What is Dialectical Behavioral Therapy

Dialectical Behavioral Therapy (DBT) is a form of psychological treatment that helps people who struggle with emotional regulation become more self-aware. Through a series of four stages, patients learn how to deal with their feelings more effectively, adopt healthy coping strategies and overcome inner turmoil while learning how to relate to, accept and understand themselves.

As a form of cognitive behavioral therapy (CBT), DBT draws many of its techniques from CBT. CBT was developed in the 1950s and has been the preferred form of treatment for many different psychological disorders for decades. CBT teaches patients to identify unhealthy beliefs called “cognitive distortions,” such as thinking about everything as either all good or all bad, and change them for the better.

DBT was originally developed to treat suicidal patients with a borderline personality disorder (BPD), but it is also now used to treat patients who show self-destructive behaviors. In some cases, DBT has even been used as a therapeutic approach for people with post-traumatic stress disorder.

A Background of Dialectical Behavioral Therapy

DBT was created in the 1980s by Marsha Linehan, an American psychologist. She wanted to create a form of treatment that would help suicidal female patients who struggled with the tumultuous emotions associated with a borderline personality disorder.

Linehan wanted to teach her patients self-acceptance. As a result, the treatment model was created with multiple interventions designed to promote acceptance strategies that welcome and encourage change through personal growth.

In 1998, Linehan founded The Linehan Institute, which was then called the Marie Institute of Behavioral Technology. Her goal was to create an organization that facilitated access to leading behavioral therapies for at-risk patients with severe mental illness.

As a part of Behavioral Tech, The Linehan Institute makes it easier for patients and therapists alike to learn more about DBT and how it works. The Institute also advocates for DBT as an effective treatment for BPD and other psychological disorders.

The Principles of Dialectical Behavioral Therapy

Inspired by CBT, DBT is grounded in the notion that patients are capable of changing their thoughts and behaviors, which gives them the capability to change themselves. The therapy is based on a philosophical process called dialectics.

Dialectics is a term that describes the process of finding the truth between two opposing forces. In dialectical therapy, those forces are self-acceptance and change. Often, it’s hard for patients to accept themselves while they are striving toward improvement. After all, if they are really meant to love themselves as is, how can they possibly identify all their weaknesses or shortcomings in order to improve?

DBT seeks to equip patients with the skills necessary to bridge the dichotomy between acceptance and change. Incorporating Buddhist practices of meditation and mindfulness, the therapy teaches patients how to live in the moment, accept themselves for who they are beyond their problems and learn to interact with others more effectively.

Validation is a major component of DBT therapy. A dialectical therapist will strive to help their clients understand that their actions “make sense” given their context regardless of whether or not they’re the best way to deal with the problem.

Validation stops a patient from looking to their therapist for approval of their actions. They do not need to be instructed but rather guided toward the right path. That right path might not be the same for everyone, and the DBT therapist’s goal is to help a patient develop the adaptive strategies needed to make conscious, well-informed decisions for themselves.

The Main Components of Dialectical Behavioral Therapy

DBT is a support-oriented therapy. A patient doesn’t rely on their therapist to tell them what’s right or wrong about themselves. Instead, a therapist acts as a guide to teach a patient how to identify what they consider their strengths and weaknesses. A newfound self-awareness enables patients to feel more confident, secure and in control of their lives.

Cognitive-based behavioral techniques are employed to help patients understand the way they think. Often times, people perpetuate circumstances that make them unhappy without even realizing the impact of their actions. For example, consider someone who turns to substance abuse because “life is meaningless anyway, and I’ll never have anyone care about me.” A therapist can help a patient identify the underlying thoughts and beliefs that reinforce these types of ideas. Rather than continuing to think that their current circumstances are permanent, a patient can learn how to evaluate the present with the help of a therapist.

The mindfulness aspect of DBT helps enhance the cognitive-based approach. A patient can learn that things don’t have to be perfect now for them to be loveable. Decisions they make today might not be the best, but that doesn’t mean they can’t learn and grow from them to make better choices in the future.

Collaboration is the third major component of DBT. Patients are given homework assignments to work on between therapy sessions. During therapy, patients may role-play situations to learn how to communicate better as well as practice self-soothing. Emotional regulation requires not only self-awareness but also coping mechanisms. Some people are innately capable of expressing themselves clearly and dealing with uncomfortable emotions while others must learn that it’s okay to feel uncomfortable things.

DBT teaches patients to accept their emotions rather than fight against them. Through coping techniques, patients learn how to handle feelings like anger and sadness without being self-destructive.

The Four Modules of Dialectical Behavioral Therapy

DBT teaches four main strategies for coping with difficult emotions and altering unhealthy behaviors. They are:

  • Mindfulness
  • Distress tolerance
  • Interpersonal effectiveness
  • Emotional regulation

Mindfulness

Although there is nothing but the present moment, most people are either fixated on the past or anxious about the future. Plagued by negative beliefs about themselves or others, people often react assumptively. Instead of evaluating current circumstances and finding the truth in them, people lash out because they perceive judgment, criticism or rejection that might not be there.

Mindfulness isn’t about ignoring problems and putting them off until later. Instead, a mindful approach helps people understand how they’re feeling here and now, disrupting past beliefs and emphasizing current capability.

Distress Tolerance

Living in the moment can be a challenge for people who dislike who they are or how they’re living. Present circumstances might only exacerbate emotional distress, and people are naturally inclined to resist pain, fear, anger and other negative emotions.

Distress tolerance techniques help patients understand that it’s okay to feel a particular way. You are not required to constantly be happy or adopt a mindset of false positivity. Instead, changing one’s life requires the ability to acknowledge and accept discomfort.

There are four main distress tolerance techniques that help clients through difficult times. These are distraction, self-soothing, improving the present and weighing the pros and cons.

Emotional Regulation

People with borderline personality disorder struggle with extreme emotional vulnerability. This means that they are highly sensitive to emotional stimuli and often struggle to return to a normal baseline after arousal. Anger, sadness, and disappointment can cause intense reactions that may have lasting consequences. The reactive instinct among these patients often creates a cyclic effect that only perpetuates the emotions that troubled them in the first place.

Emotional regulation for borderline personality clients creates a sense of empowerment through self-awareness and acceptance. In addition to becoming more tolerant of emotions like anger, patients realize that they don’t have to immediately rush to get rid of them and can instead find healthy ways to cope and work through them.

Emotional regulation helps dispel feelings of shame. It’s not wrong to get angry over something or someone. However, anger isn’t always appropriate given a certain situation, and regulatory behaviors will teach patients how to focus on what they’re feeling as well as the current situation in order to respond more appropriately.

Does DBT Work?

Dialectical behavioral therapy is evidence-based, meaning it’s undergone numerous clinical studies and been refined throughout the years to improve patients’ outlooks. A study funded by the American Foundation for Suicide Prevention found that dialectical therapy is effective in reducing self-harm behaviors and actually changes brain activity in the prefrontal cortex, which contributes to impulsivity.

Chronically suicidal patients who demonstrate severe difficulty regulating their emotions are target candidates for dialectical therapy. It has also been proven to help patients who have a co-occurring condition like substance use disorder.

Dialectical behavioral therapy is one of the most popular of all treatments for borderline personality disorder. However, it is important to note that patient willingness is one of the most important factors relating to success.

Reluctance to change is one of the greatest challenges to therapy; if a patient is unwilling to accept advice, experiment with new strategies and be transparent with their therapist, then their outlook is not as favorable as a willing client. For this reason, finding the right dialectical behavioral therapist is vital to treatment success.

Dialectical Behavioral Therapy for PTSD and Other Conditions

Many people wonder if DBT works for post-traumatic stress disorder (PTSD). While more research is needed to truly measure its efficacy, recent studies show promising results.  A 2018 study by researchers in Germany found that dialectical behavioral therapy reduced symptoms of PTSD and co-occurring borderline personality disorder. DBT is also being explored as a method of treatment for obsessive-compulsive disorder, eating disorders, anxiety, and addiction.

Choosing the Right Treatment Model for You

CBT and DBT are two of the most popular forms of therapy for borderline personality disorder. If you or someone you know has been diagnosed with BPD, finding help is possible. It’s not uncommon to try multiple forms of therapy before discovering one that works, and success can often only be achieved through experimentation.

There are many different dialectical behavioral therapy workbooks, exercises and techniques online to explore. Reviewing these resources can offer greater insight and help patients understand what to expect from treatment.

Dialectical behavioral therapy comprises four major components. One-on-one sessions typically last around two hours, and additional outside skills training and consultation help reinforce the principles of therapy and encourage a client to continue.

The first therapist someone meets might not be the best fit, and that’s okay. Being honest about goals and expectations from the beginning will allow a client to find the right therapist for them.

When a therapist and client connect, creating a treatment plan that is custom-made can increase feelings of trust and support. Borderline personality disorder and other conditions are tough for both patients and their loved ones. Fortunately, dialectical behavioral therapy offers an opportunity for patients to break the endless cycle of emotional dysregulation and lead a happier, more authentic life.