Dialectical Behaviour Therapy (DBT)

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Dialectical Behaviour Therapy (DBT)

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What is Dialectical Behaviour Therapy?

Dialectical Behaviour Therapy (DBT) is a treatment designed specifically for individuals who have extensive histories of self-harm and other self defeating behaviours, e.g. self-cutting, suicidal thoughts, suicide attempts, and drug and alcohol misuse. Many clients who undergo DBT meet the criteria for Borderline Personality Disorder (BPD), and may have associated difficulties such as depression, bipolar disorder, post-traumatic stress disorder (PTSD) or Complex Trauma, anxiety, eating disorders, or alcohol and drug problems.

DBT is a modification of Cognitive Behaviour Therapy (CBT) and was developed by Marsha Linehan (1993a). It combines standard CBT techniques with other 'third wave' techniques including mindfulness and acceptance. Whilst DBT was initially used with people with a diagnosis of BPD it as since been adapted and used with women who binge-eat, teenagers who are depressed and suicidal, and older adults who become depressed again and again.

DBT Theory

A key assumption in DBT is that self-destructive behaviours are learned coping techniques for unbearably intense and negative emotions. Negative emotions like shame, guilt, sadness, fear, and anger are a normal part of life. DBT theory suggests that some people are particularly inclined to have very intense and frequent negative emotions, which may be due to childhood trauma or an 'invalidating environment' and can lead to emotional vulnerability. A person with an emotionally vulnerability tends to have quick, intense, and difficult-to-control emotional reactions that make his or her life seem like a rollercoaster.

What is an invalidating environment?

The “environment,” in this case, is usually other people, specifically early care givers. “Invalidating” refers to a failure to treat the individual in a manner that conveys attention, respect, and understanding for them as a human being who experiences thoughts and feelings in their own right. Examples of an invalidating environment can range from mismatched personalities of children and parents (e.g., a shy child growing up in a family of extroverts who tease her about her shyness); to extremes of physical or emotional abuse. DBT theory suggests that BPD results from the transaction between emotional vulnerability and the invalidating environment.

Dialectical Behaviour Therapy

Clients in standard DBT receive three main modes of treatment – individual therapy, DBT skills group, and telephone coaching. In individual therapy, clients receive once weekly individual sessions that are typically an hour to an hour-and-a half in length. Clients also must attend a two-hour weekly skills group for at least one year. Unlike with regular group psychotherapy, these skills groups emerge as psycho-educational classes during which clients learn four sets of important skills – Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Clients are also asked to call their individual therapists for skills coaching and guidance when they experience strong urges to self harm or complete other self defeating behaviours. The therapist walks the client through alternatives to self-harm or suicidal behaviours and completes a chain analysis (an ABC analysis of what happened before the urge and how to change the consequences of the urge from self defeating to self soothing and tolerating of unmanageable affect) .

In standard DBT the individual therapist is responsible for the client's treatment package and coordinates the treatment with the other professionals – including the skills group leaders, psychiatrists, and others such as OTs and Social Workers. In collaboration with the client, the therapist keeps track of how the treatment is going, how things are going with everyone involved in the treatment, and whether or not the treatment is helping the client reach his or her goals.

Targets and treatment goals in DBT

The most significant goal in DBT is to help clients create “lives worth living.” What makes a life worth living varies from client to client. For some clients, a life worth living is getting married and having children. For others, it’s achieving qualifications and finding a life partner. Others might find it’s engaging in an activity that they have always wanted to do but never had the confidence, e.g. taking dancing lessons. While all these goals will differ, all clients have in common the task of bringing problem behaviours, especially behaviours that could result in death, under control. For this reason, DBT organizes treatment into four stages with targets. Targets refer to the problems being addressed at any given time in therapy. Here are the four stages with targeted behaviours in DBT:

Stage I:Moving from Being Out of Control of One’s Behaviour to Being in Control

Target 1: Reduce and then eliminate life-threatening behaviours (e.g., suicide attempts, suicidal thinking, intentional self-harm).

Target 2: Reduce and then eliminate behaviors that interfere with treatment (e.g., behaviour that “burns out” people who try to help, sporadic completion of homework assignments, non-attendance of sessions, non-collaboration with therapists, etc.). This target includes reducing and then eliminating the use of inpatient hospital stays as a way to handle crises.

Target 3: Decreasing behaviours that destroy the quality of life (e.g., depression, phobias, eating disorders, non-attendance at work or school, neglect of medical problems, lack of money, substandard housing, lack of friends, etc.) and increasing behaviours that make a life worth living (e.g., going to school or having a satisfying job, having friends, having enough money to live on, living in a decent apartment, not feeling depressed and anxious all the time, etc.).

Target 4: Learn skills that help people do the following:
a) Control their attention, so they stop worrying about the future or obsessing about the past. Also, increase awareness of the “present moment” so they learn more and more about what makes them feel good or feel bad through Mindfulness.
b) Start new relationships, improve current relationships, or end bad relationships.
c) Understand what emotions are, how they function, and how to experience them in a way that is not overwhelming.
d) Tolerate emotional pain without resorting to self-harm or self-destructive behaviours.

Stage II. Moving from Being Emotionally Shut Down to Experiencing Emotions Fully

The main target of this stage is to help clients experience feelings without having to shut down by dissociating, avoiding life, or experiencing symptoms of post-traumatic stress disorder (PTSD). In DBT, we say that clients entering this stage are now in control of their behaviour but are in “quiet desperation.” Teaching someone to suffer in silence is not the goal of treatment. In this stage, the therapist works with the client to treat PTSD and/or teaches the client to experience and validate all of his or her emotions without shutting the emotions down and letting the emotions take the driver’s seat.

Stage III. Building an Ordinary Life, Solving Ordinary Life Problems

In Stage III, clients work on ordinary problems like marital or partner conflict, job dissatisfaction, career goals, etc.

Stage IV. Moving from Incompleteness to Completeness/Connection

Most people may struggle with “existential” problems despite having completed therapy at the end of stage III. Even if they have the lives they wanted, they may feel somewhat empty or incomplete. Some people refer to this as “spiritual dryness” or “an empty feeling inside.”

Although these stages of treatment and target priorities are presented in order of importance, we believe they are all interconnected. If someone kills herself, she won’t get the help that she needs to change the quality of her life. Therefore, DBT focuses on life threatening behaviour first. However, if the client is staying alive but is neither coming to therapy nor doing the things required in therapy, she won’t get the help needed to solve non-life threatening problems like depression or substance abuse. For that reason, therapy-interfering behaviours are the second priority in stage I. But coming to treatment is certainly not enough. A client stays alive and comes to therapy in order to solve the other problems which are making her unhappy. To truly have a life worth living, the client must learn new skills, learn to experience emotions, and accomplish ordinary life goals. Therapy is not finished until all of this is accomplished.

What techniques do DBT therapists employ?

(a) CBT techniques

The learning of new behaviours is critical in DBT and is a focus in every individual session, skills group or phone call (for coaching). DBT employs CBT techniques in four main change strategies: Skills Training, Exposure Therapy, Cognitive Therapy, and Contingency Management. In DBT “Behaviour” refers to anything a person thinks, feels, or does. Cognitive Behaviour Therapy uses a wide variety of techniques to help people change behaviors that inhibit a “life worth living.” In DBT, as in CBT, clients are asked to change. Clients track and record their problem behaviours with a weekly diary. They also attend skills groups, complete homework assignments and role-play new ways of interacting with people when in session with their therapist. In addition, clients work with their therapist to identify how they are rewarded for self defeating behaviour or punished for adaptive behaviour. They expose themselves to feelings, thoughts or situations that they feared and avoided, and they change self-destructive ways of thinking.

(b) Acceptance & Validation

In DBT, there are several levels and types of validation. The most basic level is staying alert to the other person. This means being respectful to what she is saying, feeling, and doing. Other levels of validation
involve helping the client regain confidence both by assuming that her behaviour makes perfect sense (e.g. of course you’re angry at the shop manager because he tried to overcharge you and then lied about it) and by treating the other person as an equal (i.e., as opposed to treating her like a fragile patient).

In DBT, just as clients are taught to use cognitive behavioural strategies, they are also taught and encouraged to use validation. In treatment and in life, it is important to know what about ourselves we can change and what about ourselves we must accept (whether short term or the long term). For that reason, acceptance and validation skills are taught in the skills modules as well.

There are four skills modules all together - two emphasise change and two emphasise acceptance. For example, it is extremely important that clients who self-harm learn to accept the experience of pain instead of turning to self-defeating behaviour to solve their problems. Likewise, clients who cut themselves, binge and purge, abuse alcohol and drugs, dissociate, etc., must learn to simply “be with” reality, as painful as it may be at any given moment, in order to learn that they “can stand it.” DBT teaches a host of skills so that clients can learn to stand still instead of running away. Clients are also taught to radically accept the things that we cannot change and sit with the feelings that such situations arise within us (e.g. loud drilling in the next room whilst trying to have a conversation with someone else).

(c) Dialectics

“Dialectics” is a complex concept that has its roots in philosophy and science. “Dialectics” involves several assumptions about the nature of reality: 1) every thing is connected to everything else; 2) change is constant and inevitable; and 3) opposites can be integrated to form a closer approximation to the truth (which is always evolving). Here’s a brief example about how these assumptions would come into play in a DBT program. Suppose you are silent in groups. The other group members are affected by your silence and they try to get you to talk. You affect them and they affect you. Perhaps the group pushes you so hard that you feel like quitting and you talk even less. Then the other members get tired of your silence and withdraw. Paradoxically, this makes you feel better and causes you to talk a bit more. As you become a true member of the group, the leaders shift the way they run the group in order to manage the tension between you and the other members. In other words, you are all interconnected, influencing each other in each moment.

As time passes in the group, there are inevitable changes. Perhaps the group becomes more skilled at getting you to talk. Perhaps you take some risks and talk more. Maybe a new member enters the group while an older member of the community transitions out and the group struggles to adjust to the new arrangement. You also may become aware that your thoughts and feelings change throughout the group, as does every other group member’s. You notice that the group is constantly evolving, constantly readjusting itself. Thinking dialectically means recognizing that all points of view—yours, the other members – have validity and yet all may also be wrong-headed at the same time. If the group is working together dialectically, the group leaders and the members are in constant flux, looking at how opposing points of view can be in play and yet be synthesized. In short, the group is always balancing change and acceptance. Throughout, the group leader and the members would try to hold on to the idea that everyone is doing the best he or she can AND that everyone has got to do better.

DBT also involves specific dialectical strategies to help clients get “unstuck” from rigid ways of thinking or viewing the world. Some of these are traditional CBT interventions and others draw on Eastern ways of viewing life e.g. Mindfulness. The point of all dialectical strategies in DBT is to provide movement, speed, and flow within the therapy so that therapist and client do not become stuck in “I will not do that” vs. “Oh, yes you will!”


Linehan, M.M. (1993a). Cognitive behavioral therapy for Borderline Personality Disorder. New York: Guilford Press.

Linehan, M. M. (1993b). Skills Training Manual for Treating Borderline Personality
. New York: Guilford Press.

Lynch, T.R., Chapman, A.L., Rosenthal,M.Z., Kuo, J.R., & Linehan, M.M. (2006). Mechanisms of change in Dialectical Behavior Therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62, pp. 459–480

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