Dialectical Behavior Therapy: A Primer
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Half a century ago, a suicidal young woman named Marsha Linehan spent more than two years in a psychiatric hospital. Locked as tightly in her own personal torment as in her seclusion room, she vowed not only that she would get out, but that she would get well and help others escape the same torment. Today, Dr. Linehan, the psychologist who developed dialectical behavior therapy (DBT), has made good on her promise.
Although it has not been established how the effectiveness of DBT compares with that of other therapies, DBT is the most evidence-based treatment for borderline personality disorder. Controlled studies show it reduces both suicide attempts and hospitalization and a burgeoning literature supports its use in substance use disorders, eating disorders, depression, and other clinical problems as well. For a review of the literature on DBT, see “Who Can Benefit From DBT?”.
The popularity of DBT skills, combined with a lack of availability of comprehensive DBT in many areas, has led to the misconception that skills are all there is to it. In fact, the comprehensive DBT supported by controlled studies involves far more than just skills. Combining Zen with classical cognitive behavioral therapy (CBT) and supportive therapy, DBT is a highly structured, modular treatment in which multiple therapists perform discrete functions in a team environment. (For a complete description of DBT, see Linehan M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press; 1993.)
In a nutshell, DBT teaches principles of mindfulness—observing, describing, and participating in the moment—to help clients tolerate emotional distress. Mindfulness prepares clients for cognitive-behavioral techniques that enable them to regulate emotions and learn alternatives to self-destructive behavior. The supportive component helps clients apply new coping skills in their everyday lives.
DBT’s dialectic rests on a philosophical principle that seeks to resolve disagreement through the synthesis of opposing truths. In DBT, the most important dialectic involves learning to accept the moment even while recognizing that change must occur for life to become worth living.
This may sound like rainbows and unicorns, but DBT requires hard work and commitment—so much so that treatment begins only after clients sign a pretreatment agreement. Unlike “no-harm contracts” that have no proven benefit in reducing suicide, DBT contracts memorialize clients’ understanding of what treatment involves and their willingness to work toward agreed-upon goals. They also formalize acceptance of pre-established rules—violation of which may result in termination of therapy.
Over a course of treatment lasting about six months, each client spends an hour a week with his or her individual therapist and two or more hours per week in skills groups led by qualified trainers. Clients must complete homework assignments between sessions. A client may contact his or her individual therapist outside of sessions for telephone coaching, crisis management, and repair of the therapeutic relationship. Due to the stress of working with populations served by DBT, therapists must attend weekly groups for consultation, problem-solving strategies, and moral support.
Targets of DBT in Individual Therapy
Since DBT clients often present with a bewildering number of complaints, DBT uses a predetermined hierarchy of therapeutic targets in each modular setting. During individual therapy, life-threatening behavior such as suicide attempts is targeted first. A second target is therapy-interfering behavior by the client such as missing appointments, showing up late, not doing homework, or wasting time in sessions. More than the others, this target to not engage in behavior that interferes with therapy, applies openly and equally to the therapist.
Behaviors that interfere with quality of life are targeted third. These include dealing with addictions, eating disorders, financial problems, employment difficulties, housing issues, and a host of familiar problems that fall short of threatening life or directly interfering with therapy. For clients who take psychiatric medication, DBT considers noncompliance a quality-of-life target. The fourth and final target involves developing life skills that lead to empowerment.
During individual sessions, therapy centers around diary cards on which clients record thoughts, feelings, and behaviors along with the skills they applied to cope with them. Whenever the cards report target behaviors, these become the subject of behavioral chain analysis. Therapist and client collaborate to identify triggers and subsequent decisions that led to the target behavior in that particular situation. Once the weak links are identified, the therapist helps the client learn and apply skills to prevent similar sequences of events from happening again.
Skills groups have a different hierarchy of target behaviors. Therapy-interfering behavior comes first and often takes the form of disruptive behavior during group sessions. Ingeniously, skills groups have two co-leaders, enabling one of them to manage disruptions on a full-time basis. The other co-leader addresses the second target: learning new skills to replace maladaptive behaviors. (For a complete explanation of DBT skills along with training exercises and worksheets, see Linehan’s book Skills Training Manual for Treating Borderline Personality Disorder, published by Guilford Press; 1993.)
DBT skills begin with basic mindfulness, which teaches relaxation and greater awareness of the moment. Mindfulness includes awareness of one’s own mindset, and DBT recognizes three basic mindsets in any situation: emotion mind, reasonable mind, and wise mind. Although emotion mind can lead to impulsive decisions and reasonable mind can fail when most needed, both are considered valid. True to its dialectical roots, however, DBT teaches that wise mind emerges from the synthesis of reason and emotion. Wise mind is considered most effective for solving problems and surviving crises.
Emotion regulation skills include identifying and labeling emotions, learning how they relate to actions, and becoming less vulnerable to emotion mind. The acronym “PLEASE Master” reminds clients to take care of their physical health (by treating Physical iLlness, Eating, Avoiding drugs, Sleeping, and Exercising) and to do at least one thing each day to “Master” competence and self-respect. Emotion regulation skills help clients manage intense and labile moods, and they also work well for clients struggling with addiction and the triggers that can lead to relapse.
Distress tolerance skills help clients endure intense, unavoidable suffering. Also known as crisis survival strategies, they include distraction techniques like pleasurable activities, pushing away unpleasant thoughts, and comparing oneself to people who are less fortunate. They also make use of intense sensations that help distract clients who struggle with self-harm behavior. Popular techniques include causing pain by squeezing ice cubes or snapping one’s wrist with a rubber band.
Interpersonal effectiveness skills are the most complex skills DBT has to offer. They involve analyzing the client’s goals in interpersonal situations, then using assertiveness and effective communication to increase the likelihood of meeting those goals. These can be helpful for clients with work or relationship problems, or for inpatients who are having trouble negotiating with staff to get their needs met. Like all skills, they should be practiced in good weather before a raging storm sets in.
Changing Client Behavior
Learning new skills can change behavior, but clients may feel invalidated by the push for change. In other words, they may feel they are “wrong” for choosing behaviors that reduce their emotional pain. To combat this, DBT therapists look for opportunities to validate their clients. Stepping beyond empathic reflection, they let clients know their choices “make sense” in the context of their unique experience, even if they are ultimately self-defeating. For example, a therapist might say, “I can see how in that situation, it seemed like overdosing was the only way you could get anyone to listen to you.”
DBT therapists use contingency management to shape clients’ behavior. To avoid the unwitting reinforcement of “crisis behavior” that can occur in traditional treatment, they examine how maladaptive behavior is rewarded and adaptive behavior is punished, then look for ways to reverse the reinforcement schedule.
For example, instead of receiving an emergent appointment, a DBT client who self-harms will lose access to his or her therapist for 24 hours. Although another therapist fills in to prevent abandonment, separation from the primary therapist provides an effective aversive stimulus.
On the other hand, therapists reward adaptive behavior—such as applying DBT skills instead of self-injury—by being available for telephone consultation outside of scheduled sessions. The uninitiated often balk at this idea, fearing boundary crossings and losing sleep to one crisis call after another. In reality, clients benefit greatly from skills coaching in real-life situations and they rarely abuse consultation privileges. Moreover, telephone consultation gives clients an opportunity to generalize interpersonal skills by negotiating personal limits with their therapists.
Besides discarding arbitrary boundaries in favor of personal limits, there are other philosophical differences between DBT and traditional therapy. For example, instead of neutral reflection, DBT therapists take a directive stance toward their clients. They expect clients to act on their own behalf in all but the most extenuating circumstances. Appropriate self-disclosure is encouraged. Above all, DBT therapists see themselves as consultants to their clients, whom they regard as having the resources necessary to make decisions in their own best interests.
Even as they recognize their clients’ behavior is unacceptable, DBT therapists assume their clients are doing the best they can and will learn to do better. By adopting these opposing viewpoints simultaneously, therapists help clients accept themselves in the moment while working hard to change. Therapists who take a dialectical approach can also manage their own frustration with chronically suicidal clients, and begin breaking down black-and-white thinking that can lead to burnout.
TCBRH’s Take: It can be very helpful for clinicians who are not dialectical behavior therapists to be familiar with the complexities of DBT. Such an understanding can help determine when it is appropriate to make a DBT referral, as well as help build on the therapeutic effects of DBT in a client who has participated in that form of treatment.