes.

Since the publication of Dr. Linehan’s original study in 1991, over thirty (and counting!) randomized controlled trials have proven the effectiveness of DBT. In addition to effectively treating BPD, DBT has resulted in positive outcomes when treating major depression, bipolar disorder, ADHD, PTSD, substance use disorders, and eating disorders. For a detailed accounting of all the trials to date and a helpful explanation of the rigor and credibility of different types of research studies, visit Behavioral Tech.

What are the Components of DBT?

Full-model DBT consists of several components: weekly skills groups, weekly individual sessions with your primary therapist, between-session phone coaching, and the DBT consultation team.

DBT Skills Groups

DBT skills groups are typically run by two facilitators and teach four sets of skills: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. 

Mindfulness skills are considered the core skills, as they form the foundation for everything else taught in DBT. Mindfulness is about engaging fully with the present reality of our lives, as opposed to avoiding what we find unpleasant, or having split attention (for example, doing a fun activity with a friend and simultaneously worrying about how you’ll feel when that activity is over). The mindfulness module is repeated between all other modules.

Emotion regulation skills are used when we want to change how we’re feeling because it’s not effective for us in the moment. There is also a subset of emotion regulation skills that is used preventively; these are essentially instructions for how to build a life that leaves us less vulnerable to becoming destabilized by painful events and emotions when they inevitably arise.

Distress tolerance skills help us get through short-term crises without doing anything to make our situation worse, such as using substances to cope or abruptly ending relationships that we actually value. A subset of distress tolerance skills aims to reduce suffering and get unstuck from situations by accepting reality as it is, even when that reality is extremely painful or disappointing.

Interpersonal effectiveness skills help us get our needs met in relationships. They teach us how to ask for what we want or say no to unwanted requests in a manner that doesn’t sacrifice our self-respect or lead to losing the relationship over the long term.

Individual Sessions

Individual sessions in DBT are meant to keep you motivated to continue doing the hard work of learning and practicing the skills. DBT therapists use strategies such as behavior chain analyses to figure out the causes and functions of the behaviors you want to change, and how and when to intervene to change them. Those strategies are balanced by plenty of validation and acceptance of you, just as you are in each moment.

Phone coaching

Your primary therapist will also be available between sessions to provide you with some coaching via phone to bridge the gap between learning skills in sessions and actually taking the steps needed to apply them in challenging situations. 

Model-adherence is Key

When seeking a comprehensive DBT program, the degree to which clinicians follow the treatment model is statistically a key predictor of client outcomes; we call this adherence. There is no way to guarantee that the program and/or therapists you decide to work with will be completely adherent to the model, but there are a few factors that increase that likelihood.

One is that they participate weekly in a DBT Consultation Team. This is a crucial part of any DBT program! Therapists on a DBT Consultation Team commit to abiding by a number of agreements and use DBT strategies with each other to stay accountable to sticking with the framework of DBT, even when it would be much easier to drift towards “treatment as usual” with clients.

Linehan Board Certification is another factor that increases the likelihood of model-adherence. Certification by the Linehan Board is a lengthy and rigorous process. Certainly, many therapists who are not certified may administer excellent, adherent DBT. Likewise, there may be certified DBT therapists who have drifted away from practicing adherent DBT! But certification can give you some indication of the clinician’s commitment and ability to deliver effective treatment.

But What if I Don’t Like Groups?

Many of us feel more comfortable and effective one-on-one than in a group setting, myself included! Feelings of anxiety and even shame can arise at the prospect of joining a group. This may feel like a barrier to starting full-model DBT. 

Fortunately, DBT skills groups are not your typical group! The type of group commonly portrayed in the media is a process group; a therapeutic group in which the sharing of emotions and experiences is encouraged, and there is an emphasis on interpersonal dynamics within the group. 

By contrast, DBT skills groups have a classroom feel. They're not a place to process intense emotions; rather, the focus is on learning skills. To that end, you’ll arrive with your workbook and pen in hand, ready to take notes and complete homework assignments. Any sharing of experiences will take place within the context of homework review or by choosing to share examples during the didactic portion of the class.

That being said, skills groups are not for everyone! There may be specific reasons you would not function well in a group setting and could benefit from individual skills training. It’s also possible that your issues are not so severe that they require full-model DBT. I work with each of my clients to fully assess their needs, and I avoid recommending more intensive treatment than is necessary.

My Training in DBT

I received my foundational training in DBT in 2015 at Behavioral Tech Institute, instructed by Cedar Koons, LCSW and Janice Kuo, PhD. I was immediately drawn to the structured nature of the treatment; as an early-career therapist, I wanted a blueprint to follow, so that I could feel confident I was on the right track toward helping my clients. Over the years, I’ve learned that DBT is anything but cookie-cutter! But having a structure to start from was very helpful. I also found that dialectical philosophy and the practice of a nonjudgmental stance resonated deeply with me. Add in the problem-solving nature of DBT for my analytical brain, and I was hooked! 

I decided to undergo the rigorous process of getting certified by the Linehan Board of Certification as a DBT clinician. Throughout my six years in an outpatient hospital clinic setting and my six years and counting in private practice, I’ve had the opportunity to apply DBT to a variety of clients’ struggles and diagnoses, ranging from mild to severe, and including BPD, depression, anxiety, trauma, eating disorders, and substance use disorders. I have witnessed firsthand the alleviation of suffering and increased freedom that my clients experience when they fully throw themselves into treatment.

If you’re looking for adherent DBT treatment, or are just wondering if DBT might be right for you, I invite you to reach out for a no-obligation 15-minute consultation call.