Dialectical Behavioral Therapy is a cognitive behavioral model of psychotherapy used primarily to treat individuals diagnosed with Borderline Personality Disorder (BPD). The treatment was manualized in 1993 (Linehan, 1993a; Linehan, 1993b) and met criteria as an empirically validated, well-established treatment for BPD in 2001 (Koons et al, 2001). DBT has also been found to be effective in a range of treatment settings with a variety of populations.
The empirically based treatment of DBT is a series of cognitive behavioral strategies that are applied to BPD populations. The approach provides psycho-social skills training to encourage development of effective cognitive, emotional, and behavioral skills. Learning DBT skills increases a client’s ability to achieve positive outcomes by systematically developing effective coping mechanisms, and facilitating the decrease of maladaptive behaviors (Linehan, 1993a; Linehan, 1993b).
The characteristics that distinguish DBT are: (1) the immediate focus on acceptance and validation; (2) the emphasis on treating behavior that interferes with therapy; (3) the emphasis on the therapeutic relationship; (4) the focus on dialectics, synthesis, and process (Linehan, 1993a). DBT Theoretical Framework DBT is based upon a dialectal view of human behavior consisting of three primary principles.
The first principle is one of interrelatedness and wholeness: a system must be analyzed as a totality, as the parts are temporary and only exist in relation to the whole. The second principle is polarity: reality is not static but is made up of opposing forces, that when integrated, create a new set of opposing forces. The third principle is continuous change: the tension between oppositional yet connected parts produces a process of change, rather than a structure, which is an underlying condition of human nature (Linehan, 1993a).
In the DBT process, change occurs in the midst of dialectical tension. This tension is a process created by the client’s attempt to maintain homeostasis, while the therapist uses persuasion techniques to support the client’s process of self-transformation. The therapist overcomes the client’s resistance by on-going dialogue with the client that is both encouraging and directive (Linehan, 1993a). One of the core components of DBT is increasing the capacity to regulate emotions (Linehan, 1993a).
Among persons suffering from Borderline Personality Disorder, the inability to regulate emotions results in emotional vulnerability and maladaptive strategies for coping. Emotional vulnerability is defined by (1) high sensitivity to emotional stimuli, (2) intense response to emotional sensitivity, and (3) difficulty reducing the sensitivity and returning to a normal emotional baseline. Similar to Cognitive Behavior Therapy (CBT), DBT also includes ongoing self-monitoring of behaviors, realistic treatment goals, a strong therapeutic alliance, and treatment compliance.
Client agreement in the manualized treatment includes, but is not limited to the following: (1) A commitment to a one year, renewable agreement, (2) Compliance to the weekly meetings and attendance, (3) Notification to the therapist in advance if they are unable to attend scheduled therapy sessions, (4) Confidentiality in group settings, (5) Willingness to work on any and all problems that interfere with therapy, (6) Agreement in group treatment settings to not form personal or sexual relationships with other group members, (8) Commitment to not come to therapy under the influence of drugs or alcohol, and (9) Willingness to participate in both individual and group treatment if appropriate (Linehan, 1993a; Linehan, 1993b).
Therapist agreements in the manualized treatment include but are not limited to: (1) Professional and reasonable effort to conduct therapy with client, (2) Adherence to ethical guidelines, (3) Attendance at all scheduled sessions, and if unable, agreement to reschedule with advance notice, (4) Agreement to respect the autonomy and integrity of the client, and (5) Confidentiality within the confines of the law (Linehan, 1993a). DBT Philosophy In order to truly examine DBT, it is first important to examine how Marsha Linehan designed DBT to treat BPD.
In her book Cognitive-Behavioral Treatment of Borderline Personality Disorder, Linehan (1993 a) described DBT as the application of cognitive and behavioral therapy strategies to help work through problems. DBT is based on a dialectical philosophy that emphasizes reality as an interrelated system composed of opposing forces that are continuously changing. At the core of this philosophy is accepting the client as they are while assisting to promote healthy change. Linehan (1993a) further described DBT as:
The emphasis on assessment; data collection on current behaviors; precise operational definition of treatment targets’ a collaborative working relationship between therapist and patient, including attention to orienting the patient to the therapy program and mutual commitment to treatment goals; application of standard cognitive and behavior therapy techniques, (p. 19) DBT therapists use treatment procedures such as problem solving, exposure techniques, skill training, contingency management, and cognitive modification to help clients find new ways of working through the problems that brought them into therapy. DBT “requires that the therapist balance change and acceptance in each interaction with the patient” (Linehan, 1993a, p. 19).
This treatment philosophy along with the application of problem-solving and validation strategies becomes the DBT process (Linehan, 1993a). DBT “blends a matter of fact, somewhat irreverent, and at times outrageous attitude about current and previous parasuicidal and other dysfunctional behaviors with therapist warmth, flexibility, responsiveness to the client, and strategic self-disclosure” (Linehan, 1993a, p. 19). DBT works to reframe suicidal and other dysfunctional behaviors that had previously been part of the clients learned problem solving patterns. Therapy focuses on active problem solving and is balanced with a corresponding emphasis on validating the client’s current emotional, cognitive, and behavioral responses as they are in that moment.
Focus on dialectics and the balance of acceptance and change are crucial elements of the DBT process (Linehan, 1993b). Dialectics Although DBT has similarities to standard cognitive and behavioral techniques, it also has many defining characteristics that make it a unique treatment. It is important to review the key elements of DBT in order to extend its application to a population such as BPD. For example, DBT emphasizes dialectics. Dialectics can be described as the “reconciliation of opposites in a continual process of synthesis” (Linehan, 1993a, p. 19). It stresses “interrelatedness and wholeness, parts of a system is of limited value unless the analysis clearly relates the part to the whole” (Linehan, 1993a, p. 19).
DBT therapists work with clients to examine a more global meaning to what had previously been polarized as extreme ideas or thoughts. Linehan stated that the most fundamental dialectic is the necessity of accepting patients as they are within a context of trying to teach them to change. Linehan continued by stating that “reality is not static, but is comprised of internal opposing forces, thesis and antithesis, out of whose integration (synthesis) evolves a new set of opposing forces” (Linehan, 1993a, p. 19). Linehan described how although dialectics focus on the whole, they also emphasize how complex the whole can be, including the oppositions they contain.
With this notion in mind, DBT places an emphasis on acceptance as a balance to change (Linehan, 1993a). DBT therefore focuses on accepting the client for who he or she is in the moment, while also working toward more effective behaviors and ways of interacting with one’s present experience and the environment. In addition, DBT emphasizes the necessity of teaching clients to accept themselves and their world as they are in the moment. Linehan discussed how this unique strategy works well with BPD because it provides the validating environment so crucial to those with injured self-esteems. She also discussed the importance of providing a structured setting to learn and practice new skills.
DBT includes both acceptance of the patient’s experiences including validation of their emotional pain and suffering, and offering new psychological coping strategies that include a refocus on meaning and substance in their life, exposure to previously ‘intolerated’ emotions, prevention of emotional escape, and introduction of a behavior focus. (Marra, 2005, p. 7) This behavior focus includes “goal orientation and new solution-based strategies to replace maladaptive coping skills” (Marra, 2005, p. 7). An important caveat to remember as treatment progresses is that there is a natural process of change that occurs as treatment progresses. Linehan discussed how DBT assumes that reality is a process full of movement and change.
Therefore, immediate client stability and consistency are not a focus. Conversely, acceptance and movement with change are key elements of this process. The therapist and client work together in a changing relationship and a changing environment (Linehan, 1993 a). In her work with individuals who struggled with self-injurious and suicidality, Linehan utilized dialectics and the philosophy of balancing acceptance with change to enhance treatment effectiveness. She also observed that most of her clients presented with BPD characteristics. As such, she incorporated dialectical philosophy as the bedrock of her treatment when designing DBT for individuals with BPD characteristics.