Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is a structured program of psychotherapy with a strong educational component designed to provide skills for managing intense emotions and negotiating social relationships. Originally developed to curb the self-destructive impulses of chronic suicidal patients, it is also the treatment of choice for borderline personality disorder, emotion dysregulation, and a growing array of psychiatric conditions. It consists of group instruction and individual therapy sessions, both conducted weekly for six months to a year,
The “dialectic” in dialectical behavior therapy is an acknowledgment that real life is complex, and health is not a static thing but an ongoing process hammered out through a continuous Socratic dialogue with the self and others. It is continually aimed at balancing opposing forces and investigating the truth of powerful negative emotions.
DBT acknowledges the need for change in a context of acceptance of situations and recognizes the constant flux of feelings—many of them contradictory—without having to get caught up in them. Therapist-teachers help patients understand and accept that thought is an inherently messy process. DBT is itself an interplay of science and practice.
With its strong emphasis on emotion regulation skills, DBT is finding application as a treatment for a wide range of mental health conditions. They include:
- Personality disorders, including borderline personality disorder
- Post-traumatic stress disorder
- Binge-eating disorder
- Substance use disorder
- Bipolar disorder
Expect a course of treatment that typically consists of weekly group, skill-focused instructional meetings as well as individual therapy sessions. Individual sessions usually last an hour; group meetings, usually consisting of four to 10 people, are designed to run for an hour and a half to two hours. DBT is present-oriented and skills-based, and patients are asked to practice their skills between sessions. Patients can expect homework assignments, which might, for example, focus on taking specific, concrete steps to master relationship challenges.
DBT specifically focuses on providing therapeutic skills in four key areas.
- Mindfulness enables individuals to accept and be present in the current moment by noting the fleeting nature of emotions, which diminishes the power of emotions to direct their actions.
- DBT also inculcates distress tolerance, the ability to tolerate negative emotion rather than needing to escape from it or acting in ways that make difficult situations worse.
- Emotion regulation strategies give individuals the power to manage and change intense emotions that are causing problems in their life.
- Last but not least, DBT teaches techniques of interpersonal effectiveness, allowing a person to communicate with others in a way that is assertive, maintains self-respect, and strengthens relationships; a core principle is that learning how to ask directly for what you want diminishes resentment and hurt feelings.
DBT incorporates many of the techniques of cognitive behavioral therapy (CBT). It helps patients recognize and challenge the varieties of distorted thinking that underlie negative feelings and prompt unproductive behavior. For example, patients learn to identify when they are catastrophizing—assuming the worst will happen—in order to avoid acting as if it were the case. They review their own past and present experience for instances of all-or-nothing thinking, seeing everything in extremes of black or white, devoid of the nuance that is more generally the nature of life.
Mindfulness training is an important part of DBT. In addition to keeping patients present-focused, it slows down emotional reactivity, affording people time to summon healthy coping skills in the midst of distressing situations.
Patients are asked to keep a diary tracking their emotions and impulses, a tool that helps them gain awareness of their feelings, understand which situations are especially problematic for them, and use the information to gain control over their own behavior. In individual sessions, patients review difficult situations and feelings they faced the prior week and engage in problem-solving by actively discussing ways of behaving that might have delivered a positive outcome. In addition, patients typically have access to therapists between sessions for skills coaching if they are in a crisis.
In seeing many mental health conditions as disorders of emotion dysregulation, DBT is focused on emotions and how they feed ineffectual action patterns. Many elements of the therapy are aimed at teaching patients how to recognize, understand, label, and regulate their emotions and how to handle interpersonal situations that give rise to negative or painful emotions.
Each week, for individual therapy sessions, patients complete a diary “card” (often done via an app), a self-monitoring form that tracks individualized treatment targets relating to moods, behavior, and skills. Patients identify and rate the intensity of emotions they experience each day—fear, shame, sadness, anger, pain, suicide attempts, and more—and space is provided to discuss emotional experience in more detail if needed. In addition, using a checklist of skills—which also serves as a handy reminder to deploy them—patients note the frequency with which they engaged in positive practices, from self-soothing and radical acceptance to reducing vulnerability and acting in ways contrary to how they felt.
The information on the diary card lets the therapist know how to allocate session time. Life-threatening or self-injurious behavior takes priority, not surprisingly. After identifying the behavioral targets for a session, the therapist helps the patient engage in behavioral analysis, figuring out what led to a specific problem situation the patient encountered, including any underlying beliefs or attitudes that surreptitiously reinforce the behavior, and discussing the consequences of the patient’s actions. The therapist and patient discuss more skillful ways to solve emotional and life problems.
Because DBT is a demanding therapy to deliver even for experienced therapists, therapists typically work in consultation with a treatment team and regularly meet with a team. The team’s recommendations are often applied in individual therapy sessions.
While studies of DBT have documented improvement within a year of treatment, particularly in controlling self-harmful behavior, patients may require therapy for several years.
A DBT therapist is a licensed mental health professional who has additional training and experience in DBT. Several organizations provide certification in DBT to qualified therapists who have completed advanced academic and clinical work. Certified DBT therapists may use the designation CDBT.
DBT is a comprehensive and multifaceted therapy designed to help patients cope with extreme emotional suffering and, often, self-injurious behavior. Many patients seeking DBT have undergone other forms of therapy without experiencing significant improvement. DBT is a complex treatment modality that makes many demands of therapists and requires extensive training to be administered in the way it was developed and tested.
Many components of the therapy, such as the skills training, have been adapted to treatment programs that do not reflect the comprehensive DBT treatment protocol. Finding a clinician who has undergone training and certification in the full DBT treatment model can be important to a good outcome.
When seeking a DBT therapist, experience counts. It is advisable to seek a therapist who has not just extensive training but also experience using DBT to treat patients presenting with concerns such as yours.
Important as qualifications and experience are, so is a good fit. As with all forms of therapy, it is also advisable to find a DBT therapist with whom you feel comfortable. Look for someone with whom you can establish clarity of communication.
Here are some important questions to ask a prospective DBT therapist:
- How often have you dealt with problems such as mine before?
- How do you know whether my situation is a good candidate for DBT?
- How does DBT work?
- What is a typical plan of treatment, and how long is a typical course of therapy?
- How do you measure progress?
- What is the nature of your training in DBT?
- Do you provide comprehensive DBT or a modification?
- Do you belong to a DBT consultation team?
- What is your policy on phone calls and emails during the week?
- What length of time do you initially ask a client to commit to?