DIALECTICAL THERAPY

ABEER SALEEM
F2012-493
BEACONHOUSE NATIONAL UNIVERSITY

Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment that was originally
developed in the late 1980s by psychologist Marsha M. Linehan to treat chronically suicidal
individuals diagnosed with borderline personality disorder (BPD). Since its development, it has
also been used for the treatment of other kinds of mental health disorders such as substance
dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.
Background
Dialectical behavior therapy was developed by Marsha M. Linehan who originally set out to
address the needs of women with histories of suicidal ideation, suicide attempts, or tendencies
to self-harm through her training as a behaviorist. However, she discovered that in reality she
was treating people who were symptomatic of Borderline Personality (BPD).
Dr. Linehan herself suffered from borderline personality disorder. She was first treated for
extreme social withdrawal at age 17. Linehan detailed how when she came to the clinic at the age
of 17, she attacked herself habitually, cut her arms legs and stomach, and burned her wrists with
cigarettes. She was kept in a seclusion room in the clinic because of never-ending urge to cut
herself and to die. Since borderline personality disorder was not discovered yet, she was
diagnosed with schizophrenia and medicated heavily with Thorazine and Librium, as well as
strapped down for forced electroconvulsive therapy (ECT). She was not much better 2 years later
when she was discharged. She had an epiphany in 1967 one night while praying, that led her to
go to graduate school to earn her Ph.D. at Loyola in 1971. During that time, she found the
answer to her own demons and suicidal thoughts. Dialectical behavior therapy was the eventual
result of this thinking. DBT combines techniques from a number of different areas of

psychology, including mindfulness, cognitive-behavioral therapy, and relaxation and breathing

exercises.

The term "dialectical" means a synthesis or integration of opposites. The primary dialectic within
DBT is between the seemingly opposite strategies of acceptance and change. For example, DBT
therapists accept clients as they are while also acknowledging that they need to change in order
to reach their goals. In addition, all of the skills and strategies taught in DBT are balanced in
terms of acceptance and change. For example, the four skills modules include two sets of
acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented
skills (emotion regulation and interpersonal effectiveness).
Clients who receive DBT typically have multiple problems that require treatment. DBT uses a
hierarchy of treatment targets to help the therapist determine the order in which problems should
be addressed. The treatment targets in order of priority are:
1.

Life-threatening behaviors: First and foremost, behaviors that could lead to the client's
death are targeted, including all forms of suicidal and non-suicidal self-injury, suicidal ideation,
suicide communications, and other behaviors engaged in for the purpose of causing bodily harm.

2.

Therapy-interfering behaviors: This includes any behavior that interferes with the
client receiving effective treatment. These behaviors can be on the part of the client and/or the
therapist, such as coming late to sessions, cancelling appointments, and being non-collaborative
in working towards treatment goals.

3.

Quality of life behaviors: This category includes any other type of behavior that
interferes with clients having a reasonable quality of life, such as mental disorders, relationship
problems, and financial or housing crises.

4.

Skills acquisition: This refers to the need for clients to learn new skillful behaviors to
replace ineffective behaviors and help them achieve their goals.

Components
In its standard form, there are four components of DBT: skills training group, individual
treatment, DBT phone coaching, and consultation team.
1.

DBT skills training group is focused on enhancing clients' capabilities by teaching them
behavioral skills. The group is run like a class where the group leader teaches the skills and
assigns homework for clients to practice using the skills in their everyday lives. Groups meet on
a weekly basis for approximately 2.5 hours and it takes 24 weeks to get through the full skills
curriculum, which is often repeated to create a 1-year program. Briefer schedules that teach only
a subset of the skills have also been developed for particular populations and settings.

2.

DBT individual therapy is focused on enhancing client motivation and helping clients to
apply the skills to specific challenges and events in their lives. In the standard DBT model,
individual therapy takes place once a week for as long as the client is in therapy and runs
concurrently with skills groups.

3.

DBT phone coaching is focused on providing clients with in-the-moment coaching on

how to use skills to effectively cope with difficult situations that arise in their everyday lives.

Clients can call their individual therapist between sessions to receive coaching at the times when
they need help the most.
4.

DBT therapist consultation team is intended to be therapy for the therapists and to
support DBT providers in their work with people who often have severe, complex, difficult-totreat disorders. The consultation team is designed to help therapists stay motivated and
competent so they can provide the best treatment possible. Teams typically meet weekly and are
composed of individual therapists and group leaders who share responsibility for each client's
care.

Stages
DBT is divided into four stages of treatment. Stages are defined by the severity of the client's
behaviors, and therapists work with their clients to reach the goals of each stage in their progress
toward having a life that they experience as worth living.
1.

In Stage 1, the client is miserable and their behavior is out of control: they may be trying
to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of selfdestructive behaviors. When clients first start DBT treatment, they often describe their
experience of their mental illness as "being in hell." The goal of Stage 1 is for the client to move
from being out of control to achieving behavioral control.

2.

In Stage 2, they're living a life of quiet desperation: their behavior is under control but
they continue to suffer, often due to past trauma and invalidation. Their emotional experience is
inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one

of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD)
would be treated.
3.

In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and
find peace and happiness. The goal is that the client leads a life of ordinary happiness and
unhappiness.

4. For some people, a fourth stage is needed: finding a deeper meaning through a spiritual
existence. Linehan has posited a Stage 4 specifically for those clients for whom a life of ordinary
happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of
connectedness of a greater whole. In this stage, the goal of treatment is for the client to move
from a sense of incompleteness towards a life that involves an ongoing capacity for experiences
of joy and freedom.

REFERENCES
Allmon, D., Armstrong, H. E., Heard, H. L., Linehan, M. M., &.Suarez, A. (1991). CognitiveBehavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of
General Psychiatry, 48, 1060-1064.
Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder.
New York: Guilford Press.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., &
Recknor, K. L. (1999). Dialectical Behavior Therapy for Patients with Borderline
Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292.