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Dialectical behavior therapy (DBT) developed in the early 1990’s from the work of Marsha Linehan, Ph.D. (1993a). Linehan, a cognitive behavioralpsychologist by training, formed the principles, theory and strategies underlying DBT while working primarily with women who were suicidal and engaged in self-harming behaviors.
Video: What is DBT?
This video by Esme Shaller, Ph.D., Clinical Psychologist at the University of California, San Fransisco (UCSF), provides an excellent overview of DBT, including who it is intended for and what being in treatment might look like.
From CBT to DBT
In initially approaching treatment from a strict cognitive behavioral perspective, Linehan found these techniques deficient in working with people with multi-problematic high-risk behaviors. Cognitive behavior therapy (CBT)—the brief, time-limited therapy, in which a therapist works with a client to identify and change problematic thoughts—lead to improvements in functioning for some, but many responded to these techniques with anger or withdrawal.
Over time Linehan made adaptations to her work to address these short-comings. It is these adaptations that developed into DBT. DBT preserves the cognitive behavioral focus on changing problem thoughts and behaviors, particularly in the skills training aspect of treatment. However, it also emphasizes acceptance and validation strategies designed to recognize the difficulty of change, which can help people stay open to and engaged in the process of change.
Underlying Theory of DBT
DBT understands behaviors in terms of the bio-social theory. According to this theory, our thoughts, emotions and behaviors are closely linked-- a thought triggers an emotion, which influences behavior, which leads to another emotion, then another thought in an ongoing cycle or like links in a chain, one leading to the next.
Our individual experience of this cycle or chain of feeling, thought and behavior and, in particular, the emotional aspect of this cycle is influenced by our biology, as well as our social history.
Linehan (1993a) developed the bio-social theory to explain the intense and extreme emotions and related impulsive and high-risk behaviors experienced by some individuals.
According to her theory, these emotions and behaviors stem from the combination of a biological vulnerability to a more extreme and fluctuating emotional experience—some people are simply wired to be more emotionally sensitive—and an environment that fails to teach an individual to modulate emotion and, through trauma or other invalidating experiences, reinforces emotional escalation.
DBT Treatment Modalities
DBT grew into a treatment with 5 primary modalities:
Group skills training.
Coaching in crisis.
Structuring the environment.
The focus of individual therapy is on identifying and assessing problematic behaviors and their associated feelings and thoughts.
Therapy is generally structured around a detailed analysis of problematic behavior, the teaching and strengthening of skills for cognitive modification and emotion modulation, learning effective behavior and addressing motivation, on-going commitment to treatment, and addressing behaviors that impede treatment.
Group Skills Training
To address emotional and behavioral skill deficits, individuals must learn new strategies for interacting with their environment. DBT skills training consists of weekly groups devoted to teaching new skills and reviewing the application of these new skills in daily life. The skills are broken down into four categories or modules (Linehan, 1993b):
The 4 Modules
Mindfulness:These skills are fundamental to DBT and are often referred to as ‘core’. They teach how to bring awareness to everyday living. This requires focus in the present moment, a capability many people with impulsive and mood-related behaviors lack. Mindfulness is consciously bringing attention to feelings, thoughts, body sensations, behaviors and events without judgment.It is the opposite of rejecting, suppressing or avoiding current experiences.
Distress Tolerance:In this module, skills center on accepting and coping with pain and distressing life events. These skills answer the question, ‘how do I survive this crisis.’ They focus not on changing the moment, but on accepting the current situation and finding ways to get through it without engaging in problematic behavior.
Emotion Regulation:Emotionally sensitive individuals often are unable to modulate the painful emotions that underlie impulsive, risky behaviors. These skills include understanding current emotions, identifying obstacles to changing emotions, checking facts related to emotional reactivity, problem solving, increasing positive emotions, and changing emotions.
Interpersonal Effectiveness:Interpersonal relationships can bring joy and happiness and cause fury or despair. This module teaches skills to get what we want and need in life, while maintaining relationships and self-respect. They include strategies for asserting your needs, saying no effectively, and coping with conflict. Skills necessary for maintaining friendships, decreasing social isolation, and ending destructive relationships are also covered.
Coaching in Crisis
In order to navigate the complex world of daily stressors, interpersonal relationships, work, obligations etc., individuals must learn to use their new skills outside of the treatment environment.
Coaching in crisis is designed to allow individuals to contact treatment providers before they engage in a problematic behavior.
When an individual recognizes that they are struggling they can access coaching to help initiate skillful and effective responses to their current situation.
Structuring the Environment
Principles of behavior therapy teach us that our environment has a significant influence on behavior.
DBT maintains a focus on the environment in which an individual functions and actively works with individuals to create contingencies that reinforce adaptive and effective behaviors.
Couples or family treatment can be useful in structuring an environment that supports new skill use.
DBT assumes that effective treatment of people with high-risk behaviors and intense emotional experiences must pay as much attention to the therapist's and treatment provider's behavior as it does to the individual's.
Treatment providers, like anyone, can make mistakes, take extreme positions, become vulnerable to criticism, react from emotion rather than best practices, and become burnt out.
Consultation team is a weekly meeting for treatment providers designed to enhance their skills and keep them in the therapeutic frame (Linehan, 1993).
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Today, not all implementations of DBT are structured with all five modalities. For example, studies on binge eating disorder were effective with the skills group alone (Telch, Agras, & Linehan, 2001), and adaptations of DBT have been effective for a variety of populations, including bulimia nervosa (Hill, Craighead, & Safer, 2011) and suicidal teens (Rathus & Miller, 2002).
DBT was originally designed as an outpatient treatment for women with high-risk behaviors who typically carried multiple psychiatric diagnoses, including borderline personality disorder (BPD).
The application of DBT has a degree of flexibility based around an underlying theory and set of principles, which has allowed it to grow into an effective treatment for people with a wide variety of diagnoses and problems. As a result, DBT has been adapted as a treatment for a number of disorders characterized by emotional dis-control, such as:
Individuals dually diagnosed with intellectual disabilities and mental illness (Lew, Matta, Tripp-Tebo & Watts, 2006).
DBT has also been adapted to treat drug dependence and substance abuse (Linehan et. Al. 1999). The 2nd edition of the DBT Skills Training Module includes a section of skills to use when the crisis is addiction in its distress tolerance module. This module was developed based on a series of studies treating individuals with drug dependence with DBT (Linehan, 2015).
Its effectiveness in helping people modulate extreme emotions and reduce impulsive and destructive behaviors makes it an attractive treatment for those with substance use problems, as does its efficacy in keeping individuals in treatment, which is often a particular problem in treating people who struggle with addiction. The modular make up of skills training, along with the different modes of treatment allow treatment providers to intensify or reduce the components of treatment allowing for adaptation to an array of disorders.
Finding DBT Treatment
If you are looking for DBT treatment, you may want to consider the following options:
The Substance Abuse and Mental Health Services Administration (SAMHSA) has an excellent online treatment-finding tool. Search for providers in your area and visit their website, or call, to see if they offer DBT or other treatments of interest. Both outpatient and inpatient programs will be listed.
Contact your insurance company to learn about treatment providers in your area. Specify that you are looking for facilities that offer DBT.
Do an internet search for DBT providers in your area.
Lew M., Matta C., Tripp-Tebo C., Watts D. DBT for individuals with intellectual disabilities: A program description (2006). Mental Health Aspects of Developmental Disabilities, 9(1), 1–13.
Linehan M. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press; 1993a.
Linehan, M. M. 1993b. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.
Linehan, M.M. 2015 DBT Skills Training Manual, Second Edition. New York: The Guilford Press.
Linehan, M. M., H. Schmidt III, L. A. Dimeff, J. C. Craft, J. Kanter and K. A. Comtois. 1999. Dialectical behavior therapy for persons with borderline personality disorder and drug dependence. The American Journal of Addictions8, 279–292.
Rathus, JH & Miller, AL. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life-Threatenino Behaviors, 32, 2, 146-157.
Telch, Christy F.; Agras, W. Stewart; Linehan, Marsha M. Dialectical behavior therapy for binge eating disorder (2001). Journal of Consulting and Clinical Psychology, 69(6), 1061-1065.
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