Dialectical Behaviour Therapy (DBT) is a multimodal treatment model developed by Marsha Linehan, an American clinical psychologist, in the early 1980s (Palmer, 2002; Neacsiu, Ward-Ciesielski, & Linehan, 2012; Linehan, 1993a).
DBT is based on the principles and strategies of an early treatment known as cognitive-behavioural therapy (CBT) and was originally intended for individuals presenting with suicidal symptoms (Linehan, 1993b). DBT replaced CBT in the treatment of suicidal individuals because the latter’s strategies had failed since most clients responded to treatment by withdrawing or attacking the therapist.
Moreover, counselor experienced a variety of difficulties with the use of CBT in treating suicidal clients, especially, the competing priorities concerning the need to decrease suicidality, teaching the clients new behavioral skills, and managing distress among the clients (Neacsiu et al., 2012; Linehan, 1993b).
DBT is designed to provide a comprehensive approach to treating suicidal clients, such as people who are suffering from borderline personality disorder (BPD). The treatment is based on theoretical premises and the principles of validation, acceptance, and mindfulness (Feigenbaum, 2007; Swales, 2009; Wix, 2003).
Apart from borderline personality disorder (BPD), DBT has also been used in the treatment of anxiety, posttraumatic stress disorder (PTSD), self-destructive behaviors, impulsive behaviors, and alcohol/drug problems (Feigenbaum, 2007). This paper summarizes different aspects of DBT – the major concepts and premises, means of assessment, goal setting, processes, and applicability.
The Philosophical Elements of DBT
There are three major philosophical elements that underlie DBT including dialectics, Zen Buddhism, and behavioural science (Palmer, 2002; Neacsiu et al., 2012). The basic element of DBT in relation to behavioural science is cognitive-behavioural therapy. DBT is based on the therapeutic techniques of CBT, which emphasize on self-monitoring and collaborative efforts from both the client and the therapist (Palmer, 2002).
However, it is important to note that some aspects of CBT are not effective in addressing the problems present among suicidal clients. In order to address the challenges associated with behavioural science approaches such as CBT in the treatment of individuals with BPD, the DBT approach incorporates the principles of Zen.
Here, the Zen philosophy encourages people to forego their ideas regarding their view of reality, and focus on the current moment through acceptance, self-validation, and tolerance.
From the Zen perspective, the world is perfect as it is and each moment of reality should be accepted without judgment (Robins et al., 2004). This principle is incorporated into the mindfulness component of DBT, which emphasizes on the need for patients to intentionally live in the present moment without judging, rejecting, or getting attached to the moment (Linehan, 1993b).
On the other hand, counselors and their BPD clients will recognize that putting acceptance and change together in any treatment session is very difficult. Therefore, DBT incorporates the dialectical element, which emphasizes on the importance of synthesizing opposites.
Here, dialectics is a very important component of DBT, especially in dealing with multi-problem clients, because it allows them to initiate behavioural change by means of acceptance and self-validation (Neacsiu et al., 2002). The dialectical philosophy encourages clients to take a holistic look at different perspectives, encapsulate opposites, and move on continuously.
Dialectical Behaviour Therapy Assumptions
Alongside the philosophical elements of DBT identified in the foregoing discussions, the treatment involves a number of assumptions about the client and the counselor. On the part of the client, DBT assumes that the clients are capable of doing their best to solve their problems. Furthermore, the therapist assumes that the clients cannot fail in the DBT treatment.
Additionally, there is the assumption that the clients may not be the source of all the problems they are facing, but they must be willing to solve them either way. Most importantly, the therapy assumes that the lives of people suffering from BPD are unbearable, and therefore, the clients must be motivated to change their lives for the better (Neacsiu et al., 2012; Kliem, Kroger, & Kosfelder, 2010).
About the therapist and the therapy itself, it is presumed that the counselor has a responsibility in caring and helping the clients to change their ways and achieve their goals in life. Moreover, the therapist must conduct DBT with utmost clarity, precision, and compassion while ensuring that the therapeutic relationship with the clients exemplifies a real interaction between equals.
Further, it is presumed that the principles of behaviour apply to the therapist in the same way they apply to clients. On the other hand, the therapist needs support in caring and helping the clients suffering from BPD. Other overarching assumptions imply that the therapist can fail in delivering DBT and the treatment can fail even without the therapist’s fault (Linehan, 1993a; Miller, Rathus, & Linehan, 2007).
Theoretical Foundations of DBT
The biosocial theory of borderline personality disorder informs the dialectical behaviour therapy. The theory hypothesizes that BPD arises when an emotionally-vulnerable person interacts with an invalidating environment (Linehan, 1993a; Swales, 2009; Palmer, 2002).
Emotional vulnerability refers to instances where an individual reacts excessively to less harmful stressors and takes long time to regain baseline emotions after the stressor is removed (Swales, 2009). When a growing child is exposed to an invalidating environment, it is probable that s/he will not have the opportunity to understand his/her personal feelings and experiences.
Besides, this child may not be able to relate his/her responses to particular events in the real world as he/she lacks the support of the others in solving or coping with difficult/stressful situations, most especially when none acknowledges the problems associated with such situations (Huss & Baer, 2007).
Consequently, the child turns to the immediate environment for answers regarding his/her problems, but the environment may limit the demands that she makes on the significant others. In the long run, the child may begin hoping to gain acceptance from others as well as develop extreme emotions to make others to acknowledge her experiences.
An obvious consequence of this erratic emotional response is that it prevents the child from understanding and controlling specific emotions. Furthermore, the child may not achieve emotion modulation because the situation does not allow her to acquire the necessary skills (Crowell et al., 2009).
Overall, the child slips into a state of emotional dysregulation, which upon interacting with the invalidating environment, leads to Borderline Personality Disorder (BPD). Therefore, based on this theory, DBT is designed to help borderline patients to recover emotional control under validating environments.
Means of Assessment/BPD Diagnosis
Emotional dysregulation in a growing child can interact with the invalidating environment to cause BPD. As a result, emotional dysregulation is a central feature in the development of BPD (Neacsiu et al., 2012; Linehan, 1993a; Linehan, Bohus, & Lynch, 2007). From a DBT perspective, emotions are considered as complex involuntary responses to both the internal and external environments.
In DBT, such emotional responses are categorized into various subsystems, important to treatment because they are the main targets of different emotion regulation processes of DBT.
These subsystems include emotional vulnerability to cues, triggers, response tendencies, nonverbal and verbal expressive actions/responses, and secondary emotions, which interact in different ways to produce a particular pattern of emotions. Therefore, one can assess emotion dysregulation by examining the way an individual alters or controls various subsystems of responses under average or normal conditions.
Emotion dysregulation is characterized by excessive negative affect, irrational thoughts, impulsive emotional behaviours, dissociation under stress, and difficulties in controlling physiological arousal and in undertaking non-mood-dependent activities (Linehan et al., 2007). Various self-destructive behaviours, dysfunctional behaviours, and maladaptive responses are important indicators of emotion dysregulation.
Goal Setting in DBT
In DBT, goals for treatment are set through collaborative efforts involving both the therapist and the client. However, the therapist plays a major role in modifying the clients’ goals to fit into the treatment model. Here, a treatment target hierarchy is used in determining the problem focus in each treatment session. In most cases, the therapist gives the highest priority to addressing suicidal and self-injurious behaviours among the clients.
These behaviours are commonly referred to as out-of-control and usually categorized into life-interfering, life-threatening, and severe quality-of-life-interfering behaviours. Once a client has achieved stability and control over these dysfunctional behaviours, then the therapy focuses on activities aimed stabilizing the clients’ emotions and alleviating trauma.
Further, the therapy moves to activities that increase the clients’ self-respect and decreasing problems that cab interfere with the clients’ ability to achieve personal goals. Finally, the therapy proceeds to resolving the clients’ experiences and feelings of incompleteness (Koerner & Linehan, 1992; Kliem et al., 2010).
Moreover, it is imperative for the therapy to address various secondary targets, such as inhibited behavioural patterns, which may interfere with the progress made in treatment.
Processes and Specific Techniques in DBT
The main objectives of DBT are to enhance the clients’ capabilities and motivate them accordingly achieved by increasing the clients’ set of skilled behaviors, generalizing the learned behaviours to the natural environment, improving the clients’ motivation, reducing dysfunctional behaviours and eliminating their reinforcements, reinforcing effective behaviors and increasing the therapists’ motivation and capabilities.
These functions of DBT are further supported by four major modes of treatment, which include individual psychotherapy, skills training group therapy, consultation teams, and phone coaching. On the other hand, DBT focuses on problem-solving by means of validation and dialectical strategies.
Therefore, the treatment involves specific techniques such as change strategies, validation strategies, dialectical strategies, communication strategies, and case management strategies (Neacsiu et al., 2012). Moreover, these broad categories involve more specific processes and techniques of handling borderline clients.
There are many treatment techniques borrowed from CBT, such as targeting, attention to in-session behaviours, chain analysis, opposite action, and observing limits (Linehan, 1993a; Dimeff & Linehan, 2001).
Applicability
DBT is the most widely investigated psychosocial model of treatment for BPD. A myriad of studies have tested the efficacy of DBT in resolving different symptoms associated with BPD in a variety of populations and settings.
In studies involving highly suicidal patients, the researchers found out that DBT was effective in resolving a number of dysfunctional and maladaptive behaviours such as suicide including some cases of severe suicidal behaviors and self-jury among the participants as compared to treatment as usual (TAU).
Furthermore, it has been shown in these studies that the tendency to use psychiatric facilities was less among BPD clients who had been treated using the DBT approach (Neacsiu et al., 2012; Bedics, Atkins, Comtois, & Linehan, 2011; Pistorello et al., 2012; Harned et al., 2009; Iverson, Shenk, & Fruzzetti, 2009).
On the other hand, the effectiveness of DBT has been investigated in the treatment of other psychosocial issues, and there are promising results, particularly in treating anxiety, substance abuse, eating disorders, ADHD, and treatment-resistant depression (Rizvi, Steffel, & Carson-Wong, 2012).
References
Bedics, J. D., Atkins, D. C., Comtois, K. A., & Linehan, M. M., (2012). Treatment differences in the therapeutic relationship and introject during a 2-year randomized controlled trial of dialectical behaviour therapy versus nonbehavioural psychotherapy experts for borderline personality disorder. Journal of Consulting and Clinical Psychology, 80(1), 66-77.
Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory. Psychological Bulletin, 135, 495-510.
Dimeff & Linehan, M. M. (2001). Dialectical behaviour therapy in a nutshell. California Psychologist, 34, 10-13.
Feigenbaum, J. (2207). Dialectical behaviour therapy: An increasing evidence base. Journal of Mental Health, 16(1), 51-60.
Harned, M. S., Chapman, A. L., Dexter-Mazza, E. T., Murray, A., Comtois, K. A., & Linehan, M. M. (2009). Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: A 2-year randomized trial of dialectical behaviour therapy versus community treatment by experts. Personality Disorders: Theory, Research, and Treatment, 5(1), 35-45.
Huss, D. B., & Baer, R. A. (2007). Acceptance and change: The integration of mindfulness-based cognitive therapy into ongoing dialectical behaviour therapy in a case of borderline personality disorder with depression. Clinical Case Studies, 6(1), 17-33.
Iverson, K. M., Shenk, C., & Fruzzetti, A. E. (2009). Dialectical behaviour therapy for women victims of domestic abuse: A pilot study. Professional Psychology: Research and Practice, 40(3), 242-248.
Kliem, S., Kroger, C., & Kosfelder, J. (2010). Dialectical behaviour therapy for borderline personality disorder: A meta-analysis using mixed effects modeling. Journal of Consulting and Clinical Psychology, 78(6), 936-951.
Koerner, K., & Linehan, M. M. (1992). Integrative therapy for borderline personality disorder: Dialectical behaviour therapy. In J. C. Norcross (Ed.). Handbook of Psychotherapy integration (pp. 433-459). New York, NY: Basic Books.
Linehan, M. M. (1993a). Cognitive-behavioural treatment of borderline personality disorder. New York, NY: Guilford.
Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York, NY: Guilford.
Linehan, M. M., Bohus, M., & Lynch, T. (2007). Dialectical behaviour therapy for pervasive emotion dysregulation: Theoretical and practical underpinnings. In J. Gross (Ed.), Handbook of emotion regulation (pp. 581-605). New York, NY: Guilford.
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behaviour therapy with suicidal adolescents. New York, NY: Guilford.
Neacsiu, A. D., Ward-Ciesielski, E. F., & Linehan, M. M. (2012). Emerging approaches to counseling intervention: Dialectical behaviour therapy. The Counseling Psychologist, 40(7), 1003-1032.
Palmer, R. L. (2002). Dialectical behaviour therapy for borderline personality disorder. Advances in Psychiatric Treatment, 8(1), 10-16.
Piatorello, J. Fruzzetti, A. E., MacLane, C., Gallop, R., & Iverson, K. M. (2012). Dialectical Behaviour therapy (DBT) applied to college students: A randomized clinical trial. Journal of Consulting and Clinical Psychology. Advance Online Publication.
Rizvi, S. L., Steffel, L. M., & Carson-Wong, A. (2012). An overview of dialectical behavioral therapy for professional psychologists. Professional Psychology: Research and Practice. Advance Online Publication.
Robins, C. J., Schmidt, Linehan, M. M. (2004). Dialectical behaviour therapy: Synthesizing radical acceptance with skillful means. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioural tradition (pp. 30-44). New York, NY: Guilford.
Swales, M. A. (2009). Dialectical behaviour therapy: Description, research and future directions. The International Journal of Behavioral Consultation and Therapy, 5(2), 164-177.
Wix, S. (2003). Dialectical behaviour therapy observed. The British Journal of Forensic Practice, 5(2), 3-7.