Dialectical Behavior Therapy (DBT) is a form of Cognitive Behavioral Therapy that was developed to address individuals who had significant suicidal ideations or suicidal tendencies. As the technique became more popular, it was often found to be useful in the treatment of borderline personality disorder. Now, it is often listed as the primary treatment for borderline personality disorder and some other personality disorders where individuals have severe issues with their identity, self-worth, and self-injurious behaviors. DBT has been modified to address other issues, including depression, substance abuse, and even trauma- and stressor-related issues.
DBT is a highly specialized form of Cognitive Behavioral Therapy that requires intensive specialized training. Only qualified individuals should use the techniques of DBT.
The History of DBT
Dialectical Behavior Therapy was initially developed by psychologist Dr. Marsha M. Linehan. During its development, Dr. Linehan incorporated ideas from several different sources. The development of DBT incorporates:
- Numerous sources that include philosophy, science (e.g., biology, neuroscience, etc.), and psychological principles
- The notion of change, as DBT assumes that the world is constantly changing and the only consistent factor is change
- Integration and incorporation of opposite viewpoints, as DBT assumes that opposite views/beliefs can be incorporated
The goal of DBT is noted in its name, dialectic, a term meant to describe the philosophy of trying to synthesize opposite states. DBT treatment attempts to incorporate and bring together totally opposing viewpoints or behaviors.
DBT was developed as an approach to help psychotherapists who encountered extreme resistance from clients who had active thoughts of suicide or had attempted suicide. These clients are often very difficult to work with. Suicidal individuals suffer severe distress and consider killing themselves because they conclude they can no longer tolerate certain situations in their lives.
The typical cognitive-behavioral approach to addressing these individuals would be to try to use cognitive restructuring to help them change their belief that the situation is intolerable. Unfortunately, when addressed in this manner, many individuals who are suicidal become resistant, leave therapy, and, in some cases, become very aggressive toward the therapist. Therapists who tried a different approach, trying to get individuals to accept their feelings as opposed to attempting to change their feelings, were accused of being insensitive. Again, clients would become resistant, leave therapy, or become very aggressive toward the therapist.
DBT developed as an attempt to deal with this type of situation where it became necessary to bring together two opposite points of view: the ability to change behavior (suicide) while still believing that the world is unfair and harsh at times.
The Basic Approach
The approach of Dialectical Behavior Therapy incorporates three objectives:
- DBT is person-oriented. DBT attempts to connect with the whole person. This means not only identifying the specific issues that bring the person into therapy but also identifying the individual’s strengths. This results in a personalized approach to understanding the individual because the therapist must understand both the person’s weaknesses and their strengths.
- DBT uses principles of Cognitive Behavioral Therapy. DBT is one of many different types of Cognitive Behavioral Therapy (CBT). The basic principle of CBT is to identify specific beliefs individuals have about themselves, the world, and the future. The specific types of beliefs identified are core beliefs that are illogical or unrealistic, and often lead to dysfunctional behaviors and beliefs that help the individual to adapt and adjust (strengths). The goal is to identify irrational and illogical beliefs, use cognitive restructuring to make them more functional, and then help the individual to use their strengths to change their behavior.
- DBT concentrates on the therapeutic alliance. The therapeutic alliance is considered to be one of the general factors in psychotherapy that contributes to successful outcomes. This general factor works across all different types of psychotherapy. The therapeutic alliance refers to the working relationship that the client and therapist have with one another. A positive therapeutic alliance means that both the client and therapist are committed to reaching certain goals and working together, and they understand and respect one another. Therapists often model proactive behaviors, such as being empathetic, honest and genuine, and giving the client positive regard regardless of the client’s situation.
These three general aspects are the core components from which all of the other principles of DBT are derived. The therapist uses them to concentrate on:
- The client’s motivation to change
- The client’s capacity to change, ensuring the therapist does not place demands on the client that cannot be tolerated
- Improving motivation to increase the client’s tolerance for change
- Teaching the client new skills to help them make positive changes
- Ensuring that the treatment applies to real-world situations by practicing skills in session and then applying them out in the real world
- Understanding that some things cannot be changed and learning to accept certain conditions of reality that one has no control over
- Helping clients to update their skills and motivation through numerous workshops and other activities provided by DBT organizations
DBT Utilizes All Aspects of Therapeutic Interventions
Traditional Dialectical Behavior Therapy incorporates every aspect associated with psychotherapeutic interventions. This makes DBT a comprehensive therapeutic paradigm that incorporates:
- Individual therapy sessions: The core component of DBT treatment consists of individual therapy sessions with the client and therapist. Sessions are typically once a week, although in some cases, they may be more frequent. Individual sessions help clients to identify irrational beliefs and thinking patterns, work on ways to challenge these irrational beliefs, use cognitive restructuring methods to develop more functional beliefs, use behavioral methods to develop new skills, and develop acceptance and understanding of oneself. The therapist and client work together in sessions on specific skills and techniques, and the therapist will often assign homework for the client to complete. Homework involves using the new skills or applying new beliefs to real-world situations.
- Group therapy sessions: Group therapy sessions in DBT are typically psychoeducational sessions. Individuals who have a similar problem or similar types of diagnoses meet in a group with a therapist who presents material in the form of lectures and discussions. The group therapy sessions are structured and typically meet once a week. The course of the group sessions often lasts between 20 and 24 weeks. Individuals work on specific skills in group sessions and then apply them to the real world.
- Availability: DBT understands that the world does not conform to one’s therapy schedule. Many DBT programs allow the clients to contact a phone coach or therapist in emergency situations via special phone number. This allows individuals to get advice in emergency situations or make emergency appointments.
- Therapists who are committed to improvement: DBT therapists are expected to remain informed on the latest techniques and current research, and to continue to develop and practice their skills to help others. There are numerous workshops and conferences for DBT therapists. DBT continues to incorporate useful new information, such as that from the Motivational Interviewing paradigm and other newer forms of treatment. In addition, DBT therapists are expected to keep up with all the latest developments in psychiatry regarding medications to treat individuals with specific issues in order to offer consultation in cases where medication may be needed. Most DBT therapists cannot directly prescribe medication or give medical advice; however, they are expected to be knowledgeable enough to discuss medical issues with psychiatrists, other physicians, and clients.
Requirements to Become a DBT Therapist
Again, DBT is a form of Cognitive Behavioral Therapy. Individuals who practice Cognitive Behavioral Therapy are licensed therapists. The first requirement for anyone who wishes to be a DBT therapist is to complete specific educational requirements and receive basic training in psychotherapy. This is typically accomplished through some form of graduate school training program, such as a clinical psychology training program, a graduate program in counseling, a graduate program in social work, etc. Once the individual obtains an advanced degree, they must pass a state licensing examination. Once they pass the licensing examination (or as part of their training in graduate school), they can become trained in DBT and get certification as a DBT therapist.
What Types of Clients Does DBT Work For?
DBT was originally developed to assist therapists who treat individuals who were extremely emotionally distraught, had severe psychopathology, or were suicidal. Because the technique incorporates numerous cognitive-behavioral principles, it has also been used in the treatment of other mental health disorders, including for individuals with major depressive disorder, adjustment issues, trauma- and stressor-related disorders, eating disorders, substance use disorders, and subclinical issues with depression, anxiety, personality, etc.
It can also be useful for addressing individuals who are not compliant with other forms of treatment, such as people taking medication for bipolar disorder. DBT can be used as the primary intervention and family and couples therapy as well. Because the treatment emphasizes psychoeducation, fostering positive change, and accepting the fact that some things cannot change, it has numerous applications.
Despite its overall utility, there are instances where DBT may not be appropriate. Because DBT requires quite a bit of commitment, it may not be appropriate for individuals who are not able to devote the required time to therapeutic treatment. Remember that individuals are expected to attend both group and individual psychotherapy sessions, and this can often be time-consuming. Individuals who cannot make this commitment may find they do not benefit fully from DBT.
Because DBT is a form of CBT, it requires that the individual has some level of being grounded in reality. Individuals with severe psychosis are not appropriate for DBT interventions until the psychosis (hallucinations and delusions) can be controlled. DBT cannot directly treat psychosis, but it can treat issues with adjustment for individuals who have psychotic disorders.
DBT can be useful in helping individuals with bipolar disorder comply with their medical treatments; however, as a therapeutic intervention it would not be directly used to treat bipolar disorder symptoms, particularly mania. Some of the techniques might be useful in helping individuals who are already taking medication, but DBT would not be considered a standalone treatment for bipolar disorder.
Individuals who have significant cognitive compromise as a result of brain damage or due to certain types of developmental disorders may not benefit from the principles of DBT.