Dialectical behavior therapy (DBT) is a comprehensive treatment developed to build “a life worth living” and reach their goals in the face of complex mental health struggles and out-of-control thoughts, feelings, and behaviors. When DBT was developed, it was designed to target chronic and/or high-risk suicidal and self-harm behaviors. Initial trials of DBT were conducted with clients who met criteria for borderline personality disorder (BPD). While DBT remains one of the gold-standard evidence-based treatments for BPD and suicidal/self-harm behaviors, the treatment has accrued evidence for a wider range of diagnoses and other problems. Our colleagues at Behavioral Tech have compiled summaries of the research supporting DBT’s effectiveness here.

Modes of Treatment

Comprehensive DBT consists of 4 modes of treatment: individual therapy, group skills training, between-session coaching, and therapist consultation team.

Individual therapy

The purpose of individual therapy is to first identify the client’s goals for treatment and barriers to reaching these goals that must be addressed. After this initial planning period, the function of individual therapy is to enhance the client’s motivation and to help clients identify when and how to implement DBT skills in their daily lives. The individual DBT therapist also plays a case management role, helping the client to manage environmental factors in their lives, and when truly necessary, intervening on the client’s behalf.

Comprehensive DBT clients meets with their individual therapist once per week, typically for about one hour. The individual therapist is also typically responsible for providing between-session coaching to their clients.

Skills training

The purpose of skills training is to help client’s acquire skills that enhance their capabilities in daily life. In standard DBT, there are four skills modules covered.

1. Mindfulness
   1. Mindfulness is intentionally living with awareness in the preset moment, without judging or rejecting the moment, and without attachment to the moment.
   2. The goals of practicing mindfulness skills in DBT are to reduce suffering and increase happiness, to increase control of one’s mind, and to experience reality as it is.
2. Emotion Regulation
   1. The goals of practicing emotion regulation skills in DBT are to understand and name your own emotions, decrease the frequency of unwanted emotions, decrease emotional vulnerability, and to decrease emotional suffering.
3. Distress Tolerance
   1. The goals of practicing distress tolerance skills in DBT are to survive crisis situations without making things worse, to accept reality, and to become free.
4. Interpersonal Effectiveness
   1. The goals of practicing interpersonal effectiveness skills in DBT are to be skillful in getting what you want and need from others, to build relationships and end destructive ones, and to walk the middle path, that is, to create and maintain balance in relationships and to balance acceptance and change in relationships.

Usually, skills training is provided in a group context, in a format that looks similar to a class.

Between-session coaching

The purpose of between-session coaching is to generalize the skills that clients learn in skills training to real-life situations when they need them the most. Clients can call or text their therapist in the moments that they need help the most.

Between-session coaching is not individual therapy by phone. Calls/texts are kept relatively brief, and focus narrowly on identifying and implementing skills in the moments when they are needed. During orientation and commitment to treatment, therapists will share with clients how to best contact them for coaching.

Therapist consultation team

The purpose of the therapist consultation team is to ensure that therapists are sticking to the principles of the treatment, improving their own skills, and maintaining their own motivation to continue providing DBT.

The “D” is DBT – Dialectical

The term “dialectics” has two contexts of usage in DBT. The first is as a way of viewing the fundamental nature of reality – otherwise known as a dialectical world view.

A dialectical world view has three primary characteristics:

• The principle of interrelatedness and wholeness
  • The nature of reality is holistic, connected, and in relationship. This allows us to see that everything is caused.
• The principle of polarity
• Thesis, antithesis, synthesis: The principle of continuous change

From this worldview, we have a number of dialectical strategies that permeate all aspects of treatment in DBT. The fundamental dialectical goal of DBT is to help clients to change while also helping them to accept reality as it is.

The “B” in DBT – Behavioral 

As a behavioral treatment, DBT emphasizes behavioral targets, that is, behaviors that our clients need to increase or to decrease, in order to achieve their life worth living.

DBT Core Assumptions

All DBT therapists make the following assumptions in their work. These are indeed assumptions, not facts. The purposes of making these assumptions are to orient the DBT therapist’s behavior and to aid in treatment planning.

• Clients are doing the best that they can and want to improve.
• Clients need to do better, try harder, and be more motivated to change.
• Clients may not have caused all of their own problems, but they have to solve them anyway.
• The lives of suicidal clients are unbearable as they are currently being lived.
• Clients must learn new behaviors in all relevant contexts.
• Clients cannot fail in therapy.
• Therapists treating DBT clients need support.

The Biosocial Model

DBT is based on a biosocial theory of emotion regulation. The premise of this theory is that pervasive emotion dysregulation results from a combination of biological differences, environmental stressors, and the interaction between these biological differences and environmental stressors over time.

• Biological differences
  • Through a number of biological mechanisms in the brain and genetics, some people are simply born with more vulnerability to emotion. The components of emotional vulnerability include high sensitivity to emotional stimuli, emotional intensity, and slow return to emotional baseline.
    • High sensitivity: May look like reacting quickly and having a low threshold for an emotional reaction. In other words, it doesn’t take much to provoke an emotional reaction.
    • High intensity: May look like having emotions that are more “extreme” than other people’s. In other words, what might cause slight embarrassment to most people may cause deep humiliation; what might cause some annoyance to most people may cause rage; what might give most people a bit of apprehension may cause a panic attack or incapacitating terror.
    • Slow return to emotional baseline: May look like having emotions that stick around longer than other people’s.
• Invalidating environment
  • An invalidating environment is one in which communication of private experiences, such as emotions, is met by invalidation. That is, the emotion is invalidated, punished, or trivialized. Invalidation has two primary characteristics. First, it tells the person that they are wrong in their description and analyses of their own experiences, particularly in their views of what is causing their own emotions, beliefs, and actions. Second, it attributes their experiences to socially unacceptable characteristics or traits. For example, expression of negative emotions may be attributed to traits such as over-reactivity, over-sensitivity, paranoia, or “bad attitude”. Behaviors that may have unintended negative or painful consequences for others may be attributed as “hostile” or “manipulative”. Even expression of positive emotions may be attributed to naïveté, over-idealization, or immaturity.
  • Invalidating environments can occur on various levels, whether experienced within one’s family, or on a broader systemic level, such as through experiences of sexism, racism, and other axes of oppression.
• Interaction between biology and environment

Other Webpages

Behavioral Tech: What is DBT?

https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/

DBT-LBC: What is DBT?

https://dbt-lbc.org/index.php?page=101119