What is Dialectical Behavior Therapy? In short, Dialectical behavior therapy (DBT) is an evidence-based psychotherapy used to treat chronic or severe mental health issues. DBT utilizes the components of capability enhancement, generalization, motivational enhancement, and the structuring of the environment to help individuals achieve specific goals. The treatment targets of Dialectical Behavior Therapy are life-threatening behaviors, therapy interfering behaviors, quality of life behavior, and skills acquisition. The intervention is “dialectical” in the sense that it involves the integration of opposites. The primary dialectic synthesis within Dialectical behavior therapy is between the seemingly “opposite” strategies of acceptance and change. For example, DBT therapists focus their interventions as practitioners who 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, components, strategies, and ideas that are taught in Dialectical behavior therapy are equally balanced in terms of acceptance and change.
The Development of Dialectical Behavior Therapy
In the late 1970s, Cognitive Behavior Therapy (CBT) had gained popularity as one of the most effective psychotherapies for a range of severe mental health issues. During that time, a researcher by the name Dr. Marsha Linehan took a particular interest in investigating whether or not CBT would prove helpful for women whose suicidal tendencies were activated in response to trauma and pain. Due to her training, Dr. Lineham was initially interested in treating discrete behaviors. However, through consultation with colleagues, she concluded that she was actually treating women who met the diagnostic criteria for Borderline Personality Disorder (BPD). Dr. Lineman and her colleges quickly discovered major gaps in the effectiveness of Cognitive Behavioral Therapy among their target population of women with Borderline Personality Disorder. As a result, Dialectical Behavior Therapy was developed. The sets of strategies and the theories found in Cognitive Behavioral Therapy became the very foundation upon with Dialectical Behavior Therapy was built.
Who Can Benefit From Dialectical Behavior Therapy?
Today, Dialectical Behavior Therapy has since expanded to treat a wide variety of mental health concerns, including, but not limited to:
- Borderline personality disorder, including those with co-occurring:
- Suicidal and self-harming behavior
- Substance use disorder
- Posttraumatic stress disorder
- High irritability
- Cluster B personality disorders
- Self-harming individuals with personality disorder
- Attention deficit hyperactivity disorder (ADHD)
- Posttraumatic stress disorder related to childhood sexual abuse
- Major depression, including:
- Treatment resistant major depression
- Older adults with chronic depression and one or more personality disorders
- Bipolar disorder
- Transdiagnostic emotion dysregulation
- Suicidal and self-harming adolescents
- Pre-adolescent children with severe emotional and behavioral dysregulation
- Binge eating disorder
- Bulimia nervosa
The Cognitive-Behavioral Model
In order to truly understand Dialectical behavior therapy, it must be explored within the context of its theoretical framework. DBT is a form of cognitive behavioral treatment, which is based upon the combination of the basic principles from behavioral and cognitive psychology. The cognitive-behavioral model is based upon the assumption that our thoughts and beliefs influence our behavior, emotions, and physiology. In function, Dialectical behavior therapy is combined with cognitive and behavioral interventions. Both cognitive and behavior theories are founded on specific core concepts that serve as guiding principles.
A major concept of cognitive theory is the development and function of one’s schema. A schema is our internalized representation of the world, or patterns of thought, action, and problem solving. It dictates the way that we organize thoughts, store information, process new information, and integrate the products of those operations (knowledge). It reflects necessary biases with which we view the world, based on both our direct and indirect learning. When we encounter a new situation, we either assimilate it to “fit” our existing schema, or we accommodate it, changing the schema. Although a flexible schema is desirable, all schemas tend to be somewhat rigid by nature.
The principles and assumptions of behavior theory include:
- Behavior is what a person does, thinks, or feels that can be observed.
- People are motivated to seek pleasure & avoid pain.
- People behave based on their learning.
- Behavior is amenable to change. Behavior concern must be defined in terms of measurable indicators.
- Intervention should focus on influencing reinforcements or punishments for client behaviors.
- Thoughts & feelings are behaviors subject to reinforcement principles.
- The simplest explanations for behavior are preferred. Practitioners should avoid searching for ultimate causes of behavior.
Dialectical Behavior Therapy
Dialectical behavior therapy combines concepts from both cognitive and behavior theories. It may be appropriate for use as an intervention when an individual’s core difficulty is affective instability. From the perspective of DBT, some individuals develop pervasive problems in social functioning due to a lack of interpersonal and self-regulation skills. As a result, their potential to develop appropriate, adaptive behaviors is inhibited by both personal and environmental factors.
Behavior Chain Analysis
Overall, dialectical behavior therapy recognizes that certain internal and external stimuli have the potential to trigger problem behaviors through learned associations. In order to identify an individual’s cognitive, behavioral, affective, interpersonal, and environmental triggers, DBT utilizes an assessment strategy known as a behavior chain analysis. First, the client’s problem behavior is specified as clearly and concisely as possible. Then, the environmental conditions or cues that enhance or maintain the behavior are identified. Finally, the consequences of the behavior are considered. Another way to look at a behavior chain analysis is through the relationship sequence of A, B, and C.
A ——> B ——-> C
- A stands for Antecedent. This refers to the various triggers or cues that precede a specific behavior. Antecedents can be social, physical, environmental, emotional, or cognitive.
- B stands for Behavior. This refers to the actual problem behaviors that the individual is exhibiting.
- C stands for Consequences. During this portion of the analysis, the potential consequences of each problem behavior are explored. These can be either positive or negative, and are drawn from past experiences or inferred as future possibilities.
Using the behavior chain analysis as an assessment tool, Dialectical behavior therapy first targets a client’s immediate, life-threatening behaviors, and then moves on to address problem behaviors that may intervene with the intervention itself and the client’s overall quality of life. The end goal of DBT is to help people learn and use new skills and strategies to develop a life that they experience as worth living.
The Components of DBT
Dialectical Behavior Therapy works to achieve these goals through a variety of components.
Individual sessions address the client’s specific maladaptive behaviors while strengthening and generalizing their coping skills. Each of the individual sessions are related to the themes of the skills-training group.
In addition to individual therapy sessions, clients participate in group-oriented therapy sessions. The skills-training group explores four different modules. The first is mindfulness, which is based upon the awareness of self and context through mindful observation, as well as the ability to control one’s focus of attention on the present moment. The other three modules implement skills training in the areas of interpersonal effectiveness, emotional regulation, and distress tolerance.
An important component in Dialectical behavior therapy is coaching via telephone. Some client-practitioner contact is permitted between sessions for support and crisis intervention. The goal is to coach clients on how to use their DBT skills to effectively cope with difficult situations that arise in their everyday lives.
This is a platform for the therapists who are offering Dialectical behavior therapy. The consultation team helps DBT therapists remain competent and stay motivated to work with disorders that are especially difficult to treat, such as substance abuse. The support helps ensure that the practitioners will be able to provide the best possible treatment to their clients.
Stages of Intervention
Dialectical behavior therapy incorporates five intervention stages. The first of these is referred to as a pre-commitment stage in which the model is explained and the client is oriented to its expectations. During this stage, it is required that the client commits to three things:
- Reducing self-harm behaviors
- Working on interpersonal difficulties
- Developing new skills
Once the client has made a commitment to DBT, the next four stages of intervention can begin.
The goal of Stage 1 is for the client to move from feeling as if they are “out-of-control” to achieving behavioral control. The practitioner helps the client develop new behavior skills in order to reduce life-threatening behaviors, as well as any behaviors that may interfere with the client’s ability to consistently attend therapy. Quality-of-life issues and basic safety are addressed in this stage.
Stage 2 includes exposure to traumatic memories and the processing of past abuse. The goal of this stage is for the client to learn skills that enable them to experience and process a full range of emotions, as well as reduce post-traumatic stress symptoms. The client will progress towards moving from a state of quiet desperation to one of full emotional experiencing. This stage is particularly beneficial for those who have been diagnosed with PTSD.
Both the third and fourth stages of Dialectical behavior therapy focus on the development of self-respect and autonomy, as well as issues surrounding an individual’s own meaning and purpose. The client is challenged to set life goals, and work toward living a life of ordinary happiness and unhappiness.
In this stage, the overall goal of treatment is for the client to move from a sense of incompleteness or emptiness towards a spiritually fulfilling life. Clients are challenged to develop an ongoing capacity for experiences of joy, happiness, and freedom; as well as a sense of connectedness to something greater than themselves.
The Effectiveness of DBT
Like other interventions that are derivative of cognitive theory, Dialectical behavior therapy lends itself to empirical research methods. DBT has been extensively researched for individuals with a wide range of mental health conditions, who are receiving treatment in different practice settings across the globe. DBT has been evaluated and found to be effective among individuals from diverse backgrounds in terms of age, gender, sexual orientation, and race/ethnicity. Over and over again, Dialectical behavior therapy is an intervention which has been shown to be both well-established and efficacious.
- In 1991, the very first randomized controlled trial (RCT) of DBT was published. Dr. Marsha Linehan (who is the founder of Dialectical behavior therapy) along with her colleagues, found that DBT resulted in significant improvements for chronically suicidal and self-injuring women with borderline personality disorder. These findings were significant, as this specific clinical population had previously been considered “untreatable” (Linehan et al., 1991).
- In 2004, a controlled trial conducted in an inpatient setting found that those who received three months of DBT improved at a greater rate than those who received treatment as usual (Bohus et al. 2004).
- In 2006, findings from another research study showed that Dialectical behavior therapy may be effective in reducing suicide attempts. This data showed that those who received DBT were half as likely to attempt suicide than those who did not. They had less psychiatric hospitalizations and were far less likely to drop out of treatment, compared to those who received other psychotherapy interventions (Linehan et al. 2006).
- Overall, multiple controlled trials and independent studies found that one year of Dialectical behavior therapy decreased the instances of self-harming behaviors at a greater rate than alternative treatments. One such study reported that participants who received DBT had only .55 incidents of self-injurious behavior over one month, compared to 9.33 incidents among those who received other common treatments (SAMHSA National Registry of Evidence-based Programs and Practices).
- Another review of the modality consisting of sixteen different randomized studies found that Dialectical behavior therapy had a moderate effect on reducing the participants’ suicidal behaviors (Kliem, Kroger, & Kosfelder, 2010).
- A more recent meta-analysis of thirteen studies conducted among persons with eating disorders found that Dialectical behavior therapy was successful in addressing eating disorder behaviors (Bankoff, Karpel, Forbes, & Pantalone, 2012).
The APEX Difference
While Dialectical Behavior Therapy has proven to be useful among a wide variety of diverse individuals, there is truly no single intervention for treating any form of mental health condition. Because of this, the broad range of therapies available at Apex Recovery and the diversity of highly-qualified professionals make us able to provide highly flexible and personalized treatments to our patients.