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Dialectical behavior therapy

Dialectical behavior therapy (DBT) is an evidence-
based[1] psychotherapy that began with efforts to treat
personality disorders and interpersonal conflicts.[1] Evidence
suggests that DBT can be useful in treating mood disorders and
suicidal ideation, as well as for changing behavioral patterns
such as self-harm and substance use.[2] DBT evolved into a
process in which the therapist and client work with acceptance
and change-oriented strategies, and ultimately balance and
synthesize them—comparable to the philosophical dialectical
process of thesis and antithesis followed by synthesis.[1]

This approach was developed by Marsha M. Linehan, a

psychology researcher at the University of Washington. She The skills modules in dialectical
defines dialectical as "a synthesis or integration of behavior therapy
[3]
opposites". DBT was designed to help people increase their
emotional and cognitive regulation by learning about the
triggers that lead to reactive states and by helping to assess which coping skills to apply in the
sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions.

DBT grew out of a series of failed attempts to apply the standard cognitive behavioral therapy
(CBT) protocols of the late 1970s to chronically suicidal clients.[3] Research on its effectiveness in
treating other conditions has been fruitful;[4] DBT has been used by practitioners to treat people
with depression, drug and alcohol problems,[5] post-traumatic stress disorder (PTSD),[6]
traumatic brain injuries (TBI), binge-eating disorder,[1] and mood disorders.[7][3] Research
indicates that DBT might help patients with symptoms and behaviors associated with spectrum
mood disorders, including self-injury.[8] Work also suggests its effectiveness with sexual-abuse
survivors[9] and chemical dependency.[10]

DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing
with concepts of distress tolerance, acceptance, and mindful awareness largely derived from
contemplative meditative practice. DBT is based upon the biosocial theory of mental illness and is
the first therapy that has been experimentally demonstrated to be generally effective in treating
borderline personality disorder (BPD).[11][12] The first randomized clinical trial of DBT showed
reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment dropouts when
compared to treatment as usual.[3] A meta-analysis found that DBT reached moderate effects in
individuals with BPD.[13]

Overview
DBT is sometimes considered a part of the "third wave" of cognitive-behavioral therapy, as DBT
adapts CBT to assist patients in dealing with stress.[14][15]

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DBT strives to have the patient view the therapist as an accepting ally rather than an adversary in
the treatment of psychological issues: many treatments at this time left patients feeling "criticized,
misunderstood, and invalidated" due to the way these methods "focused on changing cognitions
and behaviors."[1] Accordingly, the therapist aims to accept and validate the client's feelings at any
given time, while, nonetheless, informing the client that some feelings and behaviors are
maladaptive, and showing them better alternatives.[3] In particular, DBT targets self-harm and
suicide attempts by identifying the function of that behavior and obtaining that function safely
through DBT coping skills.[16] DBT focuses on the client acquiring new skills and changing their
behaviors,[17] with the ultimate goal of achieving a "life worth living".[1]

In DBT's biosocial theory of BPD, clients have a biological predisposition for emotional
dysregulation, and their social environment validates maladaptive behavior.[18]

DBT skills training alone is being used to address treatment goals in some clinical settings,[19] and
the broader goal of emotion regulation that is seen in DBT has allowed it to be used in new
settings, for example, supporting parenting.[20] There has been little study into adapting DBT into
an online environment, but a review indicates that attendance is improved online, with
comparable improvements for clients to the traditional mode.[21]

Four modules

Mindfulness

Mindfulness is one of the core ideas behind all elements of

DBT. It is considered a foundation for the other skills taught in
DBT, because it helps individuals accept and tolerate the
powerful emotions they may feel when challenging their habits
or exposing themselves to upsetting situations.

The concept of mindfulness and the meditative exercises used

to teach it are derived from traditional contemplative religious
practice, though the version taught in DBT does not involve DBT wise mind—the synthesis of
any religious or metaphysical concepts. Within DBT it is the the two opposites: reasonable mind
capacity to pay attention, nonjudgmentally, to the present and emotion mind
moment; about living in the moment, experiencing one's
emotions and senses fully, yet with perspective. The practice of
mindfulness can also be intended to make people more aware of their environments through their
five senses: touch, smell, sight, taste, and sound.[22] Mindfulness relies heavily on the principle of
acceptance, sometimes referred to as "radical acceptance". Acceptance skills rely on the patient's
ability to view situations with no judgment, and to accept situations and their accompanying
emotions. This causes less distress overall, which can result in reduced discomfort and
symptomology.

Acceptance and change

The first few sessions of DBT introduce the dialectic of acceptance and change. The patient must
first become comfortable with the idea of therapy; once the patient and therapist have established
a trusting relationship, DBT techniques can flourish. An essential part of learning acceptance is to
first grasp the idea of radical acceptance: radical acceptance embraces the idea that one should
face situations, both positive and negative, without judgment. Acceptance also incorporates
mindfulness and emotional regulation skills, which depend on the idea of radical acceptance.
These skills, specifically, are what set DBT apart from other therapies.
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Often, after a patient becomes familiar with the idea of acceptance, they will accompany it with
change. DBT has five specific states of change which the therapist will review with the patient: pre-
contemplation, contemplation, preparation, action, and maintenance.[23] Precontemplation is the
first stage, in which the patient is completely unaware of their problem. In the second stage,
contemplation, the patient realizes the reality of their illness: this is not an action, but a
realization. It is not until the third stage, preparation, that the patient is likely to take action, and
prepares to move forward. This could be as simple as researching or contacting therapists. Finally,
in stage 4, the patient takes action and receives treatment. In the final stage, maintenance, the
patient must strengthen their change in order to prevent relapse. After grasping acceptance and
change, a patient can fully advance to mindfulness techniques.

There are six mindfulness skills used in DBT to bring the client closer to achieving a "wise mind",
the synthesis of the rational mind and emotion mind: three "what" skills (observe, describe,
participate) and three "how" skills (nonjudgementally, one-mindfully, effectively).[24]

Distress tolerance

Many current approaches to mental health treatment focus on changing distressing events and
circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist
attacks and other traumatic events.[25] They have paid little attention to accepting, finding
meaning for, and tolerating distress. This task has generally been tackled by person-centered,
psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual
communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.
This module outlines healthy coping behaviors (such as distractions, improving the moment, self-
soothing, and practicing acceptance of what is) that are intended to replace harmful ones.[24]

Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have
to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and
the current situation. Since this is a non-judgmental stance, this means that it is not one of
approval or resignation. The goal is to become capable of calmly recognizing negative situations
and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals
to make wise decisions about whether and how to take action, rather than falling into the intense,
desperate, and often destructive emotional reactions that are part of borderline personality
disorder.[26]

Emotion regulation

Individuals with borderline personality disorder and suicidal individuals are frequently
emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This
suggests that these clients might benefit from help in learning to regulate their emotions.
Dialectical behavior therapy skills for emotion regulation include:[27]

Identify and label emotions

Identify obstacles to changing emotions
Reduce vulnerability to emotion mind
Increase positive emotional events
Increase mindfulness to current emotions
Take opposite action
Apply distress tolerance techniques[26]

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Emotional regulation skills are based on the theory that intense emotions are a conditioned
response to troublesome experiences, the conditioned stimulus, and therefore, are required to
alter the patient's conditioned response.[4] These skills can be categorized into four modules:
understanding and naming emotions, changing unwanted emotions, reducing vulnerability, and
managing extreme conditions:[4]

Learning how to understand and name emotions: the patient focuses on recognizing their
feelings. This segment relates directly to mindfulness, which also exposes a patient to their
emotions.
Changing unwanted emotions: the therapist emphasizes the use of opposite-reactions, fact-
checking, and problem solving to regulate emotions. While using opposite-reactions, the
patient targets distressing feelings by responding with the opposite emotion.
Reducing vulnerability: the patient learns to accumulate positive emotions and to plan
coping mechanisms in advance, in order to better handle difficult experiences in the future.
Managing extreme conditions: the patient focuses on incorporating their use of mindfulness
skills to their current emotions, to remain stable and alert in a crisis.[4]

Interpersonal effectiveness

The three interpersonal skills focused on in DBT include self-respect, treating others "with care,
interest, validation, and respect", and assertiveness. The dialectic involved in healthy relationships
involves balancing the needs of others with the needs of the self, while maintaining one's self-
respect.[28]

Tools
Specially formatted diary cards can be used to track relevant emotions and behaviors. Diary cards
are most useful when they are filled out daily.[29] The diary card is used to find the treatment
priorities that guide the agenda of each therapy session. Both the client and therapist can use the
diary card to see what has improved, gotten worse, or stayed the same.[30]

Chain analysis

Chain analysis is a form of functional analysis of behavior but

with increased focus on sequential events that form the
behavior chain. It has strong roots in behavioral psychology in Chain analysis— from a prompting
particular applied behavior analysis concept of chaining.[31] A event to the problem behavior and
growing body of research supports the use of behavior chain consequences
analysis with multiple populations.[32]

Efficacy

Borderline personality disorder

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DBT is the therapy that has been studied the most for treatment of borderline personality disorder,
and there have been enough studies done to conclude that DBT is helpful in treating borderline
personality disorder.[33] Several studies have found there are neurobiological changes in
individuals with BPD after DBT treatment.[34]

Depression

A Duke University pilot study compared treatment of depression by antidepressant medication to

treatment by antidepressants and dialectical behavior therapy. A total of 34 chronically depressed
individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically-
significant differences were noted in remission rates between groups, with a greater percentage of
patients treated with antidepressants and dialectical behavior therapy in remission.[35]

Complex post-traumatic stress disorder (CPTSD)

Exposure to complex trauma, or the experience of prolonged trauma with little chance of escape,
can lead to the development of complex post-traumatic stress disorder (CPTSD) in an
individual.[36] CPTSD is a concept which divides the psychological community. The American
Psychiatric Association (APA) does not recognize it in the DSM-5 (Diagnostical and Statistical
Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental
illness), though some practitioners argue that CPTSD is separate from post-traumatic stress
disorder (PTSD).[37]

CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive,
emotional, and biological domains, among others.[38] CPTSD differs from PTSD in that it is
believed to originate in childhood interpersonal trauma, or chronic childhood stress,[38] and that
the most common precedents are sexual traumas.[39] Currently, the prevalence rate for CPTSD is
an estimated 0.5%, while PTSD's is 1.5%.[39] Numerous definitions for CPTSD exist. Different
versions are contributed by the World Health Organization (WHO), The International Society for
Traumatic Stress Studies (ISTSS), and individual clinicians and researchers.

Most definitions revolve around criteria for PTSD with the addition of several other domains.
While The APA may not recognize CPTSD, the WHO has recognized this syndrome in its 11th
edition of the International Classification of Diseases (ICD-11). The WHO defines CPTSD as a
disorder following a single or multiple events which cause the individual to feel stressed or
trapped, characterized by low self-esteem, interpersonal deficits, and deficits in affect
regulation.[40] These deficits in affect regulation, among other symptoms are a reason why CPTSD
is sometimes compared with borderline personality disorder (BPD).

Similarities Between CPTSD and borderline personality disorder

In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit
splitting, mood swings, and fears of abandonment.[41] Like patients with borderline personality
disorder, patients with CPTSD were traumatized frequently and/or early in their development and
never learned proper coping mechanisms. These individuals may use avoidance, substances,
dissociation, and other maladaptive behaviors to cope.[41] Thus, treatment for CPTSD involves
stabilizing and teaching successful coping behaviors, affect regulation, and creating and
maintaining interpersonal connections.[41] In addition to sharing symptom presentations, CPTSD
and BPD can share neurophysiological similarities, for example, abnormal volume of the amygdala
(emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital
prefrontal cortex (personality).[42] Another shared characteristic between CPTSD and BPD is the

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possibility for dissociation. Further research is needed to determine the reliability of dissociation
as a hallmark of CPTSD, however it is a possible symptom.[42] Because of the two disorders’ shared
symptomatology and physiological correlates, psychologists began hypothesizing that a treatment
which was effective for one disorder may be effective for the other as well.

DBT as a treatment for CPTSD

DBT's use of acceptance and goal orientation as an approach to behavior change can help to instill
empowerment and engage individuals in the therapeutic process. The focus on the future and
change can help to prevent the individual from becoming overwhelmed by their history of
trauma.[43] This is a risk especially with CPTSD, as multiple traumas are common within this
diagnosis. Generally, care providers address a client's suicidality before moving on to other aspects
of treatment. Because PTSD can make an individual more likely to experience suicidal ideation,[44]
DBT can be an option to stabilize suicidality and aid in other treatment modalities.[44]

Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective
than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious
behaviors (such as cutting or burning) and increases interpersonal functioning but neglects core
CPTSD symptoms such as impulsivity, cognitive schemas (repetitive, negative thoughts), and
emotions such as guilt and shame.[42] The ISTSS reports that CPTSD requires treatment which
differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing
on traumatic memories.[36] The recommended multiphase model consists of establishing safety,
distress tolerance, and social relations.[36]

Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress
Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT
discuss the time required for the therapy to be effective.[45] Individuals seeking DBT may not be
able to commit to the individual and group sessions required, or their insurance may not cover
every session.[45]

A study co-authored by Linehan found that among women receiving outpatient care for BPD and
who had attempted suicide in the previous year, 56% additionally met criteria for PTSD.[46]
Because of the correlation between borderline personality disorder traits and trauma, some
settings began using DBT as a treatment for traumatic symptoms.[47] Some providers opt to
combine DBT with other PTSD interventions, such as prolonged exposure therapy (PE) (repeated,
detailed description of the trauma in a psychotherapy session) or cognitive processing therapy
(CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories).

For example, a regimen which combined PE and DBT would include teaching mindfulness skills
and distress tolerance skills, then implementing PE. The individual with the disorder would then
be taught acceptance of a trauma's occurrence and how it may continue to affect them throughout
their lives.[48][47] Participants in clinical trials such as these exhibited a decrease in symptoms, and
throughout the 12-week trial, no self-injurious or suicidal behaviors were reported.[48]

Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD
symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure
therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is
low.[49] Biosocial theory posits that emotion dysregulation is caused by an individual's heightened
emotional sensitivity combined with environmental factors (such as invalidation of emotions,
continued abuse/trauma), and tendency to ruminate (repeatedly think about a negative event and
how the outcome could have been changed).[50]

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An individual who has these features is likely to use maladaptive coping behaviors.[50] DBT can be
appropriate in these cases because it teaches appropriate coping skills and allows the individuals
to develop some degree of self-sufficiency.[50] The first three modules of DBT increase distress
tolerance and emotion regulation skills in the individual, paving the way for work on symptoms
such as intrusions, self-esteem deficiency, and interpersonal relations.[49]

Noteworthy is that DBT has often been modified based on the population being treated. For
example, in veteran populations DBT is modified to include exposure exercises and accommodate
the presence of traumatic brain injury (TBI), and insurance coverage (i.e. shortening
treatment).[48][51] Populations with comorbid BPD may need to spend longer in the "Establishing
Safety" phase.[42] In adolescent populations, the skills training aspect of DBT has elicited
significant improvement in emotion regulation and ability to express emotion appropriately.[51] In
populations with comorbid substance use, adaptations may be made on a case-by-case basis.[52]

For example, a provider may wish to incorporate elements of motivational interviewing

(psychotherapy which uses empowerment to inspire behavior change). The degree of substance
use should also be considered. For some individuals, substance use is the only coping behavior
they know, and as such the provider may seek to implement skills training before targeting
substance reduction. Inversely, a client's substance use may be interfering with attendance or
other treatment compliance and the provider may choose to address the substance use before
implementing DBT for the trauma.[52]

See also
Psychology portal

Society portal

Education portal

Acceptance and commitment therapy – Form of cognitive behavioral therapy

Behaviour therapy – Clinical psychotherapy that uses techniques derived from behaviourism
and/or cognitive psychology
Cognitive emotional behavioral therapy – Mental health conditions
Mentalization-based treatment – Form of psychotherapy
Nonviolent Communication – Communication process intended to increase empathy
Rational emotive behavior therapy – Psychotherapy
Social skills – Competence facilitating interaction and communication with others

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General and cited sources

Koons, C.R.; Robins, C.J.; Tweed, J.L.; Lynch, T.R.; Gonzalez, A.M.; Morse, J.Q.; Bishop,
G.K.; Butterfield, M.I.; Bastian, L.A. (2001). "Efficacy of dialectical behavior therapy in women
veterans with borderline personality disorder". Behavior Therapy. 32 (2): 371–390.
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0009-5).
Linehan et al. (2006) NIMH 3 Two-Year Randomized Control Trial and Follow up of DBT
Linehan, M.M.; Comtois, K.A.; Murray, A.M.; Brown, M.Z.; Gallop, R.J.; Heard, H.L.; Korslund,
K.E.; Tutek, D.A.; Reynolds, S.K.; Lindenboim, N. (2006). "Two-year randomized controlled
trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors
and borderline personality disorder" (https://doi.org/10.1001%2Farchpsyc.63.7.757). Arch Gen
Psychiatry. 63 (7): 757–66. doi:10.1001/archpsyc.63.7.757 (https://doi.org/10.1001%2Farchps
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Linehan, M.M.; Dimeff, L.A.; Reynolds, S.K.; Comtois, K.A.; Welch, S.S.; Heagerty, P.;
Kivlahan, D.R. (2002). "Dialectical behavior therapy versus comprehensive validation plus 12-
step for the treatment of opioid dependent women meeting criteria for borderline personality
disorder". Drug and Alcohol Dependence. 67 (1): 13–26. doi:10.1016/s0376-8716(02)00011-x
(https://doi.org/10.1016%2Fs0376-8716%2802%2900011-x). PMID 12062776 (https://pubmed.
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van den Bosch, L.M.C.; Verheul, R.; Schippers, G.M.; van den Brink, W. (2002). "Dialectical
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Further reading
Chapman, A. L. (2006). "Dialectical Behavior Therapy: Current Indications and Unique
Elements" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963469). Psychiatry. 3 (9): 62–68.
PMC 2963469 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963469). PMID 20975829 (htt
ps://pubmed.ncbi.nlm.nih.gov/20975829).
Cognitive Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan.
1993. ISBN 0-89862-183-6.
DBT For Dummies (https://www.dummies.com/health/mental-health/dbt-for-dummies/) by
Gillian Galen PsyD, Blaise Aguirre MD. ISBN 978-1-119-73012-5.
Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming
Depression & Anxiety by Thomas Marra. ISBN 978-1-57224-363-7.
Dialectical Behavior Therapy with Suicidal Adolescents by Alec L. Miller, Jill H. Rathus, and
Marsha M. Linehan. Foreword by Charles R. Swenson. ISBN 978-1-59385-383-9.
Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness,
Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (New Harbinger Self-
Help Workbook) by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley. ISBN 978-1-
57224-513-6.
Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in
Control (New Harbinger Self-Help Workbook) by Scott E. Spradlin. ISBN 978-1-57224-309-5.
Fatal Flaws: Navigating Destructive Relationships with People with Disorders of Personality
and Character by Stuart C. Yudovsky. ISBN 1-58562-214-1.
Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan.
1993. ISBN 0-89862-034-1.
The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, &
Validation by Alan E. Fruzzetti. ISBN 1-57224-450-X.
The Miracle of Mindfulness by Thích Nhất Hạnh. ISBN 0-8070-1239-4.

External links
DBT and Borderline Personality Disorder (https://borderlinesupport.org.uk/)
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DBT and Relationships (http://suffolkdbt.com/dbt-and-relationships-suffolk-dbt/)

Marsha Linehan's description of DBT (http://behavioraltech.org/resources/whatisdbt.cfm)
Overview of Borderline Personality Disorder and DBT treatment (http://cogbtherapy.com/los-an
geles-dbt)
Priory's An Overview of Dialectical Behaviour Therapy (http://www.priory.com/dbt.htm)

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