What is Dialectical Behavior Therapy (DBT)?
Dialectical Behavior Therapy (DBT) is a comprehensive treatment for emotion dysregulation. “Emotion dysregulation” refers to emotions that are out-of-control. When you are dysregulated, your emotions are in the driver’s seat. Emotion dysregulation occurs when a person with highly sensitive emotions (i.e., a finely tuned emotional radar) doesn’t have the skills or support to manage all of the emotional content they are experiencing. DBT doesn’t change the nature of your emotional radar – a highly sensitive person will remain highly sensitive. DBT gives sensitive people the tools and supports they need to better manage, live with, and even harness their sensitive emotions. Emotional sensitivity can be a tremendous asset if you know how to manage it. For example, high sensitivity allows therapists to understand and support their clients and supports artists in their creativity.
The DBT Origin Story
In the 1980s, Marsha Linehan set out to develop a treatment for people with severe suicidality. At the time, there was no evidence-based treatment for suicidality. Her goal was to address this, but in order to get funding for her work, she had to pick a diagnosis to study. Dr. Linehan chose to focus her treatment efforts on borderline personality disorder (BPD) because of the high rate of suicidality among people with BPD.
Dr. Linehan was trained in behavior therapy, a popular treatment of the day, which was effective for a wide range of psychiatric problems. Dr. Linehan initially sought to use behavior therapy to treat her clients’ significant suicidality, thinking this widely effective treatment would work for her clients as well. But, in Dr. Linehan’s own words, “immediately, the treatment blew up.” Her clients felt unheard and became angry with her, yelling at her and saying things like, “you’re saying I’m the problem!”
Seeing that behavior therapy was not a fit for her acutely sensitive clients, Dr. Linehan decided to try an acceptance-based approach instead. If behavior therapy, designed to support clients in making changes did not go well, Dr. Linehan reasoned that supporting them with acceptance might go better. It did not. This time, when Dr. Linehan used the strategies of Carl Rogers–paying careful attention, listening with an unconditional positive regard, and validating painful experiences, clients appreciated the support, but expressed frustration that, “you’re not going to help me.” They felt let down in a time of extreme crisis and need.
Dr. Linehan was now left with a conundrum. She had tried change-based strategies and struck out. She had tried acceptance-based strategies and struck out again. What was left to try? Dr. Linehan could have easily concluded–as had so many providers before her–that the clients she was working with were “untreatable” and that nothing would help. Instead, Dr. Linehan decided that she needed a new treatment–one that balanced acceptance and change together. This was how DBT was born. DBT is, at its core, a treatment that fluidly and flexibly balances acceptance-based strategies with change-based strategies.
So what is a “Dialectic”?
It was Dr. Linehan’s executive secretary, Elizabeth Trias, who first pointed out to her that her treatment was “dialectical.” Dr. Linehan wasn’t familiar with the term, so she looked it up and found the following definition in Merriam Webster’s Dictionary, “A method of examining and discussing opposing ideas in order to find the truth.” In DBT, we think of dialectics as the idea that two seemingly opposing or contradictory ideas can both be true at the same time, and indeed can be synthesized to create a new, greater, truth.
The Central Dialectic: Acceptance and Change
DBT is full of dialectics and is based on a dialectical worldview. But, the central dialectic is that of acceptance and change. In DBT, we believe that “patients are doing the best they can and want to improve” (acceptance) and that “patients need to do better, try harder and be more motivated to change” (change). Elaborated a bit, we believe that all people are doing the best they can in the moment they are in, with the skills, resources, and supports they have available, and the specific experiences that have led them to that moment. And, we believe that all people need to do better, try harder, and be more motivated to change, if we support them with new skills and supports. While some might view acceptance and change as contradictory positions, DBT synthesizes them. It’s not just that acceptance and change can coexist, but that implemented effectively, acceptance leads to change, and change leads to acceptance.
“B” is for Behavior(ism)
The “B” and “T” in DBT refer to “behavior therapy.” Behavior therapies use the scientific principles of behavior change (i.e., behaviorism) to help clients achieve their goals. Behavioral science underpins a wide range of many effective therapies (e.g., cognitive behavioral therapy (CBT), exposure for anxiety and OCD, and parent management training (PMT) for disruptive behavior in young children). DBT uses the scientific principles of behavior change to help clients build new skills, stop destructive behaviors, and build lives they experience as worth living.
But What Is DBT?
DBT involves several components:
Skills training groups, which teach new ways of managing emotions. There are five types or “modules” of DBT skills: Mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and (for adolescents and their families,) middle path skills. All skills modules are taught in skills training
Therapy, which focuses on working toward individualized goals and building and maintaining motivation to do so. DBT therapy includes a number of components to support clients who are dealing with multiple, complex problems in getting the most out of treatment. For example, in DBT, all clients keep a “diary card”, which is a spreadsheet of the week, including the top behaviors you are working on in therapy and the emotions you experienced each day. This diary card gives your therapist a “cheat sheet” to your week, so that you can work together to organize your session time around the most important things that happened during the week
Skills coaching (usually conducted by phone) to help generalize new skills to “real life” settings. It’s one thing to learn new skills in a classroom-like setting, but an entirely different thing to apply the skills in your day-to-day life when you need them most. With 24/7 skills coaching, you can call (or even text) your clinician to get real-time support using new skills or responding to challenging situations
Regular support for staff providing DBT, or “therapy for the therapists,” in a DBT consultation team
DBT for adolescents and young adults additionally includes family therapy and family skills training. Some programs additionally include parent skills coaching. Family interventions focus on applying the skills to improve family relationships and to help adolescents get needed support
TLDR; DBT is a comprehensive treatment for people who struggle to manage their highly sensitive emotions. DBT integrates change-based strategies (e.g., problem solving, skills training, behaviorism, exposure, behavioral activation) with acceptance based strategies (e.g., warmth, acceptance, support, validation, mindfulness). DBT includes individual therapy, skills training (usually in a group format), 24/7 phone coaching, and support for the therapist in a DBT consultation team. To learn more about DBT, visit Behavioral Tech or check out our resources page.
References:
Linehan, M.M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press.
Linehan, M.M. (2016). Dialectical Behavior Therapy (DBT): Where we were, where we are, and where we are going [Video]. Youtube. https://www.youtube.com/watch?v=hM_Pj_MvpcM
Linehan, M.M. (2019). How Marsha Linehan developed the central feature of Dialectical Behavior Therapy. Psychology Today. https://www.psychologytoday.com/us/articles/201912/how-marsha-linehan-developed-the-central-feature-dialectical-behavior-therapy
Merriam-Webster. (n.d.). Dialectic. In Merriam-Webster.com dictionary. Retrieved November 30, 2024, from https://www.merriam-webster.com/dictionary/dialectic
