Dialectical behavioral therapy is a method that psychologist, psychiatrists, therapists and counselors employ in order to help patients address painful emotions and to de-escalate conflicts in their interpersonal relationships. DBT is broken up into four main components. These are:
- Distress tolerance
- Emotional regulation
- Interpersonal effectiveness
DBT was originally devised in order to treat patients who have some form of borderline personality disorder. BPD is a condition where an individual engages in behaviors that are seen as extreme by others but that they see as reasonable given the circumstances. Someone who has been diagnosed with a borderline personality disorder may engage in extremely impulsive behaviors, have emotional outbursts that aren’t appropriate to a situation or have a personal history of highly unstable relationships.
In addition to BPD cases, dialectical behavioral therapy has come to be utilized in the treatment of:
- Eating disorders, such as binge-eating and bulimia
- Substance use disorders
- Post-trauma stress disorders
- Bi-polar conditions
It has also been utilized in treating patients who are considered parasuicidal. These are cases where a patient conducts a suicide attempt that is not intended to result in their death, such as taking a too-small dose of pills.
The idea at the core of DBT is to ensure that a client can develop skills to regulate their own feelings, tolerate episodes of emotional distress, act mindfully toward others and communicate effectively. A weekly DBT session structure typically includes:
- A one-hour individual therapy session
- One to three hours of group skills training
- One to two hours in a therapist consultation team meeting
Ultimately, the goal is to use a comprehensive approach to treat a patient. This method is considered distinct in the sense that it is more of a larger program than a specific treatment, such as cognitive-behavioral, group or talk therapy in isolation. DBT is meant to have five functions, which are:
- Enhanced capabilities
- Generalized capabilities
- Improved motivations and diminished dysfunction
- Enhanced therapist capabilities
- Structure in a patient’s environment
When a client first comes into a program for dialectical behavioral therapy, the practitioner is expected to default to the assumption that the person has an incomplete toolbox of life skills. These often include problems with emotional self-regulation, being attentive to life in the present, navigating interpersonal interactions and coping with crisis and stress without making a situation worse. Before significant progress can be made through DBT, these life skills need to be installed or improved in order to allow the client to make progress in other areas. It is normal for these skills to be honed in the weekly group sessions as many of these skills require partners to practice. Clients may also be given homework assignments to help them focus on skills during the times when they’re not in sessions.
A critical component of DBT is making sure that clients take the skills they’re learning into their everyday lives. This requires generalization abilities because no scenario covered in a group session is ever going to be a one-for-one match to something that a person encounters in real life. Notably, therapists who use DBT may make themselves available to a patient by phone for when they have a crisis that calls for some direction in using acquired skills. Discussions will also occur during the individual therapy session each week, and the patient may be encouraged to foster skills by way of homework.
Improving Motivations and Diminishing Dysfunction
This part of the process is largely built around the individual therapy session. A therapist will provide a weekly diary card that covers known problems, such as suicide attempts, self-injury, misuse of drugs or negative emotional reactions to situations. Working from the diary card, the therapist will decide how the hour of individual time will be used for that week. Immediate issues tend to get prioritized, such as threats to the patient’s health or safety. Secondarily, specific long-term problems will be addressed, such as employment issues and school absences. Finally, the therapist will go over issues that yield quality-of-life problems.
During the individual session, the therapist will help the patient work through how different incidents occurred. The patient will also be encouraged to commit to changing behaviors that are creating problems. When a specific skill can be applied to make future versions of the same situation better, the patient and the therapist will talk about how they can be applied.
Enhancing Therapist Capabilities
One of the things that distinguished DBT from many other kinds of therapies is that it includes a focus on things the practitioner does during time away from clients. The one to two hours a week spent in team consultations is the core component of this approach. The therapist may be provided with support for feelings they have about interactions with patients. Questions to other team members about specific issues are also welcomed. The hope is that therapists can provide their clients with more diverse input and, at the same time, reduce the feeling of burnout that can come from working with particularly difficult clients or those whose stories are emotionally challenging to cope with.
Structuring an Environment
A common theme that’s seen across many different types of disorders is that clients often end up in circumstances that do not promote their well-being. One classic case most people will instantly recognize is when people with alcohol or drug use disorders have a lot of friends who also consume alcohol or drugs. A therapist will work with a patient to encourage them into an environment that isolates them from clearly negative influences. This may include, for example, getting someone with a substance use disorder into an inpatient rehab center to limit negative interactions with family members and friends who feed into their problems.
Likewise, it’s understood that the client can’t be kept in a bubble forever. As issues are addressed through sessions, the focus turns from containing the client’s environmental inputs to establishing coping mechanisms for when they have negative interactions. For example, someone who engages in self-harm may learn how to self-soothe. They’ll also be asked to take an inventory of the people in their lives with an eye toward those who overtly encourage negative behaviors or ones who function as triggers or sources of stressors. The objective is to see the patient take charge of who is in their life and how they interact with those people.
The Dialectical Philosophy
A dialectical worldview has played a role in psychology for many years. The Latin root of “dialectical” implies that many things in life exist in tension with each other. That is to say that life is often a push-pull of things that can create tension for patients.
How is this different from other behavioral therapy approaches? In particular, DBT operates under the assumption that asking clients to embrace change isn’t enough. It’s easy for an outside observer to look at a person’s life, decide something is bad and tell the patient to change X, Y and Z. A more realistic view of people’s lives quickly informs us that many things that feel maladaptive to an outsider are highly adaptive for the person going through them.
The temptation to dismiss someone is strong when they say, “You don’t know what I’m going through.” DBT acknowledges this fact and tries to get at why a particular negative behavior has become adaptive for the patient. Except for when extreme harm can come from a behavior, the therapist is encouraged to take a dialectical view rather than uniformly calling something bad.
This does not constitute accepting negative conduct. Instead, it is about working with the client to figure out where negative behaviors come from and then getting them to commit to changes that are positive.
Developing skills is critical to the DBT process. First, a patient is taught to accept feelings. That is to say, they should try to be mindful of what they’re feeling. Once they’re mindful of those feelings, they can start working on how to use active thought to change their feelings or mitigate negative responses.
Clients are also encouraged to understand that they’re not supposed to feel better just because they’ve made these changes. Instead, they should understand that the goal is to cope better with problems. In many cases, the patient should simply be trying to not make bad situations worse.
Part of accepting feelings is a concept called radical acceptance. In its basic form, this means acknowledging that some distressing situations are just awful and there’s not much that can be done about them. You may never be able to make a bad relationship with a dysfunctional relative better, for example, but there are usually plenty of ways to make it worse. Distress tolerance is about getting the client to embrace the fact that not all situations can be changed for the better and that outbursts may only intensify the awfulness.
Up to this point, the client hasn’t really been taught anything that puts them in charge of their environment. That’s intentional because DBT values the acceptance that many externalities can’t be fixed. What can be regulated, though, is the patient’s response.
The concept of emotional regulation may sound like just taking a deep breath. It’s not. Instead, clients are encouraged to:
- Compare reality to how they currently feel
- Consider potential problem-solving approaches
- Take actions that are opposite to their tendencies
- Embrace experiences and emotions rather than avoid them or fight over them
- Think about how emotions play into a situation
It’s easy to see how life can feel like a series of uncontrollable problems that keep coming at you, and it’s also easy to understand why someone might just react to that. What’s less easy is finding ways to be effective when dealing with other people in the face of that seeming onslaught of negativity.
This is where we see the tools of dialectical behavioral therapy in action. They include:
- Describing a situation to another person in a non-judgmental manner, purely stating the facts
- Explaining how you feel
- Asking for what you require without having an emotional outburst
- Explaining how it benefits them to assist you
- Staying mindful
- Not apologizing for your needs
- Hearing the other person’s needs
- Staying on the subject
- Negotiating a solution
There isn’t a single professional organization dedicated exclusively to the DBT process, but the Association for Behavioral and Cognitive Therapies is one of the more widely recognized professional organizations in the industry. The American Psychological Association also acknowledges DBT’s efficacy, so you can look for a therapist who is an APA member.